CLINICAL
Management of intravascular
devices to prevent infection
Abstract
Intravenous therapy is an essential part of clinical care used in a wide
variety of healthcare settings. Thus, intravenous catheters have
become indispensable to clinical practice. However, catheter-related-
bloodstream infections (CR-BSIs) are a major source of morbidity and
mortality, especially in hospital patients. Strategies to prevent infection
need to change and develop to reflect the advances in technology
and delivery of health care. Current guidance recommends a number
of strategies to reduce the incidence of CR-BSIs. These include
applying the principles of asepsis, the choice of catheter material,
the site of insertion and when to replace equipment used. This article
reviews the guidelines for current clinical practice.
T
he most common means of fluid
replacement for patients unable to
maintain oral hydration is by the
intravenous (IV) route; thus, IV catheters
have become indispensable to clinical prac-
tice. There has been an increase in providing
IV fluids by the subcutaneous route, although
such an alternative is not suitable for hyper-
tonic solutions, non-electrolyte solutions or
for administering medication, as these will
have difficulty being absorbed (Fainsinger et
al, 1994; Noble-Adams, 1995).
IV therapy is used in a variety of health-
care settings, not only for fluid replacement
but also for the administration of medica-
tion, blood products and total parenteral
nutrition. IV access is also required for the
monitoring of critically ill patients and for
obtaining blood samples.
Current guidance recommends a number of
strategies to reduce the incidence of catheter-
related-bloodstream infections (CR-BSIs).
These include applying the principles of asep-
sis, the choice of catheter material, the site of
insertion and when to replace equipment used.
Lynn Parker is Infection
Only a limited number of studies relating
Control Specialist, Northern
General Hospital, Sheffield to CR-BSIs have been undertaken in children
from neonatal or paediatric intensive care
Accepted for publication:
units and neonatal units. Children present
January 2002
particular problems of fluid and electrolyte
maintenance because of their relatively large
240
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Lynn Parker
surface area compared with body weight,
resulting in high fluid turnover (Livesley,
1993). Children often require microinfusions
at fractional flow rates, and IV fluids should
be administered in a controlled and precise
manner (Livesley, 1993).
PREVENTION STRATEGIES
Infection control prevention strategies need to
change and develop to reflect the advances in
technology and delivery of health care.
Reports have consistently shown that the risk
of infection declines with the standardization
of aseptic care practices, and with the
increased use of IV teams (Soifer et al, 1998).
There is an increased risk of colonization of
IV lines and CR-BSI when intravascular
catheters are inserted and maintained by
inexperienced staff (Armstrong et al, 1986).
Additionally, the incidence of CR-BSI has
been shown to be affected if nursing staff lev-
els fall below a critical point (Fridkin et al,
1996). Such prevention strategies need to
reflect the inclusion of patients, relatives and
their carers in the management of IV lines.
PATHOGENESIS
The most serious CR-BSIs are related to cen-
tral venous catheters (CVCs). The incidence
of local or systemic infections is lower with
peripheral venous catheters (Waghorn, 1994;
Fletcher and Bodenham, 1999), but they are
noticed more because of their increased use. It
is estimated that almost 6000 patients acquire
a CR-BSI in the UK each year (Waghorn,
1994; Fletcher and Bodenham, 1999).
Staphylococcus epidermidis, followed by
S. aureus, Candida spp. and enterococci, are
the most common organisms associated with
CR-BSI (Healthcare Infection Control Practices
Advisory Committee (HICPAC), 2001), with
the colonization of catheter hubs and the skin
adjacent to the insertion site the source of most
CR-BSI (Maki et al, 1987). Occasionally,
BRITISH JOURNAL OF NURSING, 2002, VOL 11, NO 4
 CLINICAL
catheters may become haematogenous, seeded
from another focus of infection in the body, but
rarely does contamination of the infusate lead
to infection (Maki et al, 1987). It is important
to remember that the material of the catheter
and the ability of the microorganism to adhere
to the surface of the catheter once inserted can
influence CR-BSI.
PRINCIPLES OF ASEPSIS
Hand decontamination is considered to be
the cornerstone of infection control practice
for all practitioners. For the insertion of
CVCs, the use of maximal sterile barrier pre-
cautions (cap, mask, sterile gown, sterile
gloves, large sterile drapes), when compared
with routine procedures, significantly
reduces the risk of CR-BSI (Raad et al,
1994). Disposable, non-sterile gloves used
with a non-touch aseptic technique may be
used for the insertion of peripheral venous
catheters (HICPAC, 2001).
Cleansing of the patient’s skin before
catheter insertion is essential; 2% chlorhexi-
dine gluconate is recommended in the litera-
ture (Maki et al, 1991; Mimoz et al, 1996),
but this is not manufactured for sale com-
mercially. Therefore, Department of Health
(2001) guidelines recommend that alcoholic
chlorhexidine gluconate solution be used to
cleanse the skin.
The type of dressing used is often a mat-
ter of individual preference. Studies show
no clinically important differences in colo-
nization or phlebitis when comparing trans-
parent dressings with gauze (Maki and
Ringer, 1987).
Table 1. Criteria for choosing the most appropriate
catheter
Type of blood vessel (peripheral venous, central venous, arterial)
Lifespan (<30 days, permanent or long-term)
Site of insertion (subclavian, femoral, internal jugular, peripheral,
peripherally inserted central catheters)
Pathway from skin to vessel (tunnelled vs non-tunnelled)
Physical length (long or short)
Individual characteristics (number of lumens, cuffed or non-cuffed,
coated with antibiotics, antiseptics or heparin)
Source: Healthcare Infection Control Practices Advisor y Committee (HICPAC)
(2001)
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VASCULAR ACCESS DEVICES
Discussion about vascular access devices can
become confusing because of the different
terminology used by clinicians. A catheter
can be determined according to the criteria
listed in Table 1.
Catheter material
Choosing the type of material that the
catheter is made from can affect the inci-
dence of CR-BSI. Teflon or polyurethane
catheters appear to have a lower incidence of
infection than those made from polyvinyl
chloride or polyethylene, with steel needles
having a similar rate of complications as
Teflon catheters (Tully et al, 1981).
Catheter insertion sites
The importance of where IV catheters are
sited on the body is related in part to the risk
of thrombophlebitis and the density of skin
flora. Thus, insertion sites on the lower
extremities of the body have an increased risk
of infection than those on the upper parts of
the body, with those on the hands having a
lower risk of phlebitis than the veins on the
wrist or upper arm (Maki and Mermel, 1998).
CVCs are generally inserted in the subcla-
vian, jugular or femoral veins, or inserted
peripherally into the superior vena cava using
the cephalic and basilic veins. The density of
skin flora at the insertion site is considered to
be a major risk factor for CR-BSI, and guidance
recommends that the subclavian site is pre-
ferred to the jugular or femoral site
(Department of Health, 2001; HICPAC, 2001).
The use of haemodialysis catheters for
renal dialysis poses the greatest risk of bac-
teraemia (HICPAC, 2001). Consequently, it is
recommended that such catheters be avoided
in preference to arteriovenous fistulas and
grafts. Cuffed catheters are preferred to non-
cuffed catheters for temporary access for dial-
ysis (HICPAC, 2001).
Umbilical vessel catheterization is often used
for vascular access in newborn infants.
Cannulation allows collection of blood samples
and haemodynamic monitoring, and both arte-
rial and venous catheters should be removed
and not replaced if there are any signs of CR-
BSI, or if thrombosis occurs (HICPAC, 2001).
Maintaining catheter patency
It is advised that catheters be routinely
flushed to maintain their patency by
BRITISH JOURNAL OF NURSING, 2002, VOL 11, NO 4
 MANAGEMENT OF INTRAVASCULAR DEVICES TO PREVENT INFECTION
preventing vascular thrombosis, microbial
adherence and CR-BSI (Infection Control
Nurses Association (ICNA), 2001). Studies
have identified no benefits of heparin over
saline flushes for peripheral venous catheters
(Randolph et al, 1998a), but heparin flushes
have been found to reduce effectively throm-
bus formation in central venous catheters
(CVCs) (Randolph et al, 1998b; Department
of Health, 2001).
Antimicrobial- and antiseptic-
impregnated catheters and cuffs
All the studies on antimicrobial and antisep-
tic catheters have used triple-lumen, non-
cuffed catheters in adults where the catheter
remained for less than 30 days (Department
of Health, 2001; HICPAC, 2001). Their use
may be beneficial for patients in intensive
care, or for those who have burns or neu-
tropenia (Veenstra et al, 1999). Types of
catheters available include:
● Chlorhexidine/silver sulfadiazine
catheters
● Minocycline/rifampicin catheters
● Platinum/silver catheters
● Silver cuffs.
Stopcocks and caps
Contamination of stopcocks is common,
although it is difficult to say if such contami-
nation is an important entry point for CR-BSI
(Lucet et al, 2000). However, stopcocks must
always be flushed thoroughly and capped
after use, and whenever a cap is removed it
should be replaced with a sterile one.
Before accessing the system it is important
that the external surfaces of the catheter hub
and connection ports are disinfected, either
with povidone-iodine or chlorhexidine glu-
conate (Department of Health, 2001).
Replacement of catheters,
administration sets and IV fluids
It has been recommended that intravascular
catheters should be replaced at regular
intervals to reduce the risk of CR-BSI (Raad
et al, 1993; Lai, 1998). The risk of phlebitis
and increased colonization has been associ-
ated with the type of catheter used (Raad et
al, 1993; Lai, 1998). However, such risk of
infection has to be balanced against the
practicalities of maintaining intravascular
access. If short, peripheral venous catheters
are left in place after 72–96 hours, the
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‘
higher will be the incidence of throm-
bophlebitis and bacterial colonization (Lai, It has been
1998). There is currently no perceived recommended
advantage for routine replacement of CVCs.
that intravascular
It is recommended that pulmonary arterial
catheters are replaced after 7 days, and that catheters should be
peripheral arterial catheters are relocated replaced at regular
every 4–5 days (Raad et al, 1993).
intervals to reduce
Phlebitis rates are not significantly differ-
ent when IV administration sets are replaced the risk of catheter-
after 96 hours, when compared with after 72 related-bloodstream
hours (Lai, 1998). Sets used for delivering
infections...The risk
lipid emulsions or blood products that
enhance microbial growth should be changed of phlebitis
more frequently (Crocker et al, 1984). (The and increased
administration set refers to the area from the
colonization has
spike of tubing going into the fluid, to the
hub of the vascular access device. A short been associated with
extension tube attached to the catheter is the type of catheter
considered part of the catheter and not the
used...However, such
administration set.)
The HICPAC guidelines recommend that risk of infection has
lipid emulsions should be completed within to be balanced
24 hours of hanging the emulsion, and that
against the
blood infusions be completed within 4
hours (Crocker et al, 1984; Barrett et al, practicalities
1993; Roth et al, 2000; HICPAC, 2001). of maintaining
’
Recommendations for IV fluids are that
intravascular
they should be replaced at least every 24
hours, and whenever the administration set access....
or catheter is changed (Ayliffe et al, 2000;
ICNA, 2001).
Table 2 summarizes the advice given for
catheter replacement, based on the HICPAC
(2001) guidelines.
In-line filters
In-line filters are used to reduce the incidence
of infusion-related phlebitis, but there are
no data at present to support their effective-
ness in preventing line infections
(Department of Health (DoH), 2001; HIC-
PAC, 2001). There is a theoretical debate
that potential benefits include:
● Reducing the risk of contaminated
infusate
● Reducing the risk of phlebitis in patients
receiving high doses of medication
● Reducing the risk of phlebitis in patients
in whom infection has already occurred
● Removing particulate matter that may
contaminate IV fluids
● Filtering endotoxin produced by Gram-
negative organisms in contaminated
infusate.
243
 CLINICAL

However, infusate-related bloodstream blocked when in use, especially when used

infection is rare, and filtration of medica- with certain fluids such as dextran, lipids
tions or infusates can be achieved more eas- and mannitol (HICPAC, 2001).
ily and cost-effectively by the pharmacy
department. In-line filters may become Systemic antibiotic prophylaxis
In adults there is no evidence that oral or
Table 2. Advice given for catheter replacement based parenteral prophylaxis reduces the incidence
on the Healthcare Infection Control Practices Advisory of CR-BSI. However, in low birthweight
Committee guidelines (HICPAC, 2001) infants, two studies have shown a reduction
in CR-BSI with prophylaxis (Kacica et al,
Replacement of 1994; Spafford et al, 1994).
Catheter type Replacement time administration set
Peripheral venous Adults: rotate site Replace IV giving
Needleless devices
catheter every 96 hours; those sets and add-on There is an attempt to reduce the incidence
inserted in devices no more than of injuries from sharps and the risk of trans-
emergencies replace every 96 hours mission of bloodborne infections to health-
after 48 hours unless clinically care workers. This has led to the introduc-
Paediatrics: do not indicated. IV tubing
tion of systems without sharps or needles.
replace unless used for
clinically indicated administering blood, They have not been shown to increase the
blood products or incidence of CR-BSI when they have been
lipid emulsions introduced and used according to the manu-
should be replaced facturer’s instructions (Arduino et al, 1997).
within 24 hours of
starting the infusion
Documentation
Peripheral arterial Adults: no more than IV tubing to be An important part of IV management is the
catheters every 4–5 days replaced when
observation of all catheter insertion sites to
Paediatrics: no changing the
recommendation. transducer detect problems, and to document accurately
Flush devices should such observations. The benefits of good record
be replaced at the keeping assist in the continuity of care by main-
same time as the taining an accurate account of treatment given,
disposable transducer —
and dissemination of information between the
every 96 hours
multidisciplinary team. The ICNA guidelines
Central venous Do not routinely Replace no more
catheters replace frequently than at
96-hour intervals. Table 3. Documentation
IV tubing used for required in relation
administering blood, to intravenous devices
blood products or
lipid emulsions Date of insertion
should be replaced
within 24 hours of Type of device
starting the infusion
Type of insertion (new site, guidewire
Pulmonary artery Replace no more As above used)
catheters frequently than every
7 days Site of insertion

Umbilical catheters Do not routinely Replace no more Name of person inserting the device
replace frequently than at Date device removed
96-hour intervals.
IV tubing used for Name of person removing the device
administering blood, Reason for removal
blood products or
lipid emulsions Culture specimen results
should be replaced
within 24 hours of Daily inspection results for: patency;
completing the leakage/bleeding; signs of infection;
infusion and dressing changes
Source: ICNA (2001)
IV = intravenous

244 BRITISH JOURNAL OF NURSING, 2002, VOL 11, NO 4

ritish Journal of Nursing. Downloaded from magonlinelibrary.com by 130.113.111.210 on December 7, 2015. For personal use only. No other uses without permission. . All rights reserve
 CLINICAL
provide examples of an IV access record sheet,
patient information sheet and audit tool for IV
insertion and management (ICNA, 2001). They
recommend that the information listed in Table
3 is always recorded.
CONCLUSION
IV therapy is an essential part of clinical care
in a wide variety of healthcare settings. CR-
BSIs are a major source of morbidity and mor-
tality, especially in hospital patients. General
recommendations emphasize the importance
of educating healthcare workers, especially
regarding hand hygiene and the need to apply
the principles of asepsis on insertion and han-
dling the catheter and administration sets, and
when accessing the system. BJN
Arduino MJ, Bland LA, Danzig LE et al (1997)
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access devices. Am J Infect Control 25: 377–80
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other risk factors for infection of hyperalimenta-
tion catheters. J Infect Dis 154: 808–16
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Crocker KS, Noga R, Filibeck DJ et al (1984) Microbial
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KEY POINTS
■ The most serious catheter-related bloodstream infections (CR-BSIs)
are associated with the use of central venous catheters.
■ Colonization of catheter hubs and the skin adjacent to the insertion
site are the source of most CR-BSIs.
■ Infection risks decline as aseptic care practices are standardized.
■ Documentation is an important part of intravenous management.
■ Current guidance recommends careful choice of catheter, site
of insertion and replacement of equipment used to reduce
the incidence of CR-BSIs.
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