Antimicrobial/Antiseptic Impregnated Catheters and Cuffs
Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin -impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing. The comprehensive strategy should include at least the following three components: educating persons who insert and maintain catheters, use of maximal sterile barrier precautions, and a >0.5% chlorhexidine preparation with alcohol for skin antisepsis during CVC insertion [106–113]. Category IA
Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI [114]. Category IB
Use povidone iodine antiseptic ointment or bacitracin/gramicidin/ polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturer’s recommendation [59, 115–119]. Category IB
Antibiotic Lock Prophylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis
Use prophylactic antimicrobial lock solution in patients with long term catheters who have a history of multiple CRBSI despite optimal maximal adherence to aseptic technique [120– 138]. Category II
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]. Category 1B
No recommendation is made regarding replacement of peripheral catheters in adults only when clinically indicated [142–144]. Unresolved issue
Replace peripheral catheters in children only when clinically indicated [32, 33]. Category 1B
Replace midline catheters only when there is a specific indication. Category II
Replacement of CVCs, Including PICCs and Hemodialysis Catheters
Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. Category IB
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. Category II
Do not use guidewire exchanges routinely for non-tunneled catheters to prevent infection. Category IB
Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection. Category IB
Use a guidewire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present. Category IB
Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II
Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency in the lower extremities, or thrombosis are present [145]. Category II
Remove and do not replace umbilical venous catheters if any signs of CRBSI or thrombosis are present [145]. Category II
No recommendation can be made regarding attempts to salvage an umbilical catheter by administering antibiotic treatment through the catheter. Unresolved issue
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]. Category IB
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]. Category IA
Add low-doses of heparin (0.25—1.0 U/ml) to the fluid infused through umbilical arterial catheters [151–153]. Category IB
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]. Category II
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]. Category II
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. Category II
Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pediatric Patients
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]. Category IB
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]. Category II
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]. Category IB
During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. Category II
Replace arterial catheters only when there is a clinical indication. Category II
Remove the arterial catheter as soon as it is no longer needed. Category II
Use disposable, rather than reusable, transducer assemblies when possible [160–164]. Category IB
Do not routinely replace arterial catheters to prevent catheter-related infections [165, 166, 167, 168]. Category II
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]. Category IB
Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile [160, 169–171]. Category IA
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]. Category II
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]. Category IA
Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit [163, 173, 174]. Category IA
Sterilize reusable transducers according to the manufacturers’ instructions if the use of disposable transducers is not feasible [163, 173–176]. Category IA
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]. Category IA
No recommendation can be made regarding the frequency for replacing intermittently used administration sets.Unresolved issue
No recommendation can be made regarding the frequency for replacing needles to access implantable ports. Unresolved issue
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]. Category IB
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]. Category IA
No recommendation can be made regarding the length of time a needle used to access implanted ports can remain in place. Unresolved issue
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]. Category II
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]. Category II
Ensure that all components of the system are compatible to minimize leaks and breaks in the system [194]. Category II
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]. Category IA
Use a needleless system to access IV tubing. Category IC
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]. Category II
Use hospital-specific or collaborative-based performance improvement initiatives in which multifaceted strategies are "bundled" together to improve compliance with evidence-based recommended practices [15, 69, 70, 201–205]. Category IB
