- Intravascular access device–associated infections may be either local or bacteremic, and the risk of developing an infection varies with the patient population, the type of device, the microbe, and the patient-microbe-device interaction.
- The status of all indwelling vascular access devices should be reviewed daily by the critical care team, with attention to the duration of placement, appearance of the exit site, and continued clinical indication for the intravascular device.
- Central venous catheters account for over 90% of all intravascular device–related bacteremias.
- Most intravascular device–related bacteremias are caused by endogenous skin flora at the catheter insertion site that migrate along the transcutaneous portion of the catheter with subsequent colonization of the catheter tip.
- Coagulase-negative staphylococci and Staphylococcus aureus account for just over 50% of all intravascular device–related bacteremias, followed in frequency by gram-negative bacilli and yeast.
- Diagnosis of intravascular device–related infection, either local or bacteremic, is best approached using a combination of clinical and laboratory criteria.
- Although treatment of central line infections due to coagulase-negative staphylococci may be successful without catheter removal, infections caused by S. aureus necessitate catheter removal.
- Central intravascular catheter infections are essentially preventable infections. Successful prevention entails attention to a careful needs assessment for the device, careful site selection, maximal barrier precautions and aseptic technique on insertion, insertion by the most skilled operators, rigorous catheter-site care, and interrupting the integrity of the system as little as possible.
The use of intravascular access devices has become an integral part of modern patient care, and nowhere is this more evident than the ICU. Progress over the last two to three decades has provided an increasing array of devices other than the original peripheral and single-lumen central catheters. Included in the list of devices currently in use are multilumen central venous catheters (CVCs); tunneled CVCs such as the Hickman, Broviac, Cook, and Quinton catheters; flow-directed pulmonary artery catheters (PACs), peripherally inserted central and midline catheters, peripheral arterial catheters, and totally implantable devices. These indwelling intravascular devices provide a route for the administration for fluids, blood products, nutritional products, and medications; allow the monitoring of hemodynamic functions; and permit bloodletting and the maintenance of emergency access. However, vascular access devices may be associated with several complications, including local and bacteremic infections related to the device, thrombosis, thrombophlebitis, and septic thrombophlebitis. Infectious complications are the most frequent and among the most serious of these complications. The magnitude of CVC-related infectious complications can be appreciated when one realizes there are an estimated 15 million days of exposure to CVCs in patients in ICUs in the United States each year.1 Bacteremias caused by intravascular devices are associated with increased morbidity, prolonging hospitalization a mean of 7 days, and have a reported attributable mortality of up to 35% in studies that are not controlled for severity of illness.1–4
The risk of developing device-related infection (either local or bacteremic) varies considerably with the patient population, the type of device and its intended use, the microorganisms ...