美國CDC對 預防靜脈導管感染的 新指引

CDC Updates IV Catheter Infection Prevention Guidelines

Laurie Barclay, MD

April 4, 2011 — The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) have updated intravascular catheter infection prevention guidelines. The new recommendations and review of underlying supporting evidence, entitled "Guidelines for the Prevention of Intravascular Catheter-Related Infections," will also appear in a special supplement of the American Journal of Infection Control and are published online in the March 30 Advance Access issue of Clinical Infectious Diseases. The American Journal of Infection Control will also present a video roundtable highlighting the viewpoints of healthcare professionals on the anticipated effects of this new guideline on infection prevention practices.

"The updated CDC guidelines are rich with new recommendations that are based on additional scientific research that has emerged since the prior version was published," said Russell N. Olmsted, MPH, CIC, 2011 president of the Association of Professionals of Infection Control and Epidemiology (APIC), in a news release. "This is an important resource to support efforts toward the elimination of catheter-related bloodstream infections [CRBSIs].... The timing for this updated guideline is perfect because, starting this year, hospitals that accept Medicare patients are required to report their central line–associated bloodstream infections to the Centers for Medicare & Medicaid Services, or risk losing 2 percent of their Medicare payments."

Collaborative Project

The updated recommendations replace previous guidelines published in 2002 by the CDC and were formulated by a working group led by the Society of Critical Care Medicine. In addition to the CDC and HICPAC, also collaborating on this project were the Infectious Diseases Society of America, Society for Healthcare Epidemiology of America, Surgical Infection Society, American College of Chest Physicians, American Thoracic Society, American Society of Critical Care Anesthesiologists, APIC, Infusion Nurses Society, Oncology Nursing Society, American Society for Parenteral and Enteral Nutrition, Society of Interventional Radiology, American Academy of Pediatrics, and Pediatric Infectious Diseases Society.

Goals of New Recommendations

"The goal of an effective prevention program should be the elimination of CRBSI from all patient-care areas," write Naomi P. O'Grady, MD, from the National Institutes of Health in Bethesda, Maryland, and colleagues from HICPAC. "Although this is challenging, programs have demonstrated success, but sustained elimination requires continued effort. The goal of the measures discussed in this document is to reduce the rate to as low as feasible given the specific patient population being served, the universal presence of microorganisms in the human environment, and the limitations of current strategies and technologies."

The new recommendations are addressed to healthcare personnel responsible for intravascular catheter insertion as well as those involved in surveillance and containment of infections in hospital, outpatient, and home healthcare settings.

Multidisciplinary strategies and topics addressed in the updated guidelines include education, training, and staffing; selection of catheters and sites; peripheral catheters and midline catheters; central venous catheters (CVCs); hand hygiene and aseptic technique; maximal sterile barrier precautions; skin preparation; catheter site dressing regimens; patient cleansing; catheter securement devices; antimicrobial/antiseptic impregnated catheters and cuffs; systemic antibiotic prophylaxis; antibiotic/antiseptic ointments; antibiotic lock prophylaxis, antimicrobial catheter flush and catheter lock prophylaxis; anticoagulants; replacement of peripheral and midline catheters; replacement of CVCs, including peripherally inserted central catheters (PICCs) and hemodialysis catheters; umbilical catheters; peripheral arterial catheters and pressure-monitoring devices for adult and pediatric patients; replacement of administration sets; needleless intravascular catheter systems; and performance improvement.

Recommendations

Some of the specific recommendations include the following:

• For peripheral and midline catheters, an upper-extremity site is preferred in adults. In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used.


• Steel needles should be avoided when administering fluids and medications that might cause tissue necrosis if extravasation occurs.


• When the duration of intravascular therapy is likely to be more than 6 days, a midline catheter or PICC is preferred to a short peripheral catheter.


• The catheter insertion site should be evaluated daily, and peripheral venous catheters should be removed if signs of phlebitis develop.


• Risks and benefits of a central venous device to reduce infectious complications should be weighed against the risk for mechanical complications.


• In adult patients, use of the femoral vein for central venous access should be avoided. For nontunneled CVC placement, a subclavian site is preferred to a jugular or a femoral site. To avoid subclavian vein stenosis, the subclavian site should be avoided in hemodialysis patients and patients with advanced kidney disease.


• For patients with chronic renal failure, a fistula or graft instead of a CVC for permanent access for dialysis should be used.


• Ultrasound guidance by those fully trained in its technique should be used to place CVCs.


• A CVC should have the minimal number of ports or lumens essential for patient treatment.


• Any intravascular catheter that is no longer essential should be promptly removed.


• When adherence to aseptic technique cannot be ensured, such as for catheters inserted during a medical emergency, the catheter should be replaced as soon as possible (within 48 hours).


• Systemic antimicrobial prophylaxis before insertion or during use of an intravascular catheter is not routinely recommended to prevent catheter colonization or CRBSI.

More information on the guidelines is available on this particular CDC Web site.

Some of the study authors have disclosed various financial relationships with the ABIM Subspecialty Board for Critical Care Medicine, Infusion Nurses Society, 3M, Becton Dickinson, Smiths Medical, Institute of Healthcare Improvement, Theradoc, Medline, APIC, Clorox, Merck, Baxter, Ortho-McNeil, Targanta, Schering-Plough, Optimer, Cadence, Cardinal, BDGeneOhm, WebEx, Cerebrio, Tyco, Medscape, ASHP, IDSA, ASM, American College of Surgeons, NQF, SHEA/CDC, HHS, Trauma Shock Inflammation and Sepsis Meeting, University of Minnesota, Ethicon, Angiotech, Astellas, Theravance, Pfizer, Ash Access, CorMedix, Catheter Connections, Carefusion, Sage, Bard, Teleflex, Cubist, Enzon, Basilea, Great Lakes Pharmaceuticals, Inventive Protocol, Cook, Inc, American Medical Systems, Cook Urological, TyRx, Medtronic, Biomet, Eisai Pharmaceuticals, Discovery Laboratories, Molnlycke, Cardinal Healthcare Foundation, Sanofi-Pasteur, Semprus, and/or Society for Healthcare Epidemiology of America.

Clin Infect Dis. Published online March 30, 2011. Extract

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