Evidence-based measures to prevent central line-associated bloodstream infections: a systematic review¹

ABSTRACT

Objective:

to identify evidence-based care to prevent CLABSI among adult patients hospitalized in ICUs.

Method:

systematic review conducted in the following databases: PubMed, Scopus, Cinahl, Web of Science, Lilacs, Bdenf and Cochrane Studies addressing care and maintenance of central venous catheters, published from January 2011 to July 2014 were searched. The 34 studies identified were organized in an instrument and assessed by using the classification provided by the Joanna Briggs Institute.

Results:

the studies presented care bundles including elements such as hand hygiene and maximal barrier precautions; multidimensional programs and strategies such as impregnated catheters and bandages and the involvement of facilities in and commitment of staff to preventing infections.

Conclusions:

care bundles coupled with education and the commitment of both staff and institutions is a strategy that can contribute to decreased rates of central line-associated bloodstream infections among adult patients hospitalized in intensive care units.

Descriptors:
Catheter-Related Infections; Central Venous Catheters; Intensive Care Units; Evidence-Based Practice

RESUMO

Objetivo:

identificar evidências de cuidados para prevenção de infecção de corrente sanguínea relacionada a cateter venoso central em pacientes adultos em Unidades de Terapia Intensiva.

Método:

revisão Sistemática realizada por meio de busca nas bases de dados Pubmed, Scopus, Cinahl, Web of Science, Lilacs, Bdenf e Cochrane. Foram buscadas pesquisas com cuidados com a cateterização e manutenção do cateter venoso central, publicados de janeiro de 2011 a julho de 2014. Os 34 estudos incluídos foram organizados em um instrumento e avaliados por meio da classificação do The Joanna Briggs Institute.

Resultados:

os estudos apresentaram bundles de cuidados com elementos como a higiene das mãos e precauções máximas de barreira; programas multidimensionais e estratégias como cateteres e curativos impregnados e o envolvimento da instituição e engajamento da equipe nos esforços para prevenção de infecção.

Conclusão:

os cuidados no formato de bundles aliados com a educação e engajamento da equipe e da instituição são estratégias que poderão contribuir para a redução das taxas de infecção de corrente sanguínea relacionada a cateter venoso central em pacientes adultos em unidades de terapia intensiva.

Descritores:
Infecções Relacionadas a Cateter; Cateteres Venosos Centrais; Unidades de Terapia Intensiva; Prática Baseada em Evidência

resumen

Objetivo:

identificar evidencias de cuidados para prevención de infección de la corriente sanguínea relacionada al catéter venoso central, en pacientes adultos en Unidades de Terapia Intensiva.

Método:

revisión sistemática realizada por medio de búsqueda en las bases de datos Pubmed, Scopus, Cinahl, Web of Science, Lilacs, Bdenf y Cochrane. Fueron buscadas investigaciones de cuidados con la cateterización y manutención del catéter venoso central, publicados de enero de 2011 a julio de 2014. Los 34 estudios incluidos fueron organizados en un instrumento y evaluados por medio de la clasificación del The Joanna Briggs Institute.

Resultados:

los estudios presentaron bundles de cuidados con elementos como: higiene de las manos y precauciones máximas de barrera; programas multidimensionales y estrategias como catéteres y curativos impregnados y, participación de la institución y compromiso del equipo en los esfuerzos para prevención de la infección.

Conclusión:

los cuidados en el formato de bundles aliados con la educación y compromiso del equipo y de la institución, son estrategias que podrán contribuir para la reducción de las tasas de infección de la corriente sanguínea relacionadas al catéter venoso central, en pacientes adultos en unidades de terapia intensiva.

Descriptores:
Infecciones Relacionadas a Catéter; Catéteres Venosos Centrales; Unidades de Terapia Intensiva; Práctica Basada en Evidencia

Introduction

Central Venous Catheters (CVC) play an important role in the treatment of hospitalized patients, especially critically ill patients¹. Intensive Care Units (ICU) employ measures such as diagnostic procedures and invasive devices that may trigger complications such as healthcare-associated infections (HAI)². The challenges imposed to the prevention of nosocomial infections are even greater in an ICU due to the variety of microorganisms, often multiresistant, which require the use of broad-spectrum antibiotics. ICUs are characterized by performing invasive procedures intended for diagnostic purposes or to enable the cure of patients, but which complicate the control of infections³. Note that central line-associated bloodstream infection (CLABSI) is the primary complication of central venous catheters⁴.

In the United States, from 250,000 to 500,000 CLABSIs are estimated to occur every year, which result in a rate from 10% to 30% of mortality⁵. A study was conducted in Brazil with 33 patients hospitalized in an adult ICU using a total of 50 CVCs. Of these, 18 were diagnosed with CLABSI. In regard to clinical outcome, 20% of the patients who presented CLABSI died. The incidence of primary bloodstream infection was 1.52/1,000 catheters-day and the CVC utilization rate 0.80⁶. Critical care workers should be aware of CLABSI rates in the ICUs in which they work and devise quality control programs to attain rates not higher than 0.5-1/1,000 CVC/day⁷.

In this sense, there is a concern over the risk of infections to which patients are exposed, the prevalence of CLABSI, the need to improve care concerning the implantation and maintenance of CVCs, and the adoption of evidence-based measures to ground the care provided by the health staff. Therefore, systematized care defined by evidence-based guidelines confers safety and quality onto the care provided by the intensive care team and can effectively reflect decreased HAI rates.

Seeking to contribute to safer care provided to critically ill patients, this study's aim was to identify evidence-based care to prevent central line-associated bloodstream infection among adult patients hospitalized in intensive care units.

Method

A systematic review was conducted in accordance with the protocol proposed by the Federal University of São Paulo (UNIFESP), together with Cochrane Brazil, namely: establishing the research question (using the PICO strategy); identifying and selecting studies; critically assessing studies; collecting data; analyzing and presenting data; and interpreting results⁸.

The PICO strategy resulted in the following question: "What are the CLABSI-related preventive measures implemented among adult patients hospitalized in an ICU?"

The search was conducted from July 21^st to August 10^th 2014 in international databases such as Web of Science, Pubmed/Medline, Scopus, Cochrane, Cinahl and Latin American databases, Lilacs/BDENF, through the Coordination of Improvement of Higher Level Personnel (CAPES) platform. The terms used in the search were selected from the MeSH (Medical Subject Headings) as MeSH terms and All Fields, and from DeCS (Health Sciences Descriptors) as descriptors and key words. The Boolean operators AND and OR were used.

The search included studies that answered the research question, were related to the topic, and addressed interventions regarding the care and maintenance of catheters. Inclusion criteria were: original research studies, published from January 2011 to July 2014; written either in Portuguese, English or Spanish; included adult patients; conducted in adult ICUs; included short-term CVCs; and presented abstracts or titles that addressed the subject.

Exclusion criteria were: papers addressing a pediatric or neonatal population; did not originate from research; addressed peripherally inserted central catheter (PICC), hemodialysis, or peripheral and arterial catheters; or did not address preventive measures to prevent central line-associated bloodstream infections.

The search strategy resulted (Figure 1) in 1,611 references, 126 of which were duplicated and were excluded with the help of Mendeley software. A total of 1,485 studies were initially selected, but after reading the titles and abstracts, 1,333 were excluded so that 152 studies remained. Two researchers read the full texts of the 152 studies and any disagreement was discussed until consensus was reached. After this stage, 118 studies were excluded for not meeting the inclusion criteria or because the full text was not available, so that 34 studies were included in this review.

Figure 1
Search strategies used in database search

The 34 studies that remained were synthesized and analyzed. They were organized in an analysis tool in Microsoft Word that included Reference, Method, Care, Result and Level of evidence. Data were assessed according to the level of evidence classified by the Joanna Briggs Institute⁹.

Results

This study presents the results with the highest level of evidence concerning measures implemented to prevent CLABSI among adult patients in ICUs. The studies included in the review (Figure 2) tested care bundles, additional interventions beyond established care, and multidimensional interventions addressing both care maintenance and implantation, as well as staff education and institutional interventions.

In regard to the type of study, the following were found: 6 randomized clinical trials (17.6%), 8 cohort studies (23.5%), 10 pre- and posttest studies (29.4%), 3 observational studies (8.8%), 3 quasi-experimental studies (8.8%), 2 systematic reviews (5.8%): one included cohort studies and the other included economic evaluations, and 2 in-vitro tests/bench studies (5.8%).

Figure 2
Studies included

Discussion

Nine studies (26.4%) primarily addressed care bundles coupled with education, safety culture or organizational strategies^{23-24,26,28-29,32,37-39}. One study presented a bundle that contained 5 elements: hand hygiene; maximal sterile barrier precautions during CVC insertion; prepare clean skin with chlorhexidine; avoid the femoral site, if possible; and remove unnecessary catheters. These elements were implemented along with control of measures implementation, collection of information to calculate infection rates, monitoring of adherence to hand hygiene, and feedback of results to the team²⁶. Level of evidence: 2.d.

One intervention that focused on quality included two distinct bundles, both contained hand hygiene as the primary element. The first bundle of CVC insertion also contained the following: maximal sterile barrier, prepare skin with chlorhexidine and avoid femoral vein, while the second referred to CVC maintenance: appropriate bandage replacement, aseptic technique to access and change connectors without needles, and daily checking the need of CVC. The intervention was allied with an educational program implemented through conferences and teaching videos, surveillance of process and results²⁸. Level of evidence: 2.d.

Following the line of care bundles, one study audited the implementation of a CVC insertion bundle and a maintenance bundle for the Institute for Healthcare Improvement (IHI) associated with checklists and results feedback to the team. The study showed that the medical and nursing approach combined through care bundles reduced the average rate of infection from 6.43 to 1.83²³. Level of evidence: 2.d.

Another study addressing care bundles presented, in addition to care already mentioned, the use of ultrasound to seek the target vein and confirm intraluminal insertion to reduce complications. The studies achieved marked reduction of global rates of infection with the strategies implemented²⁴. Level of evidence: 2.d.

To show the importance of complying with all the elements included in a bundle for it to be effective, one study associated a care bundle proposed by the Institute for Healthcare Improvement (IHI) with a verification list and monitored compliance with the bundle elements. Only 38% reported a high level of compliance. The study emphasizes that only when compliance with a care bundle is high, is it associated with reduced rates of infections³⁹. Level of evidence: 3.e.

Three studies (8.8%) presented multidimensional programs that resulted in reduced rates of infections^13,25,33. Two studies implemented the multidimensional approach INICC - International Nosocomial Infection Control Consortium, which consists of six simultaneous interventions: bundle of interventions; education; outcome surveillance; process surveillance; feedback on infection rates; and performance feedback on infection control practices ^(25,33. Level of evidence: 2.c.

A randomized controlled clinical trial tested the multifaceted approach developed by Johns Hopkins Quality and Safety Research Group, which presents evidence-based practices to prevent CLABSI and a program to improve safety, communication, and teamwork. Strategies, such as an intervention team, verification lists, recognition of nurses as potential leaders of interdisciplinary team interventions, data collection to calculate rates, and control of compliance with measures was used. The intervention group achieved a decrease of 81% in non-adjusted CLABSI rates in the 19 months after implementation and the control group achieved a decrease of 69% in 12 months after the intervention. The study emphasized that the role of the nurse as a leader of the multi-professional team was key for the success of interventions ¹³. Level of evidence: 1.c

Four studies (11.7%) addressed educational strategies as the study's main focus, among which two also assessed the cost-effectiveness of this type of intervention^11,19,21,31. Two studies presented a training program based on the simulation of sterile techniques during CVC insertion and showed that the program decreased infection rates from 3.6 to 1/1,000 catheters-day after the intervention in the first study¹¹ (1.c) and the second study reported a decrease of 3.82 to 1.29/1,000 catheters-day³¹. Level of evidence: 3.c.

One study assessed the cost-effectiveness of the strategy previously mentioned, associated with a care bundle, a catheter insertion cart and a verification list as mandatory in the program in which a nurse had the power to interrupt the procedure if the items contained in the list were not complied with. The simulation training was mandatory for all the hospital's physicians and included a pre-course, self-guided reading of papers and instructional books, a 4-hour simulation course supervised by assistant physicians and intensive care workers. The educational strategy resulted in a decrease of 58% in the incidence of CLABSI²¹. Level of evidence: 2.d. One study assessed the efficacy and cost-effectiveness of educational interventions and suggested that a variety of educational approaches could be cost effective and decrease the facility's costs¹⁹. Level of evidence of economic analysis: 2.

Institutional strategies are considered important when seeking compliance with measures concerning the implantation and maintenance of central catheters. One study focused on external audits to assess compliance with CVC insertion and maintenance practices, presenting monthly feedback to the team. Compliance with care practices increased during the intervention period, showing a significant decrease in the global incidence of infections, though the incidence rate either increased or remained stable after the intervention. The study emphasized the value of auditing- and feedback-based interventions, though reports of lack of leadership and the staff's high turnover represent weaknesses, indicating the need for studies focused on behavioral change strategies¹⁶. Level of evidence: 2.c.

Extra strategies added to already implemented care concerning the insertion and maintenance of catheters were tested as a means to lower risk of colonization and infection of CVCs^{14,17,27,30,34-36,40-41}.

Due to the association of CVC with parenteral nutrition (PN), which incurs an increased risk of CLABSI occurring, and seeking to clarify the impact of the infusion system on infection rates, a multi-center study compared sterile multichamber bags for parenteral nutrition (PN). This is considered to be a closed infusion system, with compounded parenteral nutrition (two compounds). The rate of CLABSI was 35.3% greater among patients who received compounded PN in comparison to those who received PN through the closed system¹⁴. Level of evidence: 1.c.

In regard to bandages impregnated with antiseptic and antibiotics intended to reduce the colonization of bacteria on the catheter insertion site, one study assessed the potential of a bandage containing chlorhexidine to decrease infection. The facility where the study was conducted had already implemented care concerning the insertion and maintenance of catheters, surveillance and education. CLABSI rates were significantly lower among patients using bandages with chlorhexidine, 1.51/1,000 CVS days in comparison to 5.87/1,000 CVC days in patients with conventional bandages²⁷. Level of evidence: 2.d.

The influence of different types of catheters on CLABSI prevention and decreasing biofilm formation was addressed in 3 studies^34-36. The use of catheters impregnated with Rifampicin and Miconazole (RM-C) in the femoral site in comparison to standard catheters (SC) showed an incidence significantly lower with the impregnated catheter: 8.61 vs. 0 CLABSI/1,000 catheters-day³⁴. Level of evidence: 3.c. Catheters impregnated with Chlorhexidine and Silver sulfadiazine (CHSS) in the internal jugular vein presented lower CLABSI rate than conventional catheters: 0% vs. 2.0%, incidence density of 0 vs. 5.04 CLABSI/1,000 catheters-day³⁶. Level of evidence: 3.c.

Three gradual interventions were implemented by a study focusing on the maintenance of catheters in three ICUs: rubbing the insertion site with chlorhexidine swabs for 15s; daily bathing with chlorhexidine-impregnated washcloth; and daily nursing rounds to ensure compliance with the items from a verification list that included infection control measures. The facility where the study was conducted had already been implemented the following list: bandages and catheters impregnated with chlorhexidine or with minocycline/rifampin; skin antisepsis with chlorhexidine; and intravenous connectors without needles. The study reports a progressive decrease in CLABSI rates after the gradual implementation of interventions¹⁷. Level of evidence: 2.c.

As identified in the bundles presented by the studies, avoiding the femoral site when inserting CVCs is a recommended measure, as well as giving preference to the subclavian vein. One study assessed the use of the subclavian vein in the presence of tracheostomy in comparison to the femoral vein. The "subclavian + tracheostomy" group presented lower incidence of CLABSI when compared to "femoral without tracheostomy", 3.9 vs. 10.0 CLABSI episodes/1,000 catheter days, while there was a tendency for the incidence of CLABSI in the "subclavian + tracheostomy" group to be lower, 3.9 vs. 11.2I CLABSI/1,000 catheters-days⁴⁰. Level of evidence: 3.e.

Studies tested some interventions that did not obtain significant results in reducing infections rates and colonization^{10,12,15,18,20,22,42-43}. A study investigated whether non-return valves, designed to prevent the backflow of fluids, would be efficacious in reducing infections. The conclusion, however, was that non-return valves do not prevent backflow nor serve as a bacterial filter⁴². Level of evidence: 5.c. One CVC impregnated with silver nanoparticles was assessed, but no significant effect was found and for this reason it cannot be recommended¹⁰, nor can the use of CVC Certofix^(r) Protect (B Braun), which promised to prevent biofilm formation through a charged surface⁴³. Level of evidence: 5.c.

In regard to antiseptic solutions to prepare the skin to receive a central venous catheter, a study compared the efficacy, ease of use, and cost of an antiseptic solution with chlorhexidine and a povidone-iodine solution, both alcoholic. The study reports small significant decreases only for the colonization of the catheter and limited ease of use, without significant effects for infection rates or lower cost²². Level of evidence: 2.d.

The studies show that actions that include care bundles, the education of workers, the promotion of safety culture, and the implementation of regular assessments controlling compliance with such measures, surveilling infection rates and providing feedback to workers coupled with additional strategies, such as using differentiated catheters and bandages, are important to decrease CLABSI rates among patients hospitalized in adult ICUs.

Conclusion

This study presents care measures to prevent central line-associated bloodstream infections recently addressed among patients hospitalized in intensive care units. Twenty-six out of the 34 studies analyzed presented significant results concerning decreased central line-associated bloodstream infection rates after the implementation of care. Care measures included with CVC insertion and maintenance to important strategies concerning the staff's education and engagement, safety culture, and surveillance processes.

Nine studies mainly focused on care bundles that included elements such as hand hygiene, cleaning the insertion site with chlorhexidine, avoiding the femoral site, and removing the catheter as soon as it is no longer necessary. Three studies presented multidimensional programs addressing bundles of interventions, education, surveillance, feedback on results, as well as assessment of safety culture, training addressing safety, and partnerships with leaders within the unit.

Three studies addressed educational interventions such as training based on the simulation of sterile techniques. Institutional strategies were also addressed, such as auditing, recruiting of leaders, surveillance, and monthly feedback to the team.

Differentiated care, such as bandages and catheters impregnated with chlorhexidine or antibiotic and closed infusion systems, were also addressed. Eight studies did not present significant results concerning decreased central line-associated bloodstream infection rates like those that tested non-return valves to prevent backflow or catheters using a new antiseptic solution.

This study's limitations include a lack of literature produced in Brazil in the scope of nursing and the fact that the study focuses on only one type of catheter. Studies addressing different types of catheters are important, as are systematic reviews, in order to meet the need of clinical practitioners of implementing evidence-based care.

References

• ¹
  Passamani RF, Souza SROS. Infecção relacionada a cateter venoso central: um desafio na terapia intensiva. Med HUPE-UERJ. 2011;10(1):100-8.
• ²
  Loftus K, Tilley T, Hoffman J, Bradburn E, Harvey EJ. Use of Six Sigma strategies to pull the line on central line-associated bloodstream infections in a neurotrauma intensive care unit. Trauma Nurs. 2015;22(2):78-86.
• ³
  Barros LM, Bento JNC, Caetano JA, Moreira RAN, Pereira FGF, Frota NM, et al. Prevalência de micro-organismo e sensibilidade antimicrobiana de infecções hospitalares em unidade de terapia intensiva de hospital público no Brasil. Rev Ciênc Farm Básica Apl. 2012;33(3):429-35.
• ⁴
  Siqueira GLG, Hueb W, Contreira R, Nogueron MA, Cancio DM, Caffaro RA. Infecção de corrente sanguínea relacionada a cateter venoso central (ICSRC) em enfermarias: estudo prospectivo comparativo entre veia subclávia e veia jugular interna. J Vasc Bras. 2011;10(3):211-6.
• ⁵
  The Joint Commission. Variability of surveillance practices for central line-associated bloodstream infections and its implications for health care reform. Joint Commission Benchmark. 2011;13(2):6-8.
• ⁶
  Lopes APAT, De Oliveira SLCB, Sarat CNF. Infecc¸a~o relacionada ao cateter venoso central em unidades de terapia intensiva. Ensaios e C. 2012;16(1):25-41.
• ⁷
  Timsit JF, 'Hériteau FL, Lelape A, Francais A, Ruckly S, Venier A G, et al. A multicentre analysis of catheter-related infection based on a hierarchical model. Intensive Care Med. 2012;38(10):1662-72.
• ⁸
  Universidade Federal de São Paulo. Curso de revisão sistemática e metanálise [internet]. 2001 [Acesso 15 jun 2013]. Disponível em: http://www.virtual.epm.br/cursos/metanalise/conteudo/entrada.php
  » http://www.virtual.epm.br/cursos/metanalise/conteudo/entrada.php
• ⁹
  The Joanna Brigs Institute. New JBI levels of evidence [internet]. 2014 [Acesso 18 set 2014]. Disponível em: http://joannabriggs.org/assets/docs/approach/JBI-Levels-of-evidence_2014.pdf
  » http://joannabriggs.org/assets/docs/approach/JBI-Levels-of-evidence_2014.pdf
• ¹⁰
  Antonelli M, De Pascale G, Ranieri VM, Pelaia P, Tufano R, Piazza O, et al. Comparison of triple-lumen central venous catheters impregnated with silver nanoparticles (AgTive(r)) vs conventional catheters in intensive care unit patients. Jhin. 2012;82(2):101-7.
• ¹¹
  Khouli H, Jahnes K, Shapiro J, Rose K, Mathew J, Gohil A, et al. Performance of medical residents in sterile techniques during central vein catheterization - randomized trial of efficacy of simulation-based training. CHEST. 2011;139(1):80-7.
• ¹²
  Kwakman PH, Müller MC, Binnekade JM, Van Den Akker JP, de Borgie CA, Schultz MJ, et al. Medical-grade honey does not reduce skin colonization at central venous catheter-insertion sites of critically ill patients: a randomized controlled trial. Crit Care. 2012;16(5):R214.
• ¹³
  Marsteller JA, Sexton JB, Hsu YJ, Hsiao CJ, Holzmueller CG, Provonost PJ, et al. A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units. Crit Care Med. 2012;40(11):2933-9.
• ¹⁴
  Pontes-Arruda A, Santos MCFC, Martins LF, González ERR, Kliger RG, Maia M, et al. Influence of parenteral nutrition delivery system on the development of bloodstream infections in critically ill patients: an international, multicenter, prospective, open-label, controlled study-EPICOS study. JPEN J Parenter Enteral Nutr. 2012;36(5):574-86.
• ¹⁵
  Yousefshahi F, Azimpour K, Boroumand MA, Najafi M, Barkhordari K, Vaezi M, et al. Can a new antiseptic agent reduce the bacterial colonization rate of central venous lines in post-cardiac surgery patients? J Teh Univ Heart Ctr. 2013;8(2):70-5.
• ¹⁶
  Cherifi S, Gerard M, Arias S, Byl B. A multicenter quasi-experimental study: impact of a central line infection control program using auditing and performance feedback in five Belgian intensive care units. Antimicrob Resist Infect Control. 2013;2(1):33.
• ¹⁷
  Munoz-Price LS, Dezfulian C, Wyckoff M, Lenchus JD, Rosalsky M, Birnbach DJ, et al. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. Crit Care Med. 2012;40(5):1464-9.
• ¹⁸
  Thom KA, Shanshan L, Custer M, Preas MA, Rew CD, Cafeo C, et al. Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. Am J Infect Control. 2014;42(2):139-43.
• ¹⁹
  Frampton GK, Harris P, Cooper K, Cooper T, Cleland J, Jones J, et al. Educational interventions for preventing vascular catheter bloodstream infections in critical care: evidence map, systematic review and economic evaluation. Health Technol Assess. 2014;18(15):1-365.
• ²⁰
  Armellino D, Woltmann J, Parmentier D, Musa N, Eichorn A, Silverman R, et al. Modifying the risk: Once-a-day bathing "at risk" patients in the intensive care unit with chlorhexidine gluconate. Am J Infect Control. 2014;42(5):571-3.
• ²¹
  Burden AR, Torjman MC, Dy GE, Jaffe JD, Littman JJ, Nawar F, et al. Prevention of central venous catheter-related bloodstream infections: is it time to add simulation training to the prevention bundle? J Clin Anesth. 2012;24(7):555-60.
• ²²
  Girard R, Combyb C, Jacques D. Alcoholic povidone-iodine or chlorhexidine-based antiseptic for the prevention of central venous catheter-related infections: In-use comparison. J Infect Public Health. 2012;5(1):35-42.
• ²³
  Hocking C, Pirret AM. Using a combined nursing and medical approach to reduce the incidence of central line associated bacteraemia in a New Zealand critical care unit: a clinical audit. Intensive Crit Care Nurs. 2013;29(3):137-46.
• ²⁴
  Kim JS, Holtom P, Vigen C. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences. Am J Infect Control. 2011;39(8):640-6.
• ²⁵
  Leblebicioglu H, Öztürk R, Rosenthal VD, Akan AO, Sirmatel F, Ozdemir D. Impact of a multidimensional infection control approach on central line-associated bloodstream infections rates in adult intensive care units of 8 cities of Turkey: findings of the International Nosocomial Infection Control Consortium (INICC). Ann Clin Microbiol Antimicrob. 2013;12(10):415-23.
• ²⁶
  Osório J, Álvarez D, Pacheco R, Gómez CA, Lozano A. Implementación de un manojo de medidas (bundle) de inserción para prevenir la infección del torrente sanguíneo asociada a dispositivo intravascular central en cuidado intensivo en Colombia. Rev Chilena Infectol. 2013;30(5):465-73.
• ²⁷
  Scheithauer S, Lewalter K, Schröder J, Koch A, Häfner H, Krizanovic V, et al. Reduction of central venous line-associated bloodstream infection rates by using a chlorhexidine-containing dressing. Infection. 2014;42(1):155-9.
• ²⁸
  Tang HJ, Lin HS, Lin YH, Leung PO, Chuang YC, Lai CC. The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infect Dis. 2014;14:356.
• ²⁹
  Wu PP, Liu CE, Chang CY, Huang H-C, Syu SS, Wang CH, et al. Decreasing catheter-related bloodstream infections in the intensive care unit: interventions in a medical center in central Taiwan. J Microbiol Immunol Infect. 2012;45(5):370-6.
• ³⁰
  Maki DG, Rosenthal VD, Salomao R, Franzetti F, Rangel-Frausto MS. Impact of switching from an open to a closed infusion system on rates of central line-associated bloodstream infection: a meta-analysis of time-sequence cohort studies in 4 countries. JSTOR: Infect Control Hosp Epidemiol. 2011;32(1):50-8.
• ³¹
  Barsuk JH, Cohen ER, Potts S, Demo H, Gupta S, Feinglass J, et al. Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections. BMJ Qual Saf 2014;23(9):749-56.
• ³²
  Cooper K, Frampton G, Harris P, Jones J, Cooper T, Graves N, et al. Are educational interventions to prevent catheter- related bloodstream infections in intensive care unit cost-effective? J Hosp Infect 2014;86(1):47-52.
• ³³
  Jaggi N, Rodrigues C, Rosenthal VD, Todi SK, Shahe S, Saini N. Impact of an International Nosocomial Infection Control Consortium multidimensional approach on central line-associated bloodstream infection rates in adult intensive care units in eight cities in India. Int J Infect Dis. 2013;17(12):1218-24.
• ³⁴
  Lorente L, Lecuona M, Ramos MJ, Jiménez A, Mora ML, Sierra A. Lower associated costs using rifampicin-miconazole impregnated catheters compared with standard catheters. Am J Infect Control. 2011;39(10):895-7.
• ³⁵
  Lorente L, Lecuona M, Ramos MJ, Jiménez A, Mora ML, Sierra A. Rifampicin-miconazole-impregnated catheters save cost in jugular venous sites with tracheostomy. Eur J Clin Microbiol Infect Dis. 2012;31(8):1833-6.
• ³⁶
  Lorente L, Lecuona M, Jiménez A, Santacreu R, Raja L, Gonzalez O, et al. Chlorhexidine-silver sulfadiazine-impregnated venous catheters save costs. Am J Infect Control. 2014;42(3):321-4.
• ³⁷
  Palomar M, Álvarez-Lerma F, Riera A, Díaz MT, Torres F, Agra Y, et al. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: the spanish experience. Crit Care Med. 2013;41(10):2364-72.
• ³⁸
  Render ML, Hasselbeck R, Freyberg RW, Hofer TP, Sales AE, Almenoff PL. Reduction of central line infections in veterans administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement. BMJ Qual Saf. 2011;20(8):725-32.
• ³⁹
  Furuya YE, Dick A, Perencevich EN, Pogorzelska M, Goldmann D, Stone PW. Central line bundle implementation in US intensive care units and impact on bloodstream infections. PLoS One 2011;6(1):e15452.
• ⁴⁰
  Lorente L, Jiménez A, Martín MM, Palmero S, Jiménez JJ, Mora ML. Lower incidence of catheter-related bloodstream infection in subclavian venous access in the presence of tracheostomy than in femoral venous access: prospective observational study. Clin Microbiol Infect. 2011;17(6):870-2.
• ⁴¹
  Pfaff B, Heithaus T, Emanuelsen M. Use of a 1-piece chlorhexidine gluconate transparent dressing on critically ill patients. Crit Care Nurse. 2012;32(4):35-40.
• ⁴²
  Ellger B, Kiski D, Diem D, Van Den Heuvel I, Freise H, Aken V, et al. Non-return valves do not prevent backflow and bacterial contamination of intravenous infusions. J Hosp Infect. 2011;78(1):31-5.
• ⁴³
  Richards GA, Brink AJ, McIntosh R, Steel HC, Cockeran R. Investigation of biofilm formation on a charged intravenous catheter relative to that on a similar but uncharged cateter. Med Devices. 2014;7:219-24.

• 1
  Paper extrated from Master's Thesis "Evidence-based care for prevention of central venous catheter-related bloodstream infection: a systematic review without meta-analysis", presented to Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.

Publication Dates

• Publication in this collection
  2016

History

• Received
  11 Sept 2015
• Accepted
  29 Feb 2016