Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line–associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit

doi:10.1016/j.ajic.2012.01.025

American Journal of Infection Control

Volume 40, Issue 10, December 2012, Pages 931-934

https://doi.org/10.1016/j.ajic.2012.01.025 Get rights and content

Background

A major risk factor for the development of bloodstream infection is the presence of a central venous catheter (CVC), especially in immunocompromised patients. CVC hub contamination is a risk factor for central line–associated bloodstream infection (CLABSI).

Methods

This observational before–after trial in a tertiary care hospital's oncology unit included adult patients with a CVC. During the intervention period, the practice of central line hub care was changed from cleaning with alcohol wipes to using alcohol-impregnated port protectors. To accommodate the protectors, the needless hubs were changed to a neutral pressure connector. The intervention period (January-July 2010) was compared with a historical control (January-December 2009).

Results

A total of 3,005 central line-days and 1 CLABSI (a rate of 0.3 infections/1,000 central line-days) were documented during the intervention period, compared with 6,851 central line-days and 16 CLABSIs (2.3 infections/1,000 central line-days) during the control period (relative risk, 0.14; 95% confidence interval [CI], 0.02-1.07; P = .03). The rate of contaminated blood cultures (CBCs) from central lines was 2.5% (17 of 692) during the control period, but only 0.2% (1 of 470) during the intervention period (relative risk, 0.09; 95% CI, 0.01-0.65; P = .002).

Conclusions

The implementation of alcohol-impregnated port protectors and needleless neutral pressure connectors significantly reduced the rates of CLABSIs and CBCs in our oncology patient population.

Section snippets

Methods

This quality improvement measure was a single-center analysis in the hematology/oncology unit at West Virginia University Hospitals. The study was approved by the Institutional Review Board.

Before implementation, we conducted a retrospective review of the hospital's electronic databases from January 1 through December 31, 2009, for CLABSIs and from July 1 through December 31, 2009, for CBCs. Culture results obtained within 48 hours of admission were excluded, to focus on hospital-acquired

Results

During the year before implementation, 472 patients with CVCs accounted for a total of 911 hospital admissions and 6,851 central line-days. Sixteen CLABSIs were documented during this preintervention period. The 6-month intervention period involved 282 patients, who accounted for a total of 479 hospital admissions and 3,005 central line-days. There were no significant statistical differences in baseline characteristics between the 2 groups (Table 1). The 2 groups also did not differ

Discussion

Health care–associated infections are now more commonly caused by highly resistant organisms, such as MRSA, vancomycin-resistant enterococci, extended-spectrum β-lactamase–producing Enterobacteriaceae and panresistant Acinetobacter species. These resistant organisms can be challenging to treat and are associated with increased mortality and morbidity.13, 14, 15 The paradigm for dealing with health care–associated infections needs to shift from treatment to prevention. Strategies to prevent

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Cited by (58)

Antiseptic barrier caps to prevent central line-associated bloodstream infections: A systematic review and meta-analysis
2023, American Journal of Infection Control
Citation Excerpt :
Nine studies evaluated compliance when using ABCs, 5,11,14,17,18,27-29,33 and 3 evaluated satisfaction.5,29,33 ABCs were highly appreciated by health care workers due to time-savings and ease of use.27,28 The ease of use and simple monitoring due to the green color of the ABCs increased compliance.17
Reliable and safe venous access is crucial for patients using central venous catheters (CVC). However, such CVCs carry a risk for central line-associated bloodstream infections (CLABSIs). Antiseptic barrier caps (ABCs) are a novel tool in the armamentarium for CVC disinfection. Our aim was to review the efficacy and safety of ABCs.
A literature search was conducted using MedLine, EMBASE, Cochrane library, and CINAHL. Primary aim was to compare CLABSI rates in patients using ABCs versus standard care. Secondary aims included efficacy of ABCs in relevant subgroups (age, ABC brand, clinical setting), safety, compliance, and costs. Fifteen studies were included in the meta-analysis.
In total, 391 CLABSIs in 273,993 catheter days occurred in the intervention group versus 620 CLABSIs in 284,912 days in the standard care group, resulting in a risk ratio of 0.65 (95%CI 0.55-0.76; P < .00001). Subgroup analyses showed similar effects, except for nonintensive care unit. In general, ABCs were safe, highly appreciated by patients and caregivers, and cost-effective, while compliance was easy to monitor. In most studies, a substantial risk of bias was observed.
In conclusion, while available evidence suggests that ABCs are effective, safe, easy in use, and cost-effective. However, due to the poor methodological quality of most available studies, more robust data should justify their use at this point.
Antiseptic barrier caps in central line-associated bloodstream infections: A systematic review and meta-analysis
2022, European Journal of Internal Medicine
Citation Excerpt :
The study by Flynn et al. [9] compared the effectiveness of connector decontamination with 70% alcohol wipes, alcoholic chlorhexidine gluconate wipes, or alcohol impregnated caps to prevent CLABSI in ten studies. Five studies [23,28,29,35,36] were analysed in the SRMA reporting that alcohol impregnated caps (RR: 0.43; 95%CI 0.28–0.65) and alcoholic chlorhexidine gluconate wipes (RR: 0.28; 95%CI: 0.20–0.39) were associated with significantly less catheter-associated bloodstream infections than 70% alcohol wipes. Both reviews [9,11] concluded that the cost of antiseptic barrier cap use is surpassed by the costs associated with CLABSI management and allows savings.
To evaluate the evidence concerning the effectiveness of antiseptic barrier caps vs. manual disinfection in preventing central line-associated bloodstream infection (CLABSI).
The protocol of this systematic review and meta-analysis was pre-registered in PROSPERO (CRD42021259582). PubMed, Cochrane Library and Web of Science databases were searched from 2011 to 2021. Randomized-controlled trials (RCT) and observational studies on hospitalized patients of any age were included.
Fourteen studies were included. Compared with manual disinfection, antiseptic barrier caps significantly reduced CLABSI rate per 1000 line-days (Standardized Mean Difference [SMD]: -0.02; 95%CI: -0.03 to -0.01) and number of CLABSI per patient (RR: 0.60; 95%CI: 0.41–0.89). Subgroup analysis showed that antiseptic barrier caps were more effective in reducing CLABSI rate per 1000 line-days in ICU (SMD: -0.02; 95%CI: -0.03 to -0.01) and non-ICU patients (SMD: -0.03; 95%CI: -0.05 to -0.01), adults (SMD: -0.02; 95%CI: -0.04 to -0.01), as in observational studies (SMD: -0.02; 95%CI: -0.02 to -0.01). Antiseptic barrier caps also significantly reduce CLABSI risk in ICU patients (RR: 0.65, 95%CI: 0.42–1.00), adults (RR: 0.50, 95%CI: 0.29–0.86), and observational studies (RR: 0.54; 95%CI: 0.32–0.91). No differences were found when only children or RCTs were taken into account. Median cost savings amongst studies were $21,890 [IQR 16,350–45,000] per CLABSI.
Antiseptic barrier caps appear to be effective in reducing CLABSI. The real-world impact needs to be confirmed by RCTs.
A quality improvement study on the reduction of central venous catheter-associated bloodstream infections by use of self-disinfecting venous access caps (STERILE)
2021, American Journal of Infection Control
Citation Excerpt :
The incidence rate of CLABSI per 1,000 line-days was 15.28 for the control group and 10.38 for the ABC group. Other studies reported incidence rates that ranged from 1.44 to 4.30 in control groups and 0.33-2.02 in ABC groups.1,3,4,6,12 The vast majority of these studies did not specifically report results from high-risk groups such as hematological patients.
Contamination of the catheter hub is an important source of central line-associated bloodstream infections (CLABSI); catheter hub caps incorporating a 70% isopropyl alcohol aim are designed to reduce contamination and hence CLABSI rates. Supporting data in high-risk hematological and oncological patients on the clinical effectiveness of this approach are sparse.
We conducted a before-after single center study accompanying the introduction of such caps at our department. Retrospective data from the year prior to the introduction were compared to 1 year of prospective data.
The control and antiseptic barrier cap (ABC) groups consisted of 309 and 289 patients presenting a CLABSI rate of 15.28 and 10.38 per 1,000 catheter days (P= .042), respectively. However, after multivariate analysis, ABCs were not identified as a statistically significant independent protective factor for the occurrence of CLABSI (hazard ratio 0.69, P= .120). There was no significant difference between the groups with respect to time to CLABSI (P= .681), nor the proportion of catheters removed due to suspicion of infection (P= .076).
The introduction of ABCs in this high-risk population did not significantly alter CLABSI rates.
Effect of the use of an antiseptic barrier cap on the rates of central line–associated bloodstream infections in neonatal and pediatric intensive care
2020, American Journal of Infection Control
Citation Excerpt :
It is less likely that the somewhat lower adherence to the use of the antiseptic barrier cap in the PICU has resulted in a moderate effect on CLABSI reduction of 18.6%. Still, the adherence rate in the PICU was higher than that in other studies, which have reported rates ranging from 63%-85%.19,20 Besides studying the effect of the use of the antiseptic barrier cap, we studied implementation outcomes (feasibility and fidelity) to understand the use and adherence of the intervention in daily practice.
The use of antiseptic barrier caps reduced the occurrence of central line–associated bloodstream infections (CLABSI) in adult intensive care settings. We assessed the effect of the use of antiseptic barrier caps on the incidence of CLABSI in infants and children and evaluated the implementation process.
We performed a mixed-method, prospective, observational before-after study. The CLABSI rate was documented during the “scrub the hub method” and the antiseptic barrier cap phase. Main outcomes were the number of CLABSIs per 1,000 catheter days (assessed with a Poisson regression analysis) and nurses’ adherence to antiseptic barrier cap protocol.
In total, 2,248 patients were included. The rate of CLABSIs per 1,000 catheter days declined from 3.15 to 2.35, resulting in an overall incidence reduction of 22% (95% confidence interval, –34%, 55%; P = .368).
Nurses’ adherence to the antiseptic barrier cap protocol was 95.2% and 89.0% for the neonatal intensive care unit and pediatric intensive care unit, respectively.
The CLABSI reducing effect of the antiseptic barrier caps seems to be more prominent in the neonatal intensive care unit population compared with the pediatric intensive care unit population.
The antiseptic barrier cap did not significantly reduce the CLABSI rates in this study.
New Directions in Ensuring Catheter Safety
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Tunneled dialysis catheters remain the most common vascular access used to initiate hemodialysis. Unfortunately, their use is associated with higher morbidity and mortality when compared with arteriovenous fistulae or grafts. Different types of catheters with different designs and material properties function differently. Additional devices and medications can be used to decrease the rates of infection and thrombosis. The current available tunneled dialysis catheters remain far from the desired goal and innovation in the field of dialysis vascular access remains in dire need.
What does really affect the colonization of needleless connectors?
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Major articleImpact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line–associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit

Background

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Mayo Clin Proc

Lancet Infect Dis

Am J Infect Control

Am J Infect Control

J Hosp Infect

Estimating healthcare-associated infections and deaths in US hospitals, 2002

Public Health Rep

Vital signs: central line–associated blood stream infections—United States, 2001, 2008, 2009

MMWR Morb Mortal Wkly Rep

Guidelines for the prevention of intravascular catheter–related infections

Morb Mortal Recomm Rep

Strategies to prevent central line–associated bloodstream infections in acute care hospitals

Infect Control Hosp Epidemiol

Epic2: guidelines for preventing infections associated with the use of central venous access devices (CVAD)

J Hosp Infect

Major article
Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line–associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit