Preventing infection from indwelling intravascular devices: Hospital infection society India consensus group recommendations for Indian healthcare

Raman Sardana; Amit Kumar Mandal; Deepthi Nair; Leena Mendiratta; Hena Butta; TS Jain; Arti Kapil; Chand Wattal; Charoo Hans; RK Mani; Gaurav Sagar; Namita Jaggi; Praveen Khilnani; Purva Mathur; Sanjiv Jasuja; Sudha Kansal; Vikas Manchanda; Vivek Nangia; Anita Sharma; Fatima Khan; Geeta Mehta; Gita Nataraj; Rohini Kelkar; Subhash Todi; Sujata Baveja; V Balaji; Aarti Gupta; Anita Arora; Anu Gupta; Azra Hasan; Lakshmy A Raman; Madhu Choudhry; Mahvash Haider; Manju Mani; Neha Rathor; Nitika Aggarwal; Purabi Barman; Ravneet Kaur; Shalini Malhotra; Sonia Khatter Malik; Suresh Kumar; TD Chugh; VL Malhotra; Vrushali Patwardhan; Angela Stephens; Reena Ligin; Sapna Kumari; Shilpi Singh

doi:10.4103/jpsic.jpsic_17_19

NATIONAL OR SOCIETY GUIDELINES

Year : 2019 | Volume : 7 | Issue : 2 | Page : 31-47

Preventing infection from indwelling intravascular devices: Hospital infection society India consensus group recommendations for Indian healthcare

Raman Sardana¹, Amit Kumar Mandal², Deepthi Nair³, Leena Mendiratta¹, Hena Butta⁴, TS Jain⁵, Arti Kapil⁶, Chand Wattal⁷, Charoo Hans⁸, RK Mani⁹, Gaurav Sagar¹⁰, Namita Jaggi¹¹, Praveen Khilnani¹², Purva Mathur⁶, Sanjiv Jasuja¹⁰, Sudha Kansal¹³, Vikas Manchanda¹⁴, Vivek Nangia¹⁵, Anita Sharma¹⁶, Fatima Khan¹⁷, Geeta Mehta¹⁸, Gita Nataraj¹⁹, Rohini Kelkar²⁰, Subhash Todi²¹, Sujata Baveja²², V Balaji²³, Aarti Gupta²⁴, Anita Arora²⁵, Anu Gupta²⁶, Azra Hasan²⁷, Lakshmy A Raman²⁸, Madhu Choudhry²⁹, Mahvash Haider²⁷, Manju Mani³⁰, Neha Rathor³¹, Nitika Aggarwal³², Purabi Barman³³, Ravneet Kaur³⁴, Shalini Malhotra⁸, Sonia Khatter Malik³⁵, Suresh Kumar³⁶, TD Chugh³⁷, VL Malhotra³⁸, Vrushali Patwardhan³⁹, Angela Stephens⁴⁰, Reena Ligin⁴⁰, Sapna Kumari⁴⁰, Shilpi Singh⁴⁰
¹ Department of Microbiology and Infection Control, Indraprastha Apollo Hospitals, New Delhi, India
² Department of Critical Care Medicine, Fortis Hospital, Mohali, Punjab, India
³ Department of Microbiology, Safdarjung Hospital, New Delhi, India
⁴ Department of Microbiology, Indraprastha Apollo Hospitals, New Delhi, India
⁵ Department of Pediatrics, Max Smart Hospital, Saket, New Delhi, India
⁶ Department of Microbiology, AIIMS, Delhi, India
⁷ Department of Microbiology, SGRH, New Delhi, India
⁸ Department of Microbiology, RMLH, Delhi, India
⁹ Department of Critical Care Medicine, Nayati Multi Super Speciality Hospital, Mathura, Uttar Pradesh, India
¹⁰ Department of Nephrology, Indraprastha Apollo Hospitals, New Delhi, India
¹¹ Department of Microbiology, Artemis Hospital, Gurgaon, Haryana, India
¹² Department of Pediatric Critical Care Medicine, Rainbow Hospital, New Delhi, India
¹³ Department of Critical Care Medicine, Indraprastha Apollo Hospitals, New Delhi, India
¹⁴ Department of Microbiology, MAMC, New Delhi, India
¹⁵ Department of Critical Care Medicine, Fortis Hospital, Delhi, India
¹⁶ Department of Microbiology, Fortis Hospital, Mohali, Punjab, India
¹⁷ Department of Microbiology, JLN Medical College, Aligarh, Uttar Pradesh, India
¹⁸ Department of Microbiology, (Retd) LHMC, Delhi, India
¹⁹ Department of Microbiology, KEM Hospital, Mumbai, Maharashtra, India
²⁰ Department of Microbiology, Tata Memorial Hospital, Mumbai, Maharashtra, India
²¹ Department of Critical Care Medicine, AMRI Hospital, Kolkata, India
²² Department of Microbiology, LTMG Hospital, Mumbai, Maharashtra, India
²³ Department of Microbiology, CMC, Vellore, Tamil Nadu, India
²⁴ Department of Microbiology, FMRI, Gurgaon, Haryana, India
²⁵ Department of Hospital Administration, FMRI, Gurgaon, Haryana, India
²⁶ Department of Microbiology, Fortis Escorts Heart Institute, New Delhi, India
²⁷ Department of Microbiology, HIMSR, Delhi, India
²⁸ Department of Microbiology, DHLI, Delhi, India
²⁹ Department of Microbiology, (Retd) Phoolwati Jain Clinic, New Delhi, India
³⁰ Department of Anaesthesia, Max Smart Hospital, Saket, New Delhi, India
³¹ Department of Microbiology, QRG Faridabad, Haryana, India
³² Department of Microbiology, Rainbow Hospital, New Delhi, India
³³ Department of Microbiology, BLK Superspeciality Hospital, New Delhi, India
³⁴ Department of Microbiology, Fortis Hospital, Noida, Uttar Pradesh, India
³⁵ Department of Microbiology, ESI Medical College, Faridabad, Haryana, India
³⁶ Department of Microbiology, LHMC, Delhi, India
³⁷ Department of Microbiology, (Retd.) SGRH, New Delhi, India
³⁸ Department of Microbiology, SGT, Gurgaon, Haryana, India
³⁹ Department of Microbiology, National Heart Institute, Delhi, India
⁴⁰ Department of Infection Control, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission	12-Jul-2019
Date of Acceptance	23-Jul-2019
Date of Web Publication	20-Dec-2019

Correspondence Address:
Dr. Raman Sardana
Department of Microbiology, Indraprastha Apollo Hospitals, New Delhi - 110 076
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jpsic.jpsic_17_19

How to cite this article:
Sardana R, Mandal AK, Nair D, Mendiratta L, Butta H, Jain T S, Kapil A, Wattal C, Hans C, Mani R K, Sagar G, Jaggi N, Khilnani P, Mathur P, Jasuja S, Kansal S, Manchanda V, Nangia V, Sharma A, Khan F, Mehta G, Nataraj G, Kelkar R, Todi S, Baveja S, Balaji V, Gupta A, Arora A, Gupta A, Hasan A, Raman LA, Choudhry M, Haider M, Mani M, Rathor N, Aggarwal N, Barman P, Kaur R, Malhotra S, Malik SK, Kumar S, Chugh T D, Malhotra V L, Patwardhan V, Stephens A, Ligin R, Kumari S, Singh S. Preventing infection from indwelling intravascular devices: Hospital infection society India consensus group recommendations for Indian healthcare. J Patient Saf Infect Control 2019;7:31-47

How to cite this URL:
Sardana R, Mandal AK, Nair D, Mendiratta L, Butta H, Jain T S, Kapil A, Wattal C, Hans C, Mani R K, Sagar G, Jaggi N, Khilnani P, Mathur P, Jasuja S, Kansal S, Manchanda V, Nangia V, Sharma A, Khan F, Mehta G, Nataraj G, Kelkar R, Todi S, Baveja S, Balaji V, Gupta A, Arora A, Gupta A, Hasan A, Raman LA, Choudhry M, Haider M, Mani M, Rathor N, Aggarwal N, Barman P, Kaur R, Malhotra S, Malik SK, Kumar S, Chugh T D, Malhotra V L, Patwardhan V, Stephens A, Ligin R, Kumari S, Singh S. Preventing infection from indwelling intravascular devices: Hospital infection society India consensus group recommendations for Indian healthcare. J Patient Saf Infect Control [serial online] 2019 [cited 2023 Mar 30];7:31-47. Available from: https://www.jpsiconline.com/text.asp?2019/7/2/31/273731

Introduction

Bloodstream infections (BSIs) are an important cause of morbidity and mortality in a healthcare facility. It is essential to follow standardised, evidence-based policies and protocols so as to prevent BSIs associated with indwelling intravascular medical devices. To address this issue, the Hospital Infection Society-India (HISI) took up the initiative to build up consensus on 'Infection Prevention aspects of Indwelling Intravascular Medical Devices'. The HISI is an association of medical professionals with a special interest in the prevention and control of healthcare-associated infections and antimicrobial stewardship. It is registered with the Registrar of Societies at Delhi. Founded in 1991, the Society presently has >1000 members. A HISI Educational and Awareness Initiative 'Vichar Goshthi' and Consensus Building were organised under the aegis of HISI Delhi NCR Chapter Meet on Saturday 7^th July 2018 from 1:00 pm to 4:00 pm at the Auditorium, Indraprastha Apollo Hospitals, New Delhi.

Need for consensus

The aim of this academic exercise was to build consensus on various infection prevention aspects of indwelling intravascular medical devices. It was an interactive session wherein each of the audience members from different institutions participated as interactive faculty in decision-making under an umbrella of consensus panel. The proceedings were formed into building up consensus recommendations in the concluding session. The deliberations were based upon evidence and standardised definitions for central lines, central line-associated BSI (CLABSI), and catheter-related BSI (CR-BSI) [Annexure 1]. The final recommendations and grading are tabulated in [Table 1].

Table 1: Recommendations and grading

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Scope

This document is intended to include intravascular devices, namely peripheral venous catheter, non-tunnelled central venous catheter (CVC, most commonly used), peripherally inserted central catheter (PICC), tunnelled CVC (surgically implanted, ex-Hickman), pulmonary artery catheter, midline catheter, peripheral arterial catheter, pulmonary artery catheter or a totally implantable device. The types of intravascular devices have been defined in Annexure 2.^{[1],[2],[3],[4]}

Methodology

The Consensus Panel consisted of Moderators, Chair Faculty, Expert Panel, Interactive Faculty and Repertoire Team.

Consensus panel: Roles and responsibilities

Moderators included an 'Intensivist' and a 'Clinical Microbiologist and Hospital Infection Control Expert'. They did an exhaustive search of evidence-based literature on framing relevant questions to form the basis of deliberations and consensus building. The Moderators directed the questions to the Audience Faculty on what is currently being followed in their own institutions and why and what changes to Indian context should be implemented, with evidence-based contributions from the Expert panel faculty. They seeped the non-relevant portion and also re-directed or re-modelled the questions to other expert or faculty and coordinated between Interactive faculty, Expert panel and Chair faculty
Chair faculty included Intensivists, Paediatricians, Clinical Microbiologists and Infection Control personnel and representatives from Hospital Management. The role of Chair faculty was to formulate evidence-based consensus on the answers given by the Interactive faculty and the Expert panel to the questions directed by the Moderators
Expert panel consisted of Intensivists, Clinical Microbiologists, Paediatricians and Nephrologists from both public and private healthcare facilities. The role of Expert panel was to deliberate and give their comments on the questions directed by the Moderators. These comments were based on the evidence-based practical approach followed in their own institutes. The Expert panel also discussed the pros and cons of the currently available guidelines and their practical aspects at various levels of healthcare
Interactive Faculty consisted of the delegates from different specialities, mainly Microbiologists, clinicians from multiple disciplines such as Internal Medicine, Nephrology, Paediatrics and Critical care. Interactive faculty answered the questions directed by the Moderators and apprised the practical problems being faced in their institutes
Repertoire team consisted of Microbiologists in the role of 'Chief Repertoire and Editor for Consensus' and 'Repertoire and Editorial team'. The team members transcribed the entire proceedings between Moderators, Chair faculty, Expert faculty and Interactive faculty in verbatim and compared in real-time with available standard guidelines. Repertoire team then submitted the entire report to the Chair faculty for the final consensus building
Consensus Reviewers Panel comprised experts in the field of Critical Care, Intensive Care, Paediatric Critical Care, Microbiology, Infection Control Professional and Secretaries of HISI Chapters, who were entrusted with the task of reviewing the entire consensus proceedings together with the recommendations, categorisation and rationale leading to the consensus after the event.

Grades of recommendation^{[5],[6],[7],[8]}

Grade 1A: Strong recommendation, high-quality evidence
Grade 1B: Strong recommendation, moderate-quality evidence
Grade 1C: Strong recommendation, low-quality evidence
Grade 2A: Weak recommendation, high-quality evidence
Grade 2B: Weak recommendation, moderate-quality evidence
Grade 2C: Weak recommendation, low-quality evidence
Grade 3: Unresolved.

Consensus Building

Indications and contraindications for insertion of intravascular device

Indications for insertion of central line

Consensus

Indications for central line in an adult: There are diagnostic and therapeutic indications for central line insertion. Central lines are required for parenteral nutrition, monitoring central venous pressure in haemodynamically unstable patient, plasmapheresis, longer antibiotic therapy, chemotherapy and delivery of vasoactive agents.

Indications for central line in paediatrics and neonates: The indications in paediatrics or neonates are similar to that of adults, i.e., haemodynamically unstable patient, oncology medications, longer antibiotic therapy, total parenteral nutrition. In newborn, PICC is mostly preferred. For paediatric patients on anticipated long-term intravenous therapy, the peripheral line can be replaced with PICC before patient discharge.

Insertion of Peripherally inserted central catheter is indicated in case of long-term administration of therapeutics including chemotherapy.

Indications of permanent vascular access in haemodialysis patients: A fistula or graft is preferred instead of a CVC in patients with chronic renal failure. Arteriovenous fistula or an arteriovenous graft is preferred in this order.

Insertion of central line is contraindicated incase of blood clotting disorders such as coagulopathy, thrombocytopenia and vessel thrombosis.

Rationale ^{[6],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18]}

The indications for central line insertion may include:

Access for drugs: Infusion of irritant drugs (e.g. chemotherapy), total parenteral nutrition, poor peripheral access, long-term administration of drugs
Access for extracorporeal blood circuits: Renal replacement therapy, plasma exchange
Monitoring or interventions: Central venous pressure, central venous blood oxygen saturation, pulmonary artery pressure, temporary transvenous pacing, targeted temperature management, and repeated blood sampling
Caution to be taken considering risk and benefits into account in patients with coagulopathy, thrombocytopenia, ipsilateral haemothorax or pneumothorax, vessel thrombosis, stenosis, or disruption, infection overlying insertion site and ipsilateral indwelling central vascular devices.

Indications for insertion of peripheral venous catheters

Consensus

The indications for insertion of peripheral lines in adults and children are exactly the same. The Expert Panel brought to observation that many a times, before admission in the emergency, peripheral venous lines are inserted routinely without specific indications. Such lines should only be inserted for certain indications that include administration of intravenous medications in patients either where oral intake is not feasible, or where oral medications cannot be administered. Lines should not be inserted unnecessarily without clear indications. If placed during emergency, consideration should be given to remove/replace within 48 h.

Rationale^{[6],[11],[13],[14],[18],[19]}

Peripheral venous catheters are indicated where alternative routes are less effective, especially in cases where rapid nutritional support is required (e.g. severe dehydration) or intravenous medications are indicated because of increased bioavailability or in certain emergency conditions where rapid fluid resuscitation is required.

Insertion site

Central line access

Choice of insertion site for central line access in adults

Consensus: The choice of central line access is subject to variable factors such as tentative duration for the use of central venous access, type of CVC, type of patient (i.e. underlying clinical condition, difficult intravenous access) and expertise of the operator. For non-tunnelled CVC, subclavian site was agreed in consensus over jugular and femoral sites. The Consensus group however re-emphasised to weigh the risks and benefits in each case, especially in situations where the subclavian site is adjacent to tracheostomy site, any open wound site or in patients of pneumothorax, chronic obstructive pulmonary disease and asthma. In haemodialysis patients and patients with advanced kidney disease, internal jugular or femoral site should be considered for CVC insertion to avoid risk of subclavian vein stenosis. For permanent central venous catheterisation, subclavian site was considered as favourable by the consensus group. The choice of femoral site should be reserved for certain critical situations only for short term. Besides this, the use of ultrasound guidance for insertion of central line by trained personnel was emphasised upon.

Rationale^{[2],[10],[12],[20],[21],[22],[23],[24],[25],[26]}: The risk of central line-related BSIs varies with the site of insertion of CVCs which depends on the density of local skin flora and risk of thrombophlebitis.^[20]

In adults, subclavian site is optimum for central line access. Femoral site should be avoided in adult patients. Any catheter inserted into a jugular vein should be replaced with a subclavian at the earliest since the risk of infection increases with lengthening period.

A recent review by Marik et al. showed no difference in the CR-BSIs between access through the three sites – subclavian, internal jugula, and femoral.^[23] The right side of the patient is usually preferred since it, being in direct access to the superior vena cava/inferior vena cava, allows for a shorter and easier route.^[21]

Pratt et al. in their National Evidence-Based Guidelines concluded that internal jugular insertion sites, being more in proximity to oropharyngeal secretions and difficult to immobilise, may have a greater risk for infection.^[20] The choice of insertion should be based on the risk of complications during the insertion or maintenance of the catheter in addition to the risk of infection. Catheters should not be inserted through the site of burns or infection, as far as possible.^[21] The risk for mechanical complications should also be assessed. Mechanical complications such as subclavian vein stenosis are lesser with internal jugular than with subclavian vein insertion. Higher colonisation rates have been observed with femoral catheters as well as a higher risk of deep vein thrombosis than internal jugular or subclavian catheters. The consensus working group opined that majority of the studies still focus upon femoral site representing the highest risk of infection, followed by the jugular and the subclavian in this order. However, the subclavian site should be avoided in haemodialysis patients and patients with advanced kidney disease to avoid subclavian stenosis.^{[2],[10],[22],[25]} A study focused on central venous access in adults requiring acute renal replacement therapy, concluded that, in patients with higher BMI, if a subclavian approach is not available, the jugular site should be considered over the femoral site. Catheter-related morbidity is reduced in case of femoral catheterisation as compared to jugular catheterisation if carried out by a skilled operator with maximum sterile precautions and appropriate post-insertion site precautions in non-obese severely ill patients.^[21] Ultrasound guidance aids to reduce the number of attempts for cannulation and hence reduces the risk of catheter-related complications.^[2]

Choice of insertion site for central line access in paediatrics age group

Consensus: The choice of insertion site for CVC in children remains similar to adults, i.e. preference of subclavian site followed by internal jugular and femoral site in this order. In children, the brachial site should not be used.

Rationale^{[2],[3],[10],[12],[27],[28],[29],[30],[31],[32]}: There is a scarcity of literature regarding the optimum site of central line insertion in paediatric age group. Added to this is the challenge faced in choosing the best vascular access option in paediatric patients on haemodialysis.^[32] In contrast to studies in adults where subclavian catheters are known to have lesser infection rate, this is not proven in children.^[27] Our Consensus panel evaluated various paediatrics studies in which the infection rate in non-femoral catheters was similar to that of femoral catheters. Majority of the guidelines of this age group do not prioritise the site of the upper or lower extremities or the scalp (in neonates or young infants) as insertion sites. Trieschmann et al. observed that for the paediatrics age group, the advantage of subclavian access CVCs lies in ease of access and use, good fixation and minor infection rate at least in older children.^[27] However, in infants and children undergoing cardiac surgeries, access via the femoral vein is the preferred site as it is more easily accessible and has lower insertion-related complication rates.^[28]

Peripheral venous access

Choice of insertion site for peripheral venous access in adults and paediatrics

Consensus: For adults, there was consensus on the use of an upper extremity site, preferably dorsum of the hand. The lower limb should not be used as peripheral venous access site in adults; if at all used, it should be replaced to an upper extremity site at the earliest. For children, peripheral catheter insertion can be done in the upper extremity or lower extremity, or in case of neonates and young infants, through the scalp. External jugular vein and femoral vein can also be accessed as the last choice in children.

Rationale ^{[2],[6],[13],[28],[31]}: In adults, upper extremity site is used for catheter insertion. In case a catheter is inserted in lower extremity, it should be replaced to an upper extremity site as soon as possible.

In paediatric patients, the hand, the dorsum of foot or the scalp (in neonates or young infants) can be used as the catheter insertion site.^[33]

Antisepsis for central or peripheral catheters

Hand hygiene

Consensus

Hand hygiene, comprising hand-washing and/or hand rub, is essential before insertion as well as during handling of all catheters. Before central line insertion, hand-washing with soap and water followed by alcohol-based hand rub is mandatory.

In case of peripheral line, either alcohol-based hand rub or hand-wash with soap and water is to be carried out before insertion.

Hand hygiene, comprising either alcohol-based hand rub or hand-wash with soap and water, is to be followed strictly at all times during handling of central lines or peripheral lines. The technique of hand-washing or hand rub should be carried out in the proper manner.^[34]

Rationale ^{[2],[4],[20],[24],[34],[35],[36],[37]}

Aseptic techniques should be followed for the insertion and care of intravascular catheters. Hand hygiene with conventional soap and water or with alcohol-based hand rub should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic unless aseptic technique is maintained. Guidelines for NHS Hospitals advocate hand hygiene either by use of an alcohol hand rub or washing with an antimicrobial liquid soap and water is necessary before accessing or dressing a central venous access device.^[20] Hand-washing with liquid soap and water should be carried out if hands are visibly dirty or soiled with blood or other body fluids or excretions.^[20],[34]

Use of gloves (clean gloves or sterile gloves)

Consensus

Sterile gloves should be worn for the insertion of all types of central lines. Fresh pair of sterile gloves should be used during handling of central catheters and also when guide wire exchanges are performed. Sterile gloves should also be used while changing the dressing on intravascular catheters.

Sterile gloves are desirable for the insertion of peripheral line. However, in case of resource constraint settings, disposable clean gloves instead can be used for the insertion of peripheral intravascular catheters.

Rationale ^{[2],[20],[24],[38]}

For the insertion of peripheral intravascular catheters, clean gloves rather than sterile gloves should be worn if the access site is not touched after the application of skin antiseptics. Sterile gloves should be worn for the insertion of arterial, central and midline catheters. New sterile gloves should be used before handling the new catheter when guidewire exchanges are performed. Either clean or sterile gloves can be worn when changing the dressing on intravascular catheters. The NHS guidelines emphasise upon proper hand hygiene and that either sterile or clean gloves may be used during line manipulations or when changing the dressings, or intravenous drug administration.^[20]

Other antiseptic and other requirements for insertion

Consensus

Sterile barrier precautions including cap, mask, sterile gown, sterile gloves and a full-body sterile drape should be used. For ready compliance, a checklist should be advocated. There was no recommendation upon routine use of sutureless securement device. Chlorhexidine bath should be given to Coronary Artery Bypass Graft (CABG) and special group of patients before insertion of central lines.

Rationale^{[2],[10],[12],[20],[21],[22],[23],[24],[25],[29],[39],[40]}

Maximal sterile barrier precautions should be used for the insertion of CVCs, PICCs or guidewire exchange. Aseptic techniques (e.g. hand washing) and maximal barrier precautions (e.g. sterile gowns, sterile gloves, caps, masks covering both mouth and nose and full-body patient drapes) should be used while inserting CVCs.^[29] A sterile sleeve should be used to protect pulmonary artery catheters during insertion.

Antiseptic agents

Antiseptic agents before central catheter insertion in adults

Consensus: Clean skin should be disinfected with >0.5% chlorhexidine (up to 2% chlorhexidine w/v) preparation in 70% alcohol before CVC insertion and during dressing changes. In case of patient is allergic to chlorhexidine, alternatively tincture of iodine, an iodophor or 70% alcohol can be used.

Rationale^{[2],[10],[12],[20],[21],[22],[23],[24],[25],[29],[40]}: Recent Cochrane studies have reviewed various medical databases to analyse different antisepsis regimens and compared them to studies where no antiseptic agent was used. The results, though not conclusive about reduction of CR-BSI with antisepsis as compared to without antisepsis, emphasised that the use of chlorhexidine solution may reduce rates of CRBSI and catheter colonisation as compared to cleaning with povidone-iodine. However, this study also stated that these results were based on very low-quality evidence. Maiwald et al. highlighted that little evidence exists supporting the use of chlorhexidine alone as an antiseptic.^[41] Very few evidence based-studies have shown significant comparative results between using chlorhexidine preparations with alcohol and povidone-iodine in alcohol to prepare the skin before central line insertion.^[2]

The Consensus Working Group stated that Centers for Disease Control and Prevention (2011) recommends skin cleansing with >0.5% chlorhexidine preparation with alcohol before CVC insertion. If there is a contraindication to chlorhexidine, 70% alcohol, tincture of iodine or iodophor can be used as alternatives. Before placing the catheter, antiseptics should be allowed to dry according to the manufacturer's recommendation.

Antiseptic agents before central catheter insertion in paediatrics

Consensus: Tincture of iodine, an iodophor or 70% alcohol should be used before central line insertion in paediatrics age group.

Rationale ^{[2],[6],[10],[25],[31],[41],[42]}: In paediatric patients, an antiseptic solution like chlorhexidine alcohol is used for disinfecting the skin before central catheter insertion.

Antiseptic agents before central catheter insertion in neonates

Consensus: 70% alcohol or an iodophor should be used for antiseptic skin preparation before central line insertion.

In neonates, chlorhexidine should not be used.

Rationale ^{[2],[6],[25],[31],[34],[41],[42],[43],[44]}: The topical antiseptic agents commonly used in neonates are chlorhexidine, alcohol and iodine. The common advantage with the above antiseptics is their broad-spectrum antimicrobial activity. Other than this, chlorhexidine has a residual activity but may cause local dermatitis and neurotoxicity while alcohols are not active in the presence of organic matter and have no residual activity. Iodine can cause skin irritation, with the limitation of causing hypothyroidism with systemic absorption.

Ciccia et al. evaluated the effects of 0.05% sodium hypochlorite for skin antisepsis before CVC placement in neonates and found no signs of skin toxicity in any infant.^[41] No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months.

Tincture of iodine in neonates is not preferred due to adverse effect on thyroid; however, povidone-iodine may be used.^[42]

Antiseptic agents before peripheral catheter insertion in adults

Consensus: 70% isopropyl alcohol should be used for disinfection of skin before peripheral venous catheter insertion. Other alternatives that may be used in adults are tincture of iodine, or alcoholic chlorhexidine gluconate solution, if not contraindicated.

Rationale^{[2],[24],[25],[38],[45]}: Before peripheral line insertion, skin should be disinfected with 70% isopropyl alcohol or alcoholic chlorhexidine gluconate.^[2],[45]

Antiseptic agents before peripheral catheter insertion in paediatrics

Consensus: Before peripheral catheter insertion, 70% isopropyl alcohol should be used. Tincture of iodine or an iodophor can be used alternatively before insertion of peripheral catheter in paediatrics age group

Rationale^[25],[31]: Guidelines and recommendations from published literature in peer-recognised journals are not very forthcoming about the use of chlorhexidine in children. The Society for Pediatric Anesthesia members supports its use in children aged 2–16 years.^[29] The skin may be disinfected with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion.

Antiseptic agents before peripheral catheter insertion in neonates

Consensus: Before peripheral catheter insertion, 70% isopropyl alcohol should be used. An iodophor may be used before insertion. In neonates, chlorhexidine should not be used.

Rationale^{[25],[29],[31]}: The available literature is insufficient to evaluate the safety of antiseptic solutions containing chlorhexidine in neonates and infants. Guidelines do not recommend the use of chlorhexidine-containing solutions for skin preparation in neonates (younger than 44 gestational weeks).^[29]

Dressings

Type of dressing to cover central venous catheter site in adults

Consensus

Sterile, transparent, semipermeable dressing should be used in all type of set-ups, i.e., both private and public. If the patient is diaphoretic or if the site is bleeding or oozing, a sterile gauze dressing should be used until this is resolved. Gauze should be changed in 48 h; however, transparent dressing should be replaced in 7 days until the insertion site has healed. If the dressing becomes damp, loosened or visibly soiled, then it should be replaced. In adults, daily chlorhexidine bathing rather than chlorhexidine dressings can be used. However, in case of high CRBSI rates, chlorhexidine dressings can be used.

Rationale^{[2],[12],[29],[46],[47],[48],[49],[50]}

Dressings to cover the catheter site may be either sterile gauze or sterile, transparent, semipermeable dressing. A gauze dressing is used until the site is bleeding or oozing. If the dressing becomes damp, loosened or visibly soiled, the dressing should be replaced. The evidence results to support use of chlorhexidine dressings in adults are not very conclusive as some studies show reduction in rates of bacterial colonisation and the number of CRBSIs compared with standard dressings in patients with venous or arterial catheters, and some show no difference between chlorhexidine dressings and standard care.^[46] In a Cochrane review, however, chlorhexidine-impregnated dressings were seen to reduce the incidence of catheter tip colonisation.^[47]

Topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, are not to be used as these may promote antimicrobial resistance and fungal infections. The catheter site should not be submerged in water. Dressings are replaced every 2 days for gauze dressings and at least every 7 days for transparent dressings. Replace transparent dressings used on tunnelled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed.

Type of dressing to cover central venous catheter site in paediatrics

Consensus

For paediatrics age group, chlorhexidine-impregnated dressings should not be used routinely. Adherence to antiseptic precautions is essential at all times.

Gauze dressings, if used, are replaced every 2 days and transparent dressings every 7 days. However, especially in paediatric patients where there may be a risk of displacement of the catheter, the benefit–risk ratio may need to be weighed on an individual basis.

Rationale ^{[2],[12],[29],[47],[48],[49],[50]}

Chlorhexidine-impregnated sponge dressings may be used in patients older than 2 months of age if the CLABSI rate is not decreasing despite adherence to appropriate preventive measures.^[2]

There are insufficient data, especially in children, regarding the impact of frequency of dressing upon CRBSI. In a Cochrane review, the authors concluded that increased number of high-quality studies shall be required for clear recommendations and that till then decisions may be weighed on a case-to-case basis. Central catheter sites should be inspected visually daily to ensure no localised signs of infection. Dressings should be replaced when clinically indicated and definitely if the dressing is soiled or not intact.^[50]

Type of dressing to cover central venous catheter site in neonates

Consensus

For neonates, chlorhexidine-impregnated dressings are not recommended for CVCs, due to risk of serious adverse skin reactions, especially in premature neonates.

Rationale^{[2],[12],[29],[44],[47],[48],[50],[51]}

In a Cochrane review focusing upon antimicrobial dressings in newborn infants, the authors concluded that after meta-analysis of various studies, there was no clear benefit of such dressings in newborn infants and that more studies were required for clear consensus favouring their use.

Recent literature implies that chlorhexidine-impregnated dressings should not be permitted in neonates, as the majority of reactions, especially local contact dermatitis, occurred in neonates up to 28 weeks gestational age and up to 1000 g in weight.^[51]

Type of dressing to cover peripheral venous catheter site in adults ^{[4],[38],[52]}

Consensus

Transparent dressings are to be used for peripheral venous catheter sites in adults.

Dressings should be changed when clinically indicated and immediately if soiled or damaged. If still intact, changing a dressing may contribute to introducing contamination.

Type of dressing to cover peripheral venous catheter site in paediatrics ^{[4],[38],[52]}

Consensus

Transparent film dressings should be used for peripheral venous catheter sites in paediatrics. The Panel was of the consensus that similar recommendations, as adults, be followed for dressings upon peripheral catheter sites since there was lack of high-quality evidence-based studies individualised for paediatrics.

Type of dressing to cover peripheral venous catheter site in neonates ^{[4],[38],[52]}

Consensus

Transparent film dressings should be used for peripheral venous catheter sites in neonates. The Panel was of the consensus that similar recommendations, as adults, be followed for dressings upon peripheral catheter sites since there was lack of high-quality, evidence-based studies individualised for neonates.

Rationale ^[53],[54]

Transparent films are preferred as this allows visual inspection of the site of insertion. Furthermore, it requires to be changed less frequently than gauze and tape. Gauze, if being used, should be sterile. Tape rolls should also be used with caution as rolls opened since some time, maybe a hub for bacteria. Moreover, gauze not being a waterproof barrier has the propensity to get contaminated over time and shall require to be changed more often.

Accessories

Consensus

Needleless connectors should be used. Needleless connectors should be changed as per the manufacturers' recommendations. These should be changed at least as frequently as the administration set and no more frequently than every 72 h.

To ensure antisepsis before accessing catheter hubs, needleless connectors or injection ports, alcoholic chlorhexidine, 70% isopropyl alcohol or povidone-iodine should be applied vigorously with mechanical friction for 5–15 s and allow it to dry for 30 s before use. However, alcoholic chlorhexidine may have additional residual activity compared with alcohol.

Antisepsis should be ensured at all times irrespective of the type of needleless connectors (split septum/mechanical valve) is used.

For compliance of the antisepsis protocol, an institute should make its own guidelines, and then training and re-inforcement of the training with audits are absolutely necessary.

Rationale ^{[2],[10],[55],[56],[57],[58],[59]}

Needleless system should be used to access intravenous tubing. The needleless components should be changed at least as frequently as the administration set; however, changing more frequently than every 72 h has not been seen to have proven benefit.

The port should be accessed only with sterile device after proper scrubbing of the hub with an appropriate antiseptic (chlorhexidine, povidone-iodine, an iodophor or 70% alcohol). Some guidelines prefer the use of a split septum valve over some mechanical valves due to increased risk of infection with the mechanical valves.

Antimicrobials

Consensus

Systemic antimicrobial prophylaxis should not be used routinely before insertion or use of an intravascular catheter. Anticoagulant therapy should not be routinely used to reduce the risk of catheter-related infection in general patient populations.

Antibiotic locks should not be used routinely because of the risk of emergence of resistance in exposed organisms. The use of antibiotic locks should be judicious and restricted in case of patients with history of recurrent BSIs attributable to central lines or long-term haemodialysis catheters, patients with limited venous access, or those with at risk of unfavourable outcomes from CLABSI, e.g. patients with prosthetic heart valve or aortic graft or recently implanted intravascular devices. To minimise the systemic toxicity, antimicrobial in antimicrobial lock should be aspirated rather than flushed after the dwell time has elapsed.

Topical antibiotic ointment or creams should not be used on insertion sites, except for dialysis patients. In haemodialysis patients, povidone-iodine antiseptic ointment or bacitracin/gramicidin/polymyxin B ointment at the haemodialysis catheter exits site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the haemodialysis catheter as per the manufacturer's recommendation. However, the utility of using mupirocin was not appreciated by the consensus group.

Rationale ^{[2],[3],[4],[10],[12],[25]}

Current literature does not support the use of systemic antimicrobials as prophylaxis to prevent catheter colonisation or infection before insertion or during use of the central line. Anticoagulant therapy is not routinely indicated in general patient populations to reduce the risk of central line-related infections. Antimicrobial lock solutions should only be used in patients on long-term central lines or with history of repeated BSIs in spite of adherence to aseptic technique. For patients on dialysis, povidone-iodine or antiseptic ointment or bacitracin/gramicidin/polymyxin B ointment can be used at the haemodialysis catheter exit site if this ointment does not interact with the material of the haemodialysis catheter as per the manufacturer's recommendation

Antimicrobial containing devices

Consensus

Antimicrobial containing devices should not be used routinely. These should only be reserved for use in healthcare facilities where the CLABSI trend is increasing despite compliance with the preventive strategies or catheter needs to be placed for extended period.

Rationale ^{[20],[25],[29],[60],[61]}

Some CVCs are coated or impregnated with antiseptic or antimicrobial agents, e.g., chlorhexidine/silver sulfadiazine, minocycline/rifampin, platinum/silver and ionic silver in subcutaneous collagen cuffs attached to the access device.

Antimicrobial-containing catheters may be considered if CLABSI rates are not decreasing in spite of maximum sterile barrier precautions, strict antisepsis during insertion and maintenance and continuous education, and the catheter is expected for prolonged duration, that is, >5 days.^[20],[60] The Infectious Diseases Society of America recommends such catheters for prevention of CBSI when in situ long-term catheterisation is expected (≥5 days) and the risk of CRBSI exceeds 3.3 per 1000 despite bundled precautions.^[61] These catheters may also be considered in patients at higher risk, that is immunocompromised patients or patients with disorders of skin barrier, or access near to tracheostomy or femoral access or in patients with recently implanted intravascular devices, such as prosthetic valve or aortic graft in whom BSI shall have serious implications.^[8],[29] Although a Cochrane Systematic Review and Network Meta-Analysis suggests that the minocycline-rifampicin–impregnated CVC appears to be more effective than chlorhexidine-silver sulfadiazine, current data are lacking toward the emergence of multidrug-resistant organisms toward minocycline and rifampicin following their use.^[61]

While using antimicrobial-containing devices, monitoring of patients for untoward effects such as anaphylaxis is needed.

Weaning off (replacement and removal of intravascular catheters)

Replacement protocol for central line catheters in adults

Consensus

There is no defined timeline for replacement of central lines. However, we need to remove them at the earliest. In case fever develops, non-infectious cause of the fever and any other focus of infection should be ruled out. If patient is haemodynamically stable, then blood culture should be sent to exclude CLABSI; however, if the patient is haemodynamically unstable, then the decision to replace central line is weighed on the risk and benefit ratio. CVCs or PICCs should not be removed on the basis of fever alone. If the patient fits into the definition of CLABSI or if the patient is immunosuppressed and cause of fever cannot be ascertained then CVCs or PICCs may be removed at the earliest. For ensuring timely removal of central line, it would be a good practice for the nursing staff to 'remind' the treating team during daily rounds.

Rationale ^{[2],[11],[25],[62],[63]}

Routine replacement of CVCs, PICCs, haemodialysis catheters or pulmonary catheter is not required. Presence of fever should not be the sole criteria to remove CVCs or PICCs; clinical judgment should be used regarding removal of the catheter if infection is evidenced elsewhere or non-infectious cause of fever is suspected.^[62]

Replacement protocol for central line catheters in pediatrics and Neonates

Consensus

Similar to the practices for adults, the central lines for paediatrics should be removed as soon as possible. If there are any signs of CR-BSIs, vascular insufficiency in the lower extremities or thrombosis, then umbilical artery catheters should be removed, not replaced. However, the consensus group did not support the timeline to replace umbilical catheters in neonates.

Rationale^[2],[29]

Umbilical artery catheters should not be left in place for >5 days and umbilical venous catheters can be used up to 14 days if managed aseptically.^[2]

Peripheral venous catheters in adults

Consensus

In adults, peripheral catheters may be kept for 96 h or longer. However, in case of any clinical indication for removal or if the patient develops signs of phlebitis, the peripheral venous catheter should be removed.

Rationale ^{[2],[11],[25],[38],[63]}

Peripheral catheters, for adults, should not be replaced earlier than 72–96 h to reduce risk of infection and phlebitis.^[11]

Peripheral venous catheters in paediatrics

Consensus

In children, peripheral catheters should be removed only when clinically indicated.

Rationale^{[2],[11],[63]}

Peripheral catheters, in children, are not replaced on a routine schedule.

Domiciliary care

Consensus

Domiciliary instructions about hand hygiene and care of central lines, especially the PICC, should be included in the patient–family–education. Patients who are being discharged on PICC line or on femoral catheter, a small instruction booklet in simple language should be given to patient at the time of discharge for home. A list of complication and time of next visit should also be mentioned. For care of PICC line, flushing with saline or heparin is required. If patient is discharged on femoral line, local hygiene, minimum mobility is required along with keeping the area dry. Routine diagnostic testing is not required for patient who is being discharged on PICC line or femoral catheter. Patients need to follow the instructions given in the booklet.

Rationale ^{[12],[47],[64]}

Effective domiciliary care is essential to reduce the overall rate of infectious complications of central lines, especially PICC lines. This includes the making available proper patients' education and a specific caregivers' training, along with close monitoring by trained nurses at home.^[64]

Surveillance and metrics including diagnostics

Consensus

The outcome of infection prevention aspects of indwelling intravascular medical devices can be measured through CLABSI/CR-BSI monitoring.

Surveillance protocols for CLABSI/CR-BSI monitoring: Samples for blood cultures should be collected aseptically simultaneously through a central catheter and a peripheral site, i.e., paired samples. In case differential time to positivity CVC culture versus peripheral blood culture positivity is >2 h, the central line may be implicated as the source. The remaining components of surveillance criteria for CR-BSI were deliberated upon. It was suggested that the cutoff of >15 colony-forming units (CFU)/catheter segment is not a practical approach. In neonates, if paired blood culture is not feasible, sample from single site may be collected after taking strict aseptic precautions. Samples for blood culture should preferably be collected before initiation of antimicrobial therapy. Although the terms CR-BSI and CLABSI may be used interchangeably, all the institutions and healthcare facilities represented were following the National Healthcare Safety Network criteria for surveillance of CLABSI, mainly so because the definition of CR-BSI requires cumbersome microbiological methods.

Other than measuring the CLABSI/CR-BSI, it is a good practice to compute certain metrics such as measuring different components of the prevention 'bundle' for CLABSI. Various metrics that may be used include aseptic practices during insertion, hand hygiene compliance. Frequent audits should be conducted by infection control team for cross-checking the compliance and immediate training and correction on-site. However, factors such as inadequate infrastructure, lack of awareness, insufficient workforce pose challenges in health care facilities at different levels.

Rationale ^{[2],[3],[10],[12],[55],[65],[66],[67],[68],[70],[71]}

CRBSI definition requires more resources and rigorous approach than criteria for the CLABSI definition. CRBSI criteria require one of the following:

Patient with a CVC and at least one positive Perpheral vein blood culture obtained and the differential time period of CVC culture versus peripheral culture positivity of more than 2 hours and/or simultaneous quantitative blood culture from CVC and peripheral vein show >5:1 ratio (CVC versus peripheral).
Patient with a CVC and at least one positive blood culture obtained from a peripheral vein and a positive semi quantitative (>15 CFU) culture of a catheter segment or Quantitative >10³ CFU of a catheter segment whereby the same organism is isolated from catheter segment and peripheral blood.^[3]

A CLABSI is a primary (i.e. no apparent infection at another site) BSI in a patient that had a central line within the 48-h period before the development of the BSI. The culture of the catheter tip is not a criterion for CLABSI.

Some of the metrics include adherence to all elements of the CVC Insertion Checklist, appropriate hand hygiene, maximal sterile barrier precautions, chlorhexidine skin antisepsis), daily assessment of the need for continuing CVC access and cleaning of catheter hubs and injection ports before they are accessed.^{[55],[65],[66]} Observing adherence to hand hygiene guidelines include deciding when and how frequently to observe healthcare workers conducting hand hygiene, deciding where to measure depends on the reason for measurement.^[67]

Training and education

Consensus

Training and education programmes should mandatorily form a component in every healthcare unit. Besides maintaining an adequate nurse to patient ratio of at least 1:2 in intensive care units along with adequate doctors, it is essential that they are well informed and adequately trained and competent in their practices. The training module should include preventive bundles related to central line insertion and maintenance. Practical education on diagnostics, i.e., aseptic blood sample collection, is necessary. Awareness and education on surveillance practices are essential. Frequent audits and on-site corrective measures should form part of quality control programme. The targeted audience shall include all healthcare workers, including house-keeping and paramedical staff, as also attendants and visitors.

Rationale ^{[2],[3],[4],[10],[12],[72],[73]}

Trained personnel with adequate competency should be designated for care of patients on central lines.^[2] Studies have demonstrated an increased incidence of device-related infections where there is inadequate nursing–patient ratio. Different training methods can include slide presentations and videos or journal clubs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Annexures

Annexure 1

Definitions

An antimicrobial is generally an agent that kills or stops the growth of bacteria, fungi, viruses or parasites. There are two major types of antimicrobial: antiseptic and antibiotic. Antiseptics, such as hand washes or surgical scrubs, destroy a range of micro-organisms on a surface or in living tissues, whereas antibiotics are administered in relatively small amounts with the aim of selective targeting of micro-organisms, especially bacteria
Central line: An intravascular catheter that terminates at, close to the heart, or in one of the great vessels that is used for infusion, withdrawal of blood, or hemodynamic monitoring. The great vessels include the aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocephalic veins, internal jugular veins, subclavian veins, external iliac veins, common iliac veins, femoral veins and, in neonates, the umbilical artery/vein.
Central line-associated bloodstream infection (BSI): Primary BSI in a patient that had a central line within the 48-h period before the development of BSI and is not bloodstream related to an infection at another site.
Catheter-related BSI: It is defined as clinical manifestations and at least one positive blood culture from a peripheral vein and no other apparent source, with either positive semiquantitative (>15 colony-forming units [CFU]/catheter segment) or quantitative (10³ CFU/catheter segment) culture, whereby the same organism (species and antibiogram) is isolated from the catheter segment and a peripheral blood sample; simultaneous quantitative cultures of blood samples with a ratio of 3:1 (central venous catheter [CVC] vs. peripheral); differential period of CVC culture versus peripheral blood culture positivity of 2 h; or isolation of the same organism from semiquantitative or quantitative culture segment and from blood (preferably from a peripheral vein) of a patient with accompanying symptoms of BSI and no other apparent source of infection
Catheter dressing refers to a protective material applied to the site of catheter insertion with the major aim of securing the CVC in place and includes, for instance, gauze with tape or transparent dressing

Annexure 2

Types of Intravascular Access Devices

Permanent central line: It includes tunnelled catheters, including tunnelled dialysis catheters or implanted catheters (including ports)
Temporary central line: It includes non-tunnelled or non-implanted catheter
Umbilical catheter: A vascular catheter inserted through the umbilical artery or vein in a neonate. All umbilical catheters are central lines
Non-tunnelled central venous catheter (CVC) is a single-, dual-, or triple-lumen catheter that is placed either in the internal jugular or subclavian vein with the distal tip lying in the superior vena cava
Tunnelled CVC is placed when the patient needs the device for long-term therapy. It is surgically inserted and literally tunnelled under the skin in a subcutaneous pocket
Peripherally inserted central catheter: A catheter which is inserted in a large peripheral vein such as cephalic or basilic vein and then advanced until the tip rests in the distal superior vena cava or cavoatrial junction
Peripheral venous catheter: A catheter inserted in the peripheral veins, usually of forearm or hand
Peripheral arterial catheter: A catheter usually inserted in radial artery and can also be placed in femoral, axillary, brachial, posterior tibial arteries.

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