b-2011 guidelines for the prevention of intravascular catheter-related infections-cdc

1、Guidelines for the Prevention ofIntravascular Catheter-RelatedInfections, 2011Naomi P. OGrady, M.D.1, Mary Alexander, R.N.2, Lillian A. Burns, M.T., M.P.H., C.I.C.3, E. Patchen Dellinger, M.D.4, Jeffery Garland, M.D., S.M.5, Stephen O. Heard, M.D.6, PamelaA. Lipsett, M.D.7, Henry Masur, M.D.1, Leona

2、rd A. Mermel, D.O., Sc.M.8, Michele L. Pearson, M.D.9, Issam I. Raad, M.D.10, Adrienne Randolph, M.D., M.Sc.11, Mark E. Rupp, M.D.12, Sanjay Saint, M.D., M.P.H.13 and the Healthcare Infection Control Practices Advisory Committee (HICPAC)14.1National Institutes of Health, Bethesda, Maryland2Infusion

3、Nurses Society, Norwood, Massachusetts 3Greenich Hospital, Greenwich, Connecticut 4University of Washington, Seattle, Washington5Wheaton Franciscan Healthcare-St. Joseph, Milwaukee,Wisconsin6 University of Massachusetts Medical School, Worcester, Massachusetts 7Johns Hopkins University School of Med

4、icine, Baltimore, Maryland8Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island 9Office of Infectious Diseases, CDC, Atlanta, Georgia10MD Anderson Cancer Center, Houston, Texas 11The Childrens Hospital, Boston, Massachusetts12University of Nebraska Med

5、ical Center, Omaha, Nebraska13Ann Arbor VA Medical Center and University of Michigan, Ann Arbor, MichiganGuidelines for the Prevention of Intravascular Catheter-Related Infections14 Healthcare Infection Control Practices AdvisoryCommitteeCHAIRMANBRENNAN, Patrick J., MD Chief Medical OfficerDivision

6、of Infectious DiseasesUniversity of Pennsylvania Health SystemEXECUTIVE SECRETARYBELL, Michael R., MD Deputy DirectorDivision of Healthcare Quality Promotion Centers for Disease Control and PreventionMEMBERSHIPBRATZLER, Dale, DO, MPHPresident and CEOOklahoma Foundation for Medical QualityOSTROFF, St

7、ephen, MDDirector, Bureau of Epidemiology Pennsylvania Department of HealthBURNS, Lillian A., MT, MPHInfection Control Coordinator Greenwich Hospital, Infectious Diseases DepartmentOLMSTED, Russell N., MPH, CICEpidemiologistInfection Control ServicesSt. Joseph Mercy Health SystemELWARD, Alexis, MDAs

8、sistant Professor, Pediatrics Infectious DiseasesWashington University School of Medicine Department of PediatricsDivision of Infectious DiseasesPEGUES, David Alexander, MDProfessor of Medicine, Hospital Epidemiologist David Geffen School of Medicine atUCLAPRONOVOST, Peter J., MD, PhD, FCCMDirector,

9、 Johns Hopkins Quality and Safety Research GroupJohns Hopkins Quality and Safety Research GroupHUANG, Susan, MD, MPHAssistant ProfessorMedical Director, Epidemiology and Infection PreventionDivision of Infectious Diseases UC Irvine School of MedicineSOULE, Barbara M., RN, MPA, CICPractice LeaderInfe

10、ction Prevention and Control Services Joint Commission Resources/Joint Commission InternationalLUNDSTROM, Tammy, MD, JDChief Medical Officer Providence HospitalSCHECTER, William, P., MDProfessor of Surgery Department of SurgerySan Francisco General HospitalMCCARTER, Yvette S., PhDDirector, Clinical

11、Microbiology LaboratoryDepartment of Pathology University of Florida Health ScienceCenterMURPHY, Denise M. RN, MPH, CICVice President, Quality and Patient Safety Main Line Health SystemGuidelines for the Prevention of Intravascular Catheter-Related InfectionsEX-OFFICIO MEMBERSAgency for Healthcare R

12、esearch and Quality (AHRQ) BAINE, William B., MDSenior Medical AdvisorCenter for Outcomes and EvidenceNational Institute of Health (NIH)HENDERSON, David, MDDeputy Director for Clinical CareAssociate Director for Hospital Epidemiology and Quality ImprovementNIH Clinical CenterCenter for Medicare & Me

13、dicaid Services (CMS)MILLER, Jeannie, RN, MPHDeputy Director, Clinical Standards GroupDepartment of Veterans Affairs (VA)ROSELLE, Gary A., MDNational Program Director, Infectious Diseases VA Central OfficeCincinnati VA Medical CenterFood and Drug Administration (FDA)MURPHEY, Sheila A., MDDivision of

14、 Anesthesiology, General Hospital Infection Control Dental DevicesCenter for Devices and Radiology HealthLIAISONSAdvisory Council for the Elimination of Tuberculosis (ACET)STRICOF, Rachel L., MPHConsumers UnionMCGIFFERT, LisaSenior Policy Analyst on Health IssuesProject Director Stop Hospital Infect

15、ions OrganizationAmerican College of Occupational and EnvironmentalMedicineRUSSI, Mark, MD, MPHProfessor of MedicineYale University School of Medicine Director, Occupational HealthYale-New Haven HospitalInfectious Disease Society of America (IDSA)HUSKINS, W. Charles MD, MScDivision of Pediatric Infe

16、ctious Diseases Assistant Professor of PediatricsMayo ClinicAmerican Health Care Assn (AHCA)FITZLER, Sandra L., RNSenior Director of Clinical ServicesPublic Health Agency of CanadaPATON, Shirley, RN, MNSenior Advisor Healthcare Acquired InfectionsCenter for Communicable Diseases and Infection Contro

17、lAmerican Hospital Association (AHA)SCHULMAN, Roslyne, MHA, MBADirector, Policy DevelopmentSociety for Healthcare Epidemiology of America (SHEA)MARAGAKIS, Lisa, MDAssistant Professor of Medicine John Hopkins Medical InstitutionsAssociation of Professionals of InfectionControl and Epidemiology, Inc.

18、(APIC) DeBAUN, Barbara, MSN, RN, CICSociety of Hospital MedicineSAINT, Sanjay, MD, MPHDirector, Ann Arbor VA Medical Center/University of Michigan Patient Safety Enhancement ProgramAssociation of periOperative RegisteredNursed (AORN)BLANCHARD, Joan C., RN, BSNThe Joint CommissionWISE, Robert A., MD

19、Vice PresidentDivision of Standards & Survey MethodsCouncil of State and Territorial Epidemiologists (CSTE)KAINER, Marion MD, MPHDirector, Hospital Infections and Antimicrobial Resistance ProgramTennessee Department HealthUse of trade names and commercial sources is for identification only and does

20、not implyendorsement by the U.S. Department of Health and Human Services.Guidelines for the Prevention of Intravascular Catheter-Related InfectionsAcknowledgmentsWe wish to acknowledge Ingi Lee, MD, MSCE and Craig A. Umscheid, MD, MSCE fromCenter for Evidence-based Practice, University of Pennsylvan

21、ia Health System Philadelphia, PA who performed a systematic review for issues raised the during the guideline process.Disclosure of potential conflicts of interests. N.P.O.G. served as a board member forthe ABIM Subspecialty Board for Critical Care Medicine. M.A. is an employee of the Infusion Nurs

22、es Society, Honoraria from 3M, Becton Dickinson, Smiths Medical. L.A.B. is a consultant for Institute of Healthcare Improvement, Board membership for Theradoc, Medline. Honoraria from APIC, Clorox. E.P.D. consulting from Merck, Baxter, Ortho-McNeil, Targanta, Schering- Plough, Optimer, Cadence, Card

23、inal, BDGeneOhm, WebEx, Cerebrio, and Tyco. Grant support through the NIH. Payment for lecture from Merck. Payment for development of educationalpresentation from Medscape. Travel and meeting expenses paid for by ASHP, IDSA, ASM,American College of Surgeons, NQF, SHEA/CDC, HHS, Trauma Shock Inflamma

24、tion and SepsisMeeting (Munich), University of Minnesota. J.G. Honoria from Ethicon. S.O.H. provides researchsupport from Angiotech; Honoraria from Angiotech, Merck. L.A.M provides research supportfrom Astellas, Theravance, Pfizer; Consulting for Ash Access, Cadence, CorMedix, CatheterConnections, C

25、arefusion, Sage, Bard, Teleflex; Payment for manuscript preparation fromCatheter Connections. I.I.R. provides research support from Cubist, Enzon, and Basilea;Consulting for Clorox; Stock Equity or Options in Great Lakes Pharmaceuticalsand Inventive Protocol; Speakers Bureau for Cook, Inc.; Royalty

26、income (patents owned by MD Anderson on which Dr. Raad in an inventor: American Medical Systems, Cook, Inc., Cook urological,Teleflex, TyRx, Medtronic, Biomet, Great Lakes Pharmaceuticals. A.R. consulting income from Eisai Pharmaceuticals, Discovery Laboratories. M.E.R. provides research support fro

27、m Molnlycke, Cardinal Healthcare Foundation, Sanofi-Pasteur, 3M, and Cubist; Consulting from Semprus; Honorarium for lectures from 3M, Carefusion, Baxter and Becton Dickinson. Previously served on Board of Directors for Society for Healthcare Epidemiology of America. All other authors: noconflicts.4

28、Guidelines for the Prevention of Intravascular Catheter-Related InfectionsTable of ContentsNOTICE TO READERS:7Introduction8Summary Of Recommendations9Education, Training and Staffing9Selection of Catheters and Sites10Peripheral Catheters and Midline Catheters10Central Venous Catheters11Hand Hygiene

29、and Aseptic Technique12Maximal Sterile Barrier Precautions12Skin Preparation13Catheter Site Dressing Regimens13Patient Cleansing15Catheter Securement Devices15Antimicrobial/Antiseptic Impregnated Catheters and Cuffs15Systemic Antibiotic Prophylaxis15Antibiotic/Antiseptic Ointments15Antibiotic Lock P

30、rophylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis16Anticoagulants16Replacement of Peripheral and Midline Catheters16Replacement of CVCs, Including PICCs and Hemodialysis Catheters16Umbilical Catheters17Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and P

31、ediatric Patients18Replacement of Administration Sets19Needleless Intravascular Catheter Systems19Performance Improvement20Background Information20Terminology and Estimates of Risk20Epidemiology and Microbiology in Adult and Pediatric Patients23Pathogenesis23Strategies for Prevention of Catheter-Rel

32、ated Infections in Adult and Pediatric Patients25Education, Training and Staffing25Selection of Catheters and Sites26Peripheral and Midline Catheter Recommendations26Central Venous Catheters Recommendations27Hand Hygiene and Aseptic Technique29Maximal Sterile Barrier Precautions30Skin Preparation31C

33、atheter Site Dressing Regimens32Patient Cleansing35Catheter Securement Devices365Guidelines for the Prevention of Intravascular Catheter-Related InfectionsAntimicrobial/Antiseptic Impregnated Catheters and Cuffs36Systemic Antibiotic Prophylaxis39Antibiotic/Antiseptic Ointments40Antibiotic Lock Proph

34、ylaxis, Antimicrobial Catheter Flush and Catheter Lock Prophylaxis41Anticoagulants43Replacement of Peripheral and Midline Catheters45Replacement of CVCs, Including PICCs and Hemodialysis Catheters46Umbilical Catheters49Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Pedia

35、tric Patients51Replacement of Administration Sets53Needleless Intravascular Catheter Systems54Performance Improvement57References596Guidelines for the Prevention of Intravascular Catheter-Related InfectionsNOTICE TO READERS:In 2009, the Centers for Disease Control and Prevention (CDC) and Healthcare

36、 InfectionControl Practices Advisory Committee (HICPAC) integrated current advances in guideline production and implementation into its development process (/hicpac/guidelineMethod/guidelineMethod.html). The new methodology enables CDC and HICPAC to improve the validity and usabilit

37、y of its guidelines while also addressing emerging challenges in guideline development in the area of infection prevention and control. However, the Guidelines for the Prevention of Intravascular Catheter-Related Infections were initiated before the methodology was revised. Therefore, this guideline

38、 reflects the development methods that were used for guidelines produced prior to 2009. Futurerevisions will be performed using the updated methodology.These guidelines have been developed for healthcare personnel who insert intravascularcatheters and for persons responsible for surveillance and con

39、trol of infections in hospital,outpatient, and home healthcare settings. This report was prepared by a working groupcomprising members from professional organizations representing the disciplines of criticalcare medicine, infectious diseases, healthcare infection control, surgery, anesthesiology,int

40、erventional radiology, pulmonary medicine, pediatric medicine, and nursing. The workinggroup was led by the Society of Critical Care Medicine (SCCM), in collaboration with the Infectious Diseases Society of America (IDSA), Society for Healthcare Epidemiology of America (SHEA), Surgical Infection Soc

41、iety (SIS), American College of Chest Physicians (ACCP), American Thoracic Society (ATS), American Society of Critical Care Anesthesiologists (ASCCA), Association for Professionals in Infection Control and Epidemiology (APIC), Infusion Nurses Society (INS), Oncology Nursing Society (ONS), American S

42、ociety for Parenteral and Enteral Nutrition (ASPEN), Society of Interventional Radiology (SIR), American Academy of Pediatrics (AAP), Pediatric Infectious Diseases Society (PIDS), and the Healthcare Infection Control Practices Advisory Committee (HICPAC) of the Centers for Disease Control and Preven

43、tion (CDC) and is intended toreplace the Guideline for Prevention of Intravascular Catheter-Related Infections published in7Guidelines for the Prevention of Intravascular Catheter-Related Infections2002. These guidelines are intended to provide evidence-based recommendations forpreventing intravascu

44、lar catheter-related infections. Major areas of emphasis include 1) educating and training healthcare personnel who insert and maintain catheters; 2) using maximal sterile barrier precautions during central venous catheter insertion; 3) using a 0.5% chlorhexidine skin preparation with alcohol for an

45、tisepsis; 4) avoiding routine replacement of central venous catheters as a strategy to prevent infection; and 5) using antiseptic/antibiotic impregnated short-term central venous catheters and chlorhexidine impregnated sponge dressings if the rate of infection is not decreasing despite adherence to

46、other strategies (i.e., education and training, maximal sterile barrier precautions, and 0.5% chlorhexidine preparations with alcohol for skin antisepsis). These guidelines also emphasize performance improvement by implementing bundled strategies, and documenting and reporting rates of compliance wi

47、th all components of the bundle as benchmarks for quality assurance and performance improvement.As in previous guidelines issued by CDC and HICPAC, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact. The system for c

48、ategorizing recommendations in this guideline is as follows: Category IA. Strongly recommended for implementation and strongly supported by well- designed experimental, clinical, or epidemiologic studies.Category IB. Strongly recommended for implementation and supported by some experimental, clinica

49、l, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence.Category IC. Required by state or federal regulations, rules, or standards. Category II. Suggested for implementation and supported by suggestive clinical o

50、r epidemiologic studies or a theoretical rationale.Unresolved issue. Represents an unresolved issue for which evidence is insufficient or noconsensus regarding efficacy exists.IntroductionIn the United States, 15 million central vascular catheter (CVC) days (i.e., the total number of days of exposur

51、e to CVCs among all patients in the selected population during the8Guidelines for the Prevention of Intravascular Catheter-Related Infectionsselected time period) occur in intensive care units (ICUs) each year 1. Studies have variouslyaddressed catheter-related bloodstream infections (CRBSI). These

52、infections independently increase hospital costs and length of stay 2-5, but have not generally been shown to independently increase mortality. While 80,000 CRBSIs occur in ICUs each year 1, a total of 250,000 cases of BSIs have been estimated to occur annually, if entire hospitals are assessed 6. B

53、y several analyses, the cost of these infections is substantial, both in terms of morbidity and financial resources expended. To improve patient outcome and to reduce healthcare costs, there is considerable interest by healthcare providers, insurers, regulators, and patient advocates in reducing the

54、 incidence of these infections. This effort should be multidisciplinary, involving healthcare professionals who order the insertion and removal of CVCs, those personnel who insert and maintain intravascular catheters, infection control personnel, healthcare managers including the chief executive off

55、icer (CEO) and those who allocate resources, and patients who are capable of assisting in the care of their catheters.The goal of an effective prevention program should be the elimination of CRBSI from all patient-care areas. Although this is challenging, programs have demonstrated success, but sust

56、ained elimination requires continued effort. The goal of the measures discussed in this document is to reduce the rate to as low as feasible given the specific patient population being served, the universal presence of microorganisms in the human environment, and thelimitations of current strategies

57、 and technologies.Summary of RecommendationsEducation, Training and Staffing1. Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections 715. Category IA2. Periodically assess knowledge of and adherence to guidelines for all personnel involvedin the insertion and maintenance of intra