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And Central Venous Catheter–Related Bacteremia in Intensive Care Units*

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And Central Venous Catheter–Related Bacteremia in Intensive Care Units* Prospective study of arterial and central venous catheter colonization and of arterial- and central venous catheter–related bacteremia in intensive care units* Ousmane Traoré, MD, PhD; Jérôme Liotier, MD; Bertrand Souweine, MD, PhD Objective: To compare the rates of positive quantitative culture forming units/mL. Catheter-related bacteremia was defined by a (PQC) of arterial catheter (AC) and central venous catheter (CVC) PQC and a blood culture positive for the same microorganism. The tips and of CVC- and AC-related bacteremia in intensive care unit cumulative incidence (PQCs/number of catheters inserted) was .(44. ؍ patients undergoing placement of both ACs and CVCs. 9.4% (29/308) for CVCs and 7.7% (23/299) for ACs (p Design: Prospective, descriptive survey. To control for a dif- Incidence density (PQCs/1,000 catheter days) was 12.0 for CVCs ference in the severity of patients having an AC or CVC, only versus 9.3 for ACs. At the femoral site, there was no significant patients having both an AC and a CVC were included. difference between CVCs and ACs in the cumulative incidences Setting: An adult, nine-bed medical/surgical intensive care and incidence densities of PQCs. Two instances of catheter- unit at a university teaching hospital. related bacteremia were observed, one involving a CVC and one Subjects: The analysis included 308 CVCs and 299 ACs inserted involving an AC. in 212 severely ill patients, with a mean ؎ SD Simplified Acute Conclusions: Among severely ill patients with both CVCs and Physiology Score II of 52 ؎ 22 and an intensive care unit mortality ACs, the epidemiology of PQCs of CVCs and ACs is comparable of 33% (69 of 212). when the same infection control measures are used for the Interventions: None. Measurements and Main Results: The same insertion and insertion and maintenance of both types of catheters. (Crit Care maintenance procedures were used for both types of catheter. A Med 2005; 33:1276–1280) PQC was defined by a catheter tip culture yielding >103 colony KEY WORDS: infections; arterial; central venous catheter rterial catheters (ACs) are fre- niques have reported AC-related infec- published reports comparing rates of pos- quently used for continuous tions (4–7). One randomized study sug- itive quantitative culture (PQC) of CVCs hemodynamic monitoring of gested that the use of sterile barrier and ACs or of CVC- and AC-related bac- and drawing blood samples precautions when inserting ACs without teremia in a patient group undergoing Afrom critically ill patients. These patients both types of catheterization. Our pro- the use of a guidewire has no greater are often at increased risk of nosocomial effect on decreasing colonization or in- spective study was designed to compare infections because of their underlying fection than standard procedure, unlike these rates of colonizations/infections in disease, and catheter-related infection is with central venous catheters (CVCs) (7). an intensive care unit (ICU) where the one of the main severe complications of The authors noted that the incidence of insertion and maintenance procedures arterial or central venous catheterization AC-related infectious complications was used for ACs were the same as those for (1–3). comparable to that of CVC-related infec- CVCs. Most reports on complications related tious complications in the literature. to ACs have focused on mechanical prob- However, that study (7), like most MATERIALS AND METHODS lems. Recently a few investigators using other published reports (1, 5, 7–11), in- standardized quantitative culture tech- Study Population. This prospective study volved ACs only; thus, comparison of was performed in a nine-bed medical/surgical rates of AC- and CVC-related infections ICU at the university teaching hospital of Cler- was not possible. A few studies have de- mont-Ferrand, France, between September *See also p. 1437. scribed infectious complications of CVCs 15, 2000, and December 31, 2002. All the From the Service de Réanimation Médicale Poly- patients admitted to the ICU during this pe- valente et Néphrologie (JL, BS) and the Service and ACs that were placed in two different d’Hygiène Hospitalière (OT), Hôpital G. Montpied, Cler- patient populations (4, 12). This makes riod were eligible. All patients who required Ն mont-Ferrand, France. comparison difficult because there may CVC and AC placement for a duration 48 hrs Supported, in part, by a grant from the Faculté de be differences in the severity of the pa- during their hospital stay were included in the study. Only the catheters placed and removed Médecine de Clermont-Ferrand, Clermont-Ferrand, tients’ condition, and severity is a deter- France. The authors have no financial interests to in the unit were analyzed, whether CVCs and disclose. mining factor of risk of infection since ACs were in place at the same time or sequen- Copyright © 2005 by the Society of Critical Care the most critically ill patients are those tially. All patients underwent placement of Medicine and Lippincott Williams & Wilkins whose CVCs and ACs are handled the polyurethane single-lumen or multiple-lumen DOI: 10.1097/01.CCM.0000166350.90812.D4 most. To our knowledge there are no CVCs (from Seldiflex Plastimed, St. Leu-la- 1276 Crit Care Med 2005 Vol. 33, No. 6 Foret, France, during the period of September culture technique previously described by inserted in 212 patients—128 men and 15, 2000, through December 31, 2001, and Brun-Buisson et al. (17). For patients exhibit- 84 women (sex ratio, 1.52)—with a mean from Arrow-Howes, Reading, PA, until Decem- ing clinical signs of infection (fever, chill, hy- Ϯ SD age of 61.4 Ϯ 17 yrs (median, 66 ber 31, 2002) and ACs (Leader Cath, Vygon, potension, leukocytosis/leukopenia), periph- yrs), a median SOFA score at 24 hrs of 7, eral blood samples were collected at the time Ecouen, France). The CVCs and the ACs used and a mean SAPS II at 24 hrs of 52 Ϯ 22 in this study had no antibiotic or antiseptic of catheter removal and subsequently cul- properties. The Seldinger technique was used tured. Standard microbiological methods were (median, 50). Of the 212 patients, 119 for catheter insertion. In our unit, CVCs are used to identify the colonizing/infecting or- (56%) had invasive mechanical ventila- used to deliver medications and nutritional ganisms. tion Ͼ48 hrs and 79 (37%) had at least support and to measure central venous pres- Definitions. A PQC was defined as a quan- one dialysis session while in the ICU. For 3 sure. CVCs are never used for blood sampling. titative culture tip yielding Ͼ10 colony form- these 212 patients, the mean Ϯ SD length ACs are used to draw blood samples and to ing units/mL. Catheter-related bacteremia of ICU stay was 17.2 Ϯ 17.9 days (median, monitor arterial blood pressure. (CRB) was defined by isolation of the same 10; range, 2–110), the mean omega score/ For both CVCs and ACs, the indication for phenotypic microorganisms from both periph- day was 15.6 Ϯ 7.3 (median, 14.8; range, catheterization, the insertion site, and the eral blood and catheter tip in a culture grow- 3.9–51), and the ICU mortality rate was number of CVC lumens were left to the dis- ing Ͼ103 cfu/mL when there was no other cretion of the attending physician. CVCs were overt source of the bacteremia except the 33% (69/212). not tunneled and no guidewire-assisted catheter. Catheterizations. Of the 308 CVCs, 19 changing of catheters was done for either Statistical Analysis. PQC and CRB rates (6%) were single-lumen, 23 (8%) were CVCs or ACs. All of the CVCs and ACs were were expressed in terms of cumulative inci- double-lumen, and 266 were triple- inserted at the bedside by the attending phy- dences and incidence densities. Cumulative lumen (86%). The mean Ϯ SD duration of sicians. Catheter insertion and dressing of the incidence is expressed as percentage and inci- CVC placement was 7.9 Ϯ 4.9 days (me- insertion site were done according to our pre- dence density as PQCs per 1,000 catheter days. dian, 7 days), and it was longer for CVCs viously published ICU procedure (13), which Categorical variables were compared by the inserted at the subclavian site (p ϭ .005). requires the wearing of a cap, mask, gown, and chi-square test or Fisher’s exact test, and con- CVC-PQC was observed in 29 (9.4%) of sterile gloves for CVC and AC insertion. The tinuous variables were compared by analysis of puncture site was prepared with alcoholic so- variance or by Mann-Whitney test or Kruskall- 308 cases, with no significant difference lution of 0.5% chlorhexidine, and the sur- Wallis test when necessary. The Kaplan-Meier in relation to the number of lumens (p ϭ rounding areas were covered with sterile test was used to compare the risk of PQCs over .38). The incidence density of PQC was 12 drapes. A sterile, occlusive, adhesive, transpar- time between CVCs and ACs. Two-tailed p val- per 1,000 days of CVC use. There was no ent dressing (Tegaderm, 3M, London, ON, ues Ͻ .05 were considered to indicate statis- difference in the mean duration of CVC Canada) was applied. For both CVCs and ACs, tical significance. Analyses were performed placement with or without PQC (7.9 Ϯ occlusive dressings and intravenous tubes with Epi Info 6 software (Centers for Disease 2.8 days [median, 8 days] vs. 7.9 Ϯ 5.1 were routinely changed every 48 hrs by a Control and Prevention, Atlanta, GA). [median, 7 days; p ϭ .8]). On the basis of nurse wearing a cap, mask, and sterile gloves.
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