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CHAPTER 4: Infection Prevention and Surveillance in the Intensive Care Unit 25

systems are similar to those recommended for central venous catheters.
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TABLE 4-1 Specific Recommendations for Preventing Intravascular Catheter–
Related Infections Recommendations for the proper care and use of both arterial catheters
and pressure transducer systems are shown in Table 4-1.
Before insertion
• Proper hand hygiene before and after manipulation of intravascular catheter or catheter ■ URINARY CATHETERS
insertion site
Urinary catheter use is the primary cause of urinary tract infections
• Educate health care personnel involved in the insertion, care, and maintenance of cen- among critically ill patients. There are two clinical entities associated
tral venous catheter with urinary catheter use: catheter-associated asymptomatic bacteriuria
At insertion (CA-ASB) and catheter-associated urinary tract infection (CA-UTI).
• Use an all-inclusive catheter insertion procedure cart or kit These are differentiated by the presence of clinical symptoms (eg, new
onset or worsening fever, rigors, altered mental status, flank pain).
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• Aseptic technique during catheter insertion and care
A national survey of health care–associated infections in 112 medi-
• Use of hat, mask, sterile gowns and gloves, and large sterile drape during central venous cal ICUs found urinary tract infections to be responsible for 31% of
catheter (CVC) insertion all ICU-acquired infections, making urinary tract infections the most
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• Use of alcohol chlorhexidine solution with a concentration of chlorhexidine gluconate common health care–associated infection. Most of these infections are
greater than 0.5% or other skin antiseptic (tincture of iodine, iodophor, or 70% alcohol) asymptomatic, but between 0.4% and 3.6% of patients with a urinary
for insertion-site antisepsis tract infection develop a secondary bloodstream infection. 38,39 The most
effective way to reduce CA-UTI and CA-ASB is restriction of urinary
• Use a catheter checklist to evaluate adherence to prevention methods
catheter use, removal of unnecessary urinary catheters, and hand
• Antimicrobial/antiseptic-coated CVC should be used if high incidence of CLABSI rate hygiene before and after manipulating urinary catheters. In addition,
despite basic prevention practice, for patients with limited venous access and a history potentially modifiable risk factors for infections with urinary catheters
of recurrent CLABSI, or for patients with higher risk of severe sequelae from CLABSI include avoiding the use of open urinary drainage systems and breaks
• Avoid using arterial or venous cutdown procedures to insert catheters in closed drainage systems, using condom urinary catheter for male
patients and avoiding retrograde flow from collection bags into the
• Avoid using the femoral vein for central venous access
bladder (Table 4-2). 36
• Consider using chlorhexidine-containing sponge dressing for CVC insertion site
After insertion ■ RESPIRATORY THERAPY EQUIPMENT AND NASOGASTRIC TUBES
• Routine replacement of central venous catheters, pulmonary arterial catheters, arterial Respiratory failure requiring mechanical ventilation is one of the most
catheters, and umbilical catheters to prevent infection is not recommended common indications for ICU admission. Nasogastric tubes are used
• Do not replace catheters suspected of being infected over a guidewire often for both gastric decompression and to permit feeding of ICU
patients. Both mechanical ventilation and nasogastric intubation bypass
• Replace IV administration sets and tubing no more frequently than every 72 hours the normal mucosal defenses of the upper and lower respiratory tract,
unless infection is suspected or blood products or lipid emulsions are used which leaves patients at risk for health care–associated sinusitis and
• Replace catheter-site dressing when loose, damp, or soiled pneumonia.
• Use sterile sleeve for pulmonary artery catheters Among ICU patients, the vast majority of health care–associated
pneumonias are ventilator-associated pneumonias. Ventilator-associated
• Consider the use antimicrobial locks for patients with limited venous access and a his- pneumonia is most likely the result of aspiration of contaminated oro-
tory of recurrent CLABSI or patients with higher risk of severe sequelae from a CLABSI pharyngeal and gastric secretions and contaminated condensate in the
Pressure transducer systems ventilator circuit. Risk factors include the supine position, sedation or
40
• Use disposable systems when possible with a sterile, closed flush system impaired consciousness, and reduced gastric acidity. Contaminated
• Replace transducer, tubing, flush solution, and flush device every 96 hours
CLABSI, central line-associated bloodstream infection; CVC, central venous catheter. TABLE 4-2 Recommendations for Preventing Urinary Catheter–Related Infections
Data from Marschall, J, Mermel, LA, Classen D, et al. Strategies to prevent central line-associated • Urinary catheters should not be used solely for the convenience of health care personnel
bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. October 29, 2008; and should be removed when no longer necessary
(suppl 1):S22-S30. 32 • Personnel should be trained on proper aseptic insertion and maintenance of urinary catheters
antimicrobial solution into an unused catheter lumen. A few potential • Proper hand hygiene should be performed before and after manipulating catheters
concerns of antibiotic lock therapy include systemic side effects from • Insertion of catheters should be performed using aseptic technique and sterile equipment
leakage of lock solution or the emergence of drug-resistant organisms. • A sterile, continuously closed system should be maintained
Moreover, it might be impractical in the ICU settings because of the
frequent need for continuous infusion of intravenous fluid or drugs. • If necessary, perform closed continuous irrigation of catheter with sterile irrigant
■ ARTERIAL CATHETERS AND PRESSURE TRANSDUCERS • Urine samples from catheter and collecting bag should be collected aseptically
• Urine collection bags always should be below the level of the bladder
Compared with central venous catheters, the incidence of catheter- • Maintain unobstructed urinary flow
associated bloodstream infection attributable to arterial catheters has • Consider use of antimicrobial-coated catheters to delay or reduce the onset of catheter-
not been as well studied but is estimated to be roughly 1.5% per device associated bacteriuria
or 2.9 cases per 1000 catheter-days. Pressure transducer systems have
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been a common source of epidemic outbreaks of health care–associated • Consider nurse-based or electronic physician reminder system to reduce inappropriate
infection. From 1977 to 1987, these devices were the most common urinary catheterization
source of epidemic bloodstream infection investigated by the CDC. • Consider use of condom catheterization as an alternative to short term indwelling catheter-
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These outbreaks were prolonged (mean 11 months) and involved large ization to reduce catheter-associated bacteriuria in men who are not cognitively impaired
numbers of patients (mean 24 patients). In each case, reusable trans- Data from Hooton TM, Bradley SF, Cardenas DD, et al. Diagnosis, prevention, and treatment of catheter-
ducers were either improperly disinfected or fitted with improperly associated urinary tract infection in adults: 2009 International Clinical Practice Guidelines from the
sterilized domes. Preventive measures for arterial catheter-transducer Infectious Diseases Society of America. Clin Infect Dis. March 1;50(5):625-663.

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