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The Risk of Bloodstream Infection in Adults With Different Intravascular Devices: A Systematic Review of 200 Published Prospective Studies

  • Dennis G. Maki
    Correspondence
    Individual reprints of this article are not available. Address correspondence to Dennis G. Maki, MD, H5/574, University of Wisconsin Hospital and Clinics, Madison, WI 57392
    Affiliations
    Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School and the Infection Control Department, University of Wisconsin Hospital and Clinics, Madison
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  • Daniel M. Kluger
    Affiliations
    Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School and the Infection Control Department, University of Wisconsin Hospital and Clinics, Madison
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  • Christopher J. Crnich
    Affiliations
    Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School and the Infection Control Department, University of Wisconsin Hospital and Clinics, Madison
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      OBJECTIVE

      To better understand the absolute and relative risks of bloodstream infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults in which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI.

      METHODS

      English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremia [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream infection AND the specific type of intravascular device (eg, central venous port). Mean rates of IVD-related BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days.

      RESULTS

      Point incidence rates of IVD-related BSI were lowest with peripheral intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the intensive care unit. Surgically implanted long-term central venous devices—cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)—appear to have high rates of infection when risk is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodialysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

      CONCLUSIONS

      Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies in which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs in use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related infection have focused on short-term noncuffed CVCs used in intensive care units, infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.
      BSI (bloodstream infection), CDC (Centers for Disease Control and Prevention), CVC (central venous catheter), ICU (intensive care unit), IV (intravenous), IVD (intravascular device), PA (pulmonary artery), PICC (peripherally inserted central venous catheter)
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      Linked Article

      • Prevention of Catheter and Intravascular Device-Related Infections: A Quality-of-Care Mandate for Institutions and Physicians
        Mayo Clinic ProceedingsVol. 81Issue 9
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          In this issue of Mayo Clinic Proceedings, Maki et al1 summarize the relative risk of bloodstream infections that result from various forms of catheters and intravascular devices. Their calculations are based on a review of 200 published prospective observational or clinical trials. The authors point out that their calculations of the infection rates may be slightly high, representing the upper bound of the 95% confidence interval, since they analyzed only studies that took into account all patients with intravascular devices that were prospectively cultured.
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