Intravascular Catheters: Infection Prevention, Research Paper Example

The use of intravascular infusion therapy in hospitals and other clinical settings is quite common. IV lines are typically safe and effective, and are used millions of times a year with no adverse effects. It must be remembered, however, that while IVs present a route into the body for medications, transfusions, and the like, they also represent a potential entry-point for pathogens and infectious materials. When IV lines are not in use, the catheters are typically left in place, facilitating the connection of future IV solutions. Far too often, as these IV catheters lay dormant, awaiting further use, the exposed tips are left exposed to the open air. While it is standard procedure to wipe the open ports before connecting a new solution, this may not be enough to prevent contamination. Any germs that have managed to collect in and on the ports that are not subsequently removed can then easily be flushed directly into the body. This potential source of contamination could be easily ameliorated through the use of a simple cap placed over the end of the catheter when it is not in use. This paper proposes that the use of such caps on dormant IV catheters should be standard operating procedure in all settings where IV lines are used.

Review of Literature

Contemporary hospital care is as good as it has ever been; advances in medical science mean that more patients are surviving injury and disease than was ever before possible. As advancements in medicine have grown, though, so too have some of the potential hazards. One significant risk factor for hospital patients is the prevalence of hospital-acquired infections (HAIs). A review of relevant literature demonstrates the risks associated with the use of IV therapy as well as the efficacy of IV caps when used as part of a rigorously applied infection-control program.

The term HAI refers to any infection that a patient acquires apart from his or her original diagnosis at the time of admission to the hospital. HAIs can be caused by viruses, bacteria, parasites or other pathogens, and can be transmitted through contact with contaminated equipment, hospital personnel, or other hospital patients. Urinary tract infections, chest infections, and infections of surgical wounds are among the most commonly-seen types in the hospital setting (Beckford-Ball, 2008), though there is any number of other types of infections that can arise during the course of a patient’s stay.

In recent years the public awareness of methicillin-resistant Staphylococcus aureus (MRSA) has grown; these are the so-called “superbugs” that, largely due to the overprescribing of antibiotics, have developed a resistance to nearly all courses of treatment. MRSA can be found in the community at large, though outside of the hospital setting it is typically harmless; in the hospital setting the prevalence of MRSA rises to a clinically-significant number because of the concentration of patients as well as the presence of disease, wounds, and other sites where bacteria can flourish. The evidence is clear that rigorous infection-control procedures can severely limit the rate of MRSA and MRSA infections in the hospital setting; unfortunately, some studies have shown a woefully low rate of compliance by hospital staff with such procedures (Beckford-Ball, 2008).

There are several fundamental procedures involved in controlling infections in the hospital setting; while they may all seem like common-sense ideas, they are only effective if they are put into practice. The first step involves removing sources of infection by treating existing infections and adhering to decontamination procedures. The next step is to prevent the transfer of infections through good hand hygiene involving aseptic procedures and isolation where appropriate. Finally, staff should seek to prevent infections through the appropriate use of antibiotics, and to help patients maintain resistance through proper nutrition (Beckford-Ball, 2008).

10-20% of HAIs are associated with the use of intravascular catheters (Hadaway, 2002). Almost all patients in the ICU environment, and a significant percentage of patients throughout a hospital, will require the use of an intravascular device (Dennis, 2010). Complications from infection can lengthen the stay of patients and cause significant problems in recovery from illness or surgery. The most common type of problematic intravascular catheter is the central venous catheter (CVC); roughly half of all infections associated with intravascular devices involve CVCs (Dennis, 2010). In the U.S. nearly 50,000 ICU patients develop CVC-related infections every year (Ingram, 2009). The most common causes of such infections are coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus species and Candida species (Ingram, 2009). Infections from these and other sources are associated with a significant rate of comorbidity and death. While specific numbers are difficult to determine, research shows that thousands of deaths every year are associated with such infections (Ingram, 2009).

An IV catheter must be colonized before an infection can develop. It is possible for the catheter to be colonized internally, after insertion, though contamination of the hub; it may also become contaminated during insertion due to improper preparation of the insertion site (Ingram, 2009). It is also possible, though less common, for water-borne pathogens to breach the entry point of the catheter after insertion (Ingram, 2009) .  The exterior of the catheter can become rapidly colonized through contamination by contact with other parts of the patient’s own skin, or through contact with bedding, clothing, other patients, or staff (Ingram, 2009).

A fundamental factor in the contamination and colonization of IV catheters from gram-positive organisms on the skin is that they can adhere to the outer surface of the catheter (Eggiman, 2007). After a catheter is inserted, the body’s reaction coats the surface of the catheter in fibrin. Several organisms significant in the development of IV catheter infections, such as coagulase-negative staphylococci and S. aureus, can bind to this layer of fibrin through fibronectin, a glycoprotein (Eggiman, 2007). Further, slime is produced by both these bacteria in the form of glycocalyx; this slime can harbor Staphylococci in significant numbers (Eggiman, 2007). The makeup of the slime provides a protective barrier for the Staphylococci, keeping it safe from typical immune responses as well as from antibacterial actions (Eggiman, 2007). While antibiotics –both prophylactic and post-infection- can combat IV-related infections, they are insufficient in eliminating bacteria embedded in the slime/fibrin coatings of catheters.

There are a range of standard procedures involved in preparing and maintain the site of an IV catheter. The first step involves the preparation of the skin at the injection site. One of the preferred solutions for preparing the skin is Chlorhexidine gluconate; the CDC lists it as the best choice for such use (Dennis, 2010). Chlorhexidine gluconate comes in several preparations, including a swabstick that contains 2% chlorhexidine gluconate in 70% isopropyl alcohol. Chlorhexidine is a broad-spectrum agent that neutralizes most bacteria and viruses, as well as some sources of fungal infection. It functions by disrupting cell membranes, and it remains effective by binding with skin cells, prolonging its efficacy for hours after it is applied.

There are other solutions available for skin preparation, including tincture of iodine at 1% and 2%. A mixture of povidone-iodine may also be used; this solution is effective against both bacteria and viruses. These solutions function differently than chlorhexidine gluconate; rather than disrupting the cell membrane, they penetrate the cell and replace inter-celluar contens with iodine. The CDC lists these solutions as acceptable alternatives to chlorhexidine gluconate, though in the case of povidone-iodine and other iodophors at least two minutes of contact is required for the solution to release free iodine.

Yet another option for the preparation of a catheter injection site is the use of isopropyl alcohol. Isopropyl alcohol has a broad spectrum of action against bacteria; it is also effective against many viruses and fungi. Unlike some other solutions, however, isopropyl alcohol does not leave an antiseptic barrier on the skin’s surface; its properties remain effective only until it dries. Further, isopropyl alcohol, used excessively, can cause dryness and irritation of the skin. It is perhaps most effective in treating surfaces of catheters and hubs, with skin preparation better left to the aforementioned solutions. It is not just skin preparation that will combat infection; it is important to consider the chain of infection to fully understand how best to prevent infection.

The chain of infection, which originally had four links, now has six links, with the last two having been added within the last decade (Ingram, 2009). Each step in the chain must be present, and in the proper sequence, for infection to take hold. The first link in the chain is, of course, the infectious agent; this agent is any micro-organism that can produce disease (typically bacteria, viruses, and fungi). Because the use of an IV catheter involves puncturing the skin, the earlier-described skin preparation solutions are an important first step in preventing such infectious agents from entering the body. The use of an IV increases the likelihood of acquiring an infection by seven times, making preventative measures imperative.

The second link in the chain is the “reservoir.” The reservoir is any environment that allows the infectious agent to survive and propagate. The reservoir can be on equipment, on the patient’s own clothes of skin, the skin or clothes of other patients or of medical staff, and on any other surface that has not been decontaminated. There are two basic types of infections, endogenous and exogenous. Endogenous infections involve the infectious agent being present on the patient’s own skin; while we are all typically immune to the millions of bacteria we harbor, opportunistic infections can be caused by these bacteria under certain circumstances.  Exogenous infections are those that arise from contamination from other persons or through contact with contaminated objects. For all practical purposes it is difficult or impossible to determine whether an infection is endogenous or exogenous, making rigorous infection-control procedures imperative.

Because the reservoir can be the patient, objects in the environment, or other people, it is necessary to ensure that infection-control procedures are applied to all potential reservoirs. Along with preparing the skin surface, it is necessary to ensure that the area around the patient is as decontaminated as possible. Any objects or devices that will come in contact with the patient or with a potential reservoir must also be decontaminated. Whenever possible, the use of disposable, single-use devices is preferred. Polyurethane catheters have shown to have the lowest rate of microbial adherence and colonization, and should be used whenever possible.

The third link in the chain of infection is the portal of exit. This term refers to the route by which the infectious agent leaves the reservoir. In terms of infectious agents carried in the body, the portal of exit can be through secretions on the surface of the skin. The best treatment for this portal of exit is through the application of proper hand hygiene. Hand hygiene refers not just to the act of hand-washing, but also to the use of antibacterial agents and surgical hand-scrubbing. This has been shown to be one of the most effective means of breaking the cycle of infection. Further means of blocking the route of exit include the use of medical-grade gloves, aprons, and even masks, and goggles, though most of these are uncommon during the introduction of an IV catheter.

Closely tied to the portal of exit is the means of transmission; should the portal of exit not be effectively blocked, a catheter that then became contaminated could easily transmit an infectious agent into the body. Improperly-prepared skin can also provide a portal of exit and a subsequent means of transmission, further emphasizing the need for properly addressing the specific tasks involved in avoiding such transmission. Sites for the IV catheter must be careful chosen, as some areas of the body can harbor more bacteria than others, such as areas that are not typically exposed to air or sites that are susceptible to becoming moist. Once the catheter is in place, it should be well secured and sealed as effectively as possible. This helps to minimize discomfort and inflammation at the site while also helping to block the entry of possible contaminants.

The next link in the chain of infection is the portal of entry. In the case of an IV catheter, the catheter itself, as well as the hole produced by the catheter, provides potential portals of entry. Despite the best efforts to prepare the patient’s skin surface, if the catheter becomes contaminated through contact with an exogenous infectious agent during insertion, infection can result. This further reinforces the need to ensure proper hand hygiene and other preventative measures. Once the IV catheter is in place, the hub or port of the catheter presents an ongoing risk factor for a possible portal of entry.

The final link in the chain of infection is a susceptible host. Patients whose bodily defenses are compromised by illness, suppressive medications, or other factors may be more susceptible to infections than the average person; this again reinforces the need to ensure that the first five steps in the chain of infection are properly addressed. In the case of IV catheters, it is the fifth link –the portal of entry- that presents the most significant ongoing concern (Hadaway, 2002). While the other steps are typically addressed at the time of insertion, the ongoing presence of the catheter continues to present a potential portal of entry as long as it is in place, and therefore it is imperative that proper steps be taken to ensure that it remains as free of contamination as possible.

Along with properly addressing these steps of infection, it is imperative for health care professionals to keep accurate, up-to-date records of all procedures and treatments. This does not just ensure the patient’s health and well-being; it also serves to protect the staff and the hospital against potential liability. The more procedures that can be efficiently documented the better. Even for something as relatively routine as the administration of an IV catheter, a checklist of all the necessary steps can be both a helpful reminder and can serve as proof that all appropriate standards of care are met during the procedure.

Because it is the continued presence of the IV catheter that creates the most significant risk of infection (after the initial insertion), it is imperative that health care providers properly assess and document the site of the IV regularly. The site should be checked for swelling, redness, or tenderness; the application of a semi-permeable membrane over the catheter simplifies such monitoring. If gauze or other similar type of bandage is used, it must be periodically removed and replaced; during the course of replacement the site can be properly assessed.

When developing infection-control procedures, it is necessary to emphasize the importance of decontamination procedures. It may be habit for many nurses and doctors to maintain good hand hygiene, but even the cleanest hand can become quickly contaminated through contact with a contaminated surface, object, or piece of equipment. Diligence is the key to infection control, and hospitals must ensure staff compliance with infection-control procedures of they are to be effective.

Along with the pro-active procedures performed by staff, there are many products and devices used by nurses and doctors that are designed to reduce the risk of infection. An obvious example of this would be any single-use/disposable item, such as sharps and IV catheters. Like many bacteria, MRSA is prevalent on the skin and on mucous membranes; anything that pierces the skin can potentially force bacteria into the bloodstream. An IV catheter, left exposed, presents an obvious risk factor for infection. While catheters are typically swabbed with alcohol before new lines are attached, a simple cap placed over the ports could significantly reduce the risk of infection through the site (Eggiman, 2007).

Health care providers should take care to properly inform patients about what to expect when they have an IV catheter in place. Properly administered, an IV catheter should be relatively painless, and it is important that patients inform nurses or other health care providers if they experience any pain or discomfort, as these may be sign of developing infection.

In the hospital setting, a peripheral IV site should be changed after 72 hours, while the site of a CVC may be used for longer periods at the discretion of the physician (Eggiman, 2007). IV catheters that were put in place during an emergency before the patient arrived at the hospital should be changed as quickly as possible, typically within 24 hours, to ensure that any potential contamination during the hurried insertion of the catheter is not allowed to become established (Eggima, 2007). Primary and secondary tubing should also be replaced every 72 hours, with some medications and fluids requiring more frequent tube-changes (Eggiman, 2007).

If infection is suspected, a determination will be made by a physician or other health care provider about the extent of the infection (whether it is localized to the site or has spread to the bloodstream). It is obviously better to catch an infection as early as possible to avoid having the infection spread throughout the body. If infection is suspected, the catheter is removed and sent to be cultured and tested, and the site is cleaned and treated with the application of antibiotics. Blood tests may be necessary to determine the extent of the infection and to decide on an appropriate course of treatment.

Because the presence of the IV catheter is in itself a risk factor for infection, it is imperative that all possible steps be taken to ensure that the catheter and its component parts do not become contaminated. There are several method used to prevent the introduction of bacteria into or onto the catheter, as well as methods to prevent colonization by infectious agents should contamination occur. The open ports of the IV catheter often have a membrane system of other mechanism that serves to physically block the passage of liquids when an IV tube is not in place, while the interiors and exteriors of the catheter may be pretreated with antibacterial solutions designed to prevent colonization.

The greatest risk factor for possible contamination is the exposed port of the IV catheter (Ingram, 2009). While it is standard procedure to clean the port with alcohol swabs before connecting a new tube, there is always the risk that a hurried or otherwise inefficient cleaning will leave infectious agents behind. It is this portal of transmission that must be diligently monitored. Most current literature on the subject recommends the use of caps on unused ports as a simple, effective means of keeping the ports free of contamination (Ingram, 2009; Hadaway, 2002). These caps, like the interiors of the ports themselves, are often treated with antibacterial solutions at the time of manufacture.

Conclusion

The available evidence shows that properly-administered infection control procedures drastically reduces the risk of infection through IV catheters.  It has long been understood that applying antiseptic solutions to he site of an IV injection on a regular basis, as well as using antiseptics on IV ports when new IV solutions are administered, are effective means of minimizing the development of infections in patients receiving IV therapy. In virtually every clinical setting that utilizes IV therapy protocols will be in place that dictate how infection-control protocols will be carried out. Time and again the same procedures, from hand-washing and the use of anti-bacterial solutions to the application of antiseptic solutions to IV sites and ports, are seen in books, articles, and the in-house guidelines for facilities that administer IV therapy. Conspicuously absent from all but the most recent literature, however, are recommendations about simple, effective prophylactic barriers in the form of caps fitted over dormant IV ports.

Because the use of caps for dormant IV ports is relatively new and hardly widespread, such use provides ample opportunity for further research. The available literature has demonstrated that these IV caps can significantly contribute to reducing infection risks; more research conducted in this field will likely only help to affirm the need for such caps in all IV-therapy settings.

If any forms of infection-control methods or equipment are to be effective, they must be utilized as part of a comprehensive program. Research has demonstrated that nurses and other health-care professionals who are responsible for administering or maintaining IV lines –as well as any health-care professionals who are at risk of spreading infections or otherwise contaminating patients- do not fail to adequately adhere to infection-control protocols out of “laziness” (Beckford-Ball, 2008).

When such protocols are not properly followed, it is typically a result of inadequate training and preparation. Controlling and reducing infections related to IV therapy requires the proper use of established procedures, and should also include the use of caps for dormant IV ports. Effective, comprehensive training and education about infection-control protocols will help to ensure adequate compliance, and adding the use of caps for dormant IV ports to such protocols will help to ensure that their integration into clinical settings is done in a smooth and efficient manner. It is clear that the use of IV caps can help to significantly reduce the risk of infection for patients; their integration in all clinical settings that administer IV therapy should be made a mandatory component of any set of infection-control protocols.

References

Beckford-Ball, J. (2008). The control and prevention of hospital-acquired infections. Nursing Times, 100(29): 28.

Dennis, M. M. (2010). Competent I.V. management. Nursing Management, 32(8): 21-23.

Eggimann, P. (2007). Prevention of intravascular catheter infection. Current Opinion in Infectious Diseases, 20(4): 360-369.

Hadaway, L. (2002). What you can do to decrease catheter-related infections. Nursing, 32(9): 46-48.

Ingram, P. (2009). Prevention of infection in peripheral intravenous devices. Nursing Standard, 20(49): 49-56.