Date Published: November 1, 2018
Publisher: Public Library of Science
Author(s): Caroline Fraser, Katie Harron, Laura Dalton, Ruth Gilbert, Sam J. Oddie, Umberto Simeoni.
There is uncertainty about the variation in infection prevention practices for central venous catheters (CVC) in neonatal units (NNUs) and how practices relate to national guidance.
To evaluate evidence supporting infection prevention practices for CVCs recommended in national guidelines and to compare with reported practices for peripherally inserted central catheters (PICC), a type of CVC widely used in NNUs.
We searched national guidelines for neonates and children to identify infection prevention practices for CVCs and conducted an overview of studies to determine the quality of evidence underpinning recommendations. We surveyed 134 NNUs in England and Wales to ascertain reported practice.
We found low quality evidence supporting CVC care bundles and use of 2% alcoholic chlorhexidine to decontaminate catheter ports and skin before insertion. Moderate quality evidence supported recommendations against routinely replacing CVCs and against chlorhexidine-impregnated dressings. 90% (44/49) of NICUs and 40% (34/85) of LNUs responded. 66% (48/73) of NNUs reported using CVC care bundles for insertion; 62% (45/73) used bundles for maintenance. 63% (32/51) of those using bundles reported monitoring adherence. 85% (61/72) of NNUs did not routinely replace PICCs and 89% (63/71) did not use chlorhexidine-impregnated dressings. Antiseptic use varied with alcoholic 2% chlorhexidine used for skin preparation in 33% (23/71) of NNUs and for catheter ports in 52% (37/71).
Lack of consistency across NNUs in antiseptic use and low rates of reported CVC care bundle use may reflect the low quality of evidence of the effectiveness and safety of these interventions in NNUs. Clinical trials are needed to quantify benefits and harms of infection prevention practices in NNUs.
Central venous catheters (CVCs) allow the administration of parenteral nutrition, fluids and medication in neonatal units (NNUs). Peripherally inserted central catheters (PICCs) are a type of CVC often used in NNUs because they can be inserted at the bedside and can remain in situ for many days. However, CVCs increase the risk of bloodstream infection (BSI).[1, 2] Neonatal BSI is associated with mortality, increased length of stay and long term morbidity.[3–5] Pathogens colonising the skin enter the bloodstream during CVC insertion or through migration along the catheter surface after insertion.[6–8] In addition, pathogens may be introduced into the blood stream when the CVC connection is breached to administer medication or fluids.[7, 9] Neonates have an elevated risk of BSI compared with older children and adults due to their immunological immaturity, thinner and more permeable skin, exposure to frequent invasive procedures and reliance on parenteral nutrition.[10–12]
We found variation in adherence to recommended care practices, and a lack of high quality evidence supporting these in neonates. Reported practice from the majority of NNUs was in accordance with recommendations against routine replacement of PICCs and against use of chlorhexidine-impregnated foam dressing, supported by moderate quality evidence. Despite only low quality evidence to support the use of care bundles in neonates, the majority of NNUs reported using insertion and maintenance bundles.