Clinical review: New technologies for prevention of intravascular catheter-related infections
© BioMed Central Ltd 2004
Published: 29 September 2003
Intravascular catheters have become essential devices for the management of critically and chronically ill patients. However, their use is often associated with serious infectious complications, mostly catheter-related bloodstream infection (CRBSI), resulting in significant morbidity, increased duration of hospitalization, and additional medical costs. The majority of CRBSIs are associated with central venous catheters (CVCs), and the relative risk for CRBSI is significantly greater with CVCs than with peripheral venous catheters. However, most CVC-related infections are preventable, and different measures have been implemented to reduce the risk for CRBSI, including maximal barrier precautions during catheter insertion, catheter site maintenance, and hub handling. The focus of the present review is on new technologies for preventing infections that are directed at CVCs. New preventive strategies that have been shown to be effective in reducing risk for CRBSI, including the use of catheters and dressings impregnated with antiseptics or antibiotics, the use of new hub models, and the use of antibiotic lock solutions, are briefly described.
Keywordscatheter-related bloodstream infections central venous catheters new technologies prevention
Intravascular catheters represent an essential part of the management of critically and chronically ill patients. However, their use is often complicated by serious infections, mostly catheter-related bloodstream infections (CRBSIs), which are associated with increased morbidity, duration of hospitalisation, and additional medical costs. The incidence of CRBSI varies considerably by type of catheter, frequency of catheter manipulation and patient-related factors, such as underlying disease and severity of illness . However, the majority of CRBSIs are associated with central venous catheters (CVCs) , and in prospective studies the relative risk for CRBSI is up to 64 times greater with CVCs than with peripheral venous catheters [2–4].
New technologies for the prevention of central venous catheter-related bloodstream infection
Antimicrobial impregnated dressings
Chlorhexidine impregnated sponge dressing
Consider for CVCs expected to be in place for >5 days
Silver impregnated subcutaneous collagen cuff
Conflicting results in several clinical trials of efficacy
Antimicrobial impregnated catheters
Consider if institutional rate of CRBSI is high despite consistent application of preventive measures and CVC is expected to be in place for >5 days
Chlorhexidine–silver sulfadiazine impregnated catheters
Only the external surface of the CVC is coated. Not effective for CVCs left in place for >2 weeks
Minocycline–rifampin impregnated catheters
Short-term and long-term CVCs
Both the internal and external surfaces of the CVC are coated. Prolonged antimicrobial activity
Catheter hub contained a iodinated alcohol solution
A recent trial failed to show any preventive benefit from the use of this hub
Povidone–iodine satured sponge
Increased risk for CRBSI associated with improper use
Antimicrobial lock solutions
Consider only for patients with recurrent CRBSIs despite consistent application of preventive measures
For short-term CVCs (i.e. those in place <10 days), which are most commonly colonized by cutaneous organisms along the external surface of the catheter, the most important preventive systems are those that decrease the extraluminal contamination. In contrast, with long-term CVCs (i.e. those in place >10 days), in which endoluminal spread from the hub appears to be the primary mechanism of infection, technologies that reduce endoluminal colonization in addition to extraluminal invasion of the catheter should provide additional protection against CRBSI.
This report is based on a literature review of published articles in the prevention of intravascular catheter-related infections. The review was conducted by searching the Medline database of the National Library of Medicine, Bethesda, MD, USA using the following key terms: catheter-related infections, catheter-related bloodstream infections, intravascular devices, central venous catheter, prevention, infection control practices, guidelines, and new technologies. The bibliographies of selected articles were also reviewed for pertinent studies.
Antimicrobial impregnated catheters and dressings
Chlorhexidine impregnated sponge dressing
A sponge dressing impregnated with chlorhexidine gluconate (BioPatch®; Johnson and Johnson, Arlington, TX, USA) applied at the insertion site of CVCs has been shown to reduce skin colonization and bacterial migration along the external surface of the catheter as compared with skin disinfection with povidone–iodine . Therefore, it may be effective for the prevention of infections associated with short-term CVCs, in which extraluminal colonization is the primary mechanism of infection. However, local contact dermatitis to the BioPatch® dressing has been observed in low-birth-weight neonates, who require prolonged central access during the first 2 weeks of life .
Silver impregnated subcutaneous collagen cuff
A silver impregnated collagen cuff attached to CVCs and left below the skin insertion site significantly decreased the risk for extraluminal colonization associated with short-term catheters (mean duration of placement <10 days) [6, 7]. The ionic silver has broad spectrum activity against bacteria and fungi, and the cuff provides a mechanical barrier to the migration of microorganisms along the external surface of the catheter . Nevertheless, clinical trials involving short-term CVCs have yielded conflicting results [6–9]. In two randomized clinical trials conducted in surgical patients assigned to receive a CVC with or without a silver cuff [7, 8], the incidence of CRBSI was significantly greater in the control than in the cuffed catheter group (3.7% versus 1%). In the third clinical trial , however, no difference in the rates of catheter colonization or incidence of CRBSI was observed between patients who received and those who did not receive a silver cuffed CVC. Moreover, the cuff failed to reduce CRBSIs associated with catheters left in place for 20 days or longer [6, 10, 11]. This may be attributable to the biodegradable nature of the collagen and to the fact that the silver ions chelated to the cuff are released within 3–7 days. In addition, in this setting intraluminal spread from the hub is the dominant mechanism of catheter colonization. Another potential problem with the cuff is the protrusion of the system after insertion if the physician does not have sufficient experience with the insertion technique.
Catheters impregnated with antimicrobial agents
Several studies have shown that CVCs impregnated with antiseptic or antibiotic agents decreased the risk for catheter colonization and CRBSIs [12–16] in comparison with unimpregnated catheters [14, 15]. The best studied antimicrobial catheters are those impregnated with a combination of chlorhexidine and silver sulfadiazine (C-SS) or minocycline and rifampin [15, 17].
Chlorhexidine and silver sulfadiazine impregnated catheters
Catheters coated with C-SS have been shown to decrease the risk for colonization by twofold and the risk for CRBSI by at least fourfold compared with uncoated catheters . The main limitations of these catheters is that only the external surface of the catheter is coated, thus conferring no protection from microorganisms invading the internal surface of the catheter from contaminated hubs, and that the catheters have reduced antimicrobial activity and poor efficacy with long-term use (>2 weeks) [18–20]. Thus, these catheters have been shown to be particularly efficacious in reducing the risk for CRBSI associated with short-term CVCs  but failed to reduce the risk for CRBSI in situations requiring long-term catheterization . In the largest clinical trial , which included 538 patients randomly assigned to receive a C-SS impregnated catheter or a nonimpregnated catheter, in which the mean duration of catheterization was 20 ± 12 days, no significant difference in the incidence of CRBSI was observed between the control group (4.7%) and the C-SS catheter group (5%) . However, catheters impregnated intraluminally with chlorhexidine in addition to C-SS extraluminal impregnation are now available, and preliminary studies indicate their prolonged antimicrobial activity and improved efficacy in preventing infections .
C-SS impregnated catheters are more expensive than standard catheters, but they should reduce costs in settings in which the incidence of CRBSI is greater than 3.3 per 1000 catheter-days , despite adherence to other preventive strategies. A cost-effectiveness analysis concluded that using these catheters would decrease direct medical costs by US$ 196 per catheter inserted .
Resistance to the antiseptic components of this device has not been demonstrated in clinical studies . There is concern about the potential anaphylaxis associated with the use of C-SS impregnated catheters, probably related to the chlorhexidine component, and 12 cases of anaphylactic reactions have been reported from Japan , and one case from the UK . However, there have been no reports of such reactions from the USA, where more than 3 million catheters were sold during 2000 .
Minocycline–rifampin coated catheters
Catheters coated with minocycline–rifampin have the advantage of coating both the internal and external surfaces of the catheters, and have been associated with a lower rate of infection than have C-SS impregnated catheters. In a prospective clinical trial in which patients were randomly assigned to receive either minocycline–rifampin or C-SS catheters, the rate of CRBSI was significantly lower in the former group than in latter group (0.3% versus 3.4%) . Indeed, catheters coated with minocycline–rifampin exhibited broad spectrum inhibitory activity both in vitro and in vivo against Gram-positive bacteria, Gram-negative bacteria, and Candida albicans that was significantly superior to that with C-SS impregnated catheters . Moreover, the antibiotic activity of minocycline–rifampin is retained for longer periods in situ [15, 20, 25, 26]. Although more expensive than C-SS impregnated catheters, a recent analysis suggested that CVCs coated with minocycline–rifampin are cost-effective for patients catheterized for at least 1 week and lead to overall cost savings when patients are catheterised for 2 weeks or longer .
Although no resistance to the antimicrobial components of these devices has been demonstrated in clinical studies [15, 25], an in vitro study demonstrated a 10- to 16-fold increase in the minimal inhibitory concentration of the minocycline–rifampin combination with respect to Staphylococcus epidermidis, suggesting that resistance to this combination can develop. The study also indicated that minocycline had a protective role against development of rifampin resistance, because resistance to rifampin increased only 80-fold when rifampin was used in combination with minocycline, in contrast to 25 000-fold when rifampin was used alone . However, a thorough investigation is required to determine the risk for emergence of resistance to minocycline–rifampin associated with long-term use of these catheters.
Polyurethane catheters combined with silver, carbon and platinum (oligon-treated catheters) represent a new option for the prevention of CRBSI. In a prospective randomized trial, Ranucci and coworkers  compared the rates of CVC colonization and CVC bloodstream infections between 268 patients with an oligon-treated catheter and 277 patients with a polyurethane catheter treated with benzalkonium chloride. Patients in the oligon group demonstrated a lower risk for catheter colonization (relative risk 0.63, 95% confidence interval 0.46–0.86; P = 0.003), whereas no significant differences in CVC bloodstream infections were found between the oligon and the control groups.
Silver iontophoretic device
Another technology is the silver iontophoretic device, in which silver ions are released through a low voltage current to carbon-impregnated CVCs  or through silver wires that are attached to the proximal segment of a silicone catheter . Although this technology has been shown to prevent catheter infections [20, 31], the clinical safety and efficacy of this device have not been demonstrated.
Hubs and needleless connectors
Catheter hub containing a iodinated alcohol solution
A catheter hub containing an antiseptic chamber filled with 3% iodinated alcohol has been shown to reduce the rate of CRBSIs by fourfold compared with a standard hub model . This model will be most useful with long-term CVCs, in which hub and lumen colonization are the leading causes of CRBSI. On the other hand, a recent clinical trial failed to show any benefit from the use of this hub in preventing CRBSI .
Povidone–iodine saturated sponge
Another model, which uses a povidone–iodine connection shield to encase the catheter hub, showed a significant reduction in the rate of CRBSI as compared with a control hub (0% versus 24%; P < 0.05) in a randomized controlled clinical trial involving patients receiving total parenteral nutrition .
The use of needleless intravenous access devices, introduced to reduce the risk associated with occupational exposure of health care workers to blood-borne pathogens , was associated with an increased rate of CRBSI [36–38], which may be related to improper handling and inaccurate use of these devices . However, the potential for needleless connectors to increase the risk for CRBSI is uncertain, and recent clinical trials have shown that these devices do not increase the risk for infection  when they are used correctly and in combination with rigorous aseptic techniques.
Antimicrobial lock solution
Antimicrobial lock is a novel technique in which an antimicrobial solution, often consisting of an anticoagulant along with an antibiotic agent, is instilled into the lumen of the catheter and allowed to remain for a defined period, usually 6–12 hours, after which it is removed. Antimicrobial lock solutions have shown to be mostly effective for the prevention of infections associated with long-term CVCs [41, 42] but they could also be useful in short-term catheters .
Various antimicrobial agents have been shown to be efficacious in reducing the risk for infection, including vancomycin–heparin and vancomycin–ciprofloxacin–heparin solutions [42, 44]. Because the use of vancomycin is an independent risk factor for the acquisition of vancomycin-resistant enterococci , this practice is not recommended for routine use . However, in individual cases in which a patient requires indefinite vascular access but continues to experience CRBSIs despite rigorous observance of infection control measures, the use of vancomycin lock solution to preserve vascular access should be considered. A novel lock solution consisting of minocycline and EDTA (M-EDTA) has also been shown to have antimicrobial activity against the most common organisms associated with CRBSI, including Gram-positive and Gram-negative bacteria and Candida albicans, resulting in prevention of infection . In a prospective cohort study, M-EDTA proved to be efficacious in preventing port-related infections without causing any adverse events . However, randomized clinical trials are needed to test further the ability of M-EDTA to prevent long-term CVC infections.
Prophylactic use of anticoagulant agents, including heparin or warfarin, reduced the incidence of catheter thrombosis [20, 41, 42]. Because thrombi could serve as a nidus for microbial colonization of CVCs [48, 49], the use of anticoagulants may have a role in the prevention of CRBSI. For example, in a double-blind randomized controlled study conducted in a pediatric intensive care unit, heparin bonding was associated with a significant reduction in the incidence of infection (4% and 33% in heparin-bonded and non-heparin-bonded CVCs, respectively) . Furthermore, in a meta-analysis evaluating benefit of heparin prophylaxis (doses of 3 U/ml total parenteral nutrition, 5000 U every 6 or 12 hours, or 2500 U of subcutaneous low-molecular-weight heparin every day) in patients with CVCs, the risk for catheter-related central venous thrombosis was reduced with the use of prophylactic heparin . The meta-analysis also found a significantly decreased risk for bacterial colonization of the catheter and an associated reduction in CRBSI with use of heparin; however, studies included used variable definitions of catheter-related infections and the findings require confirmation by trials adhering to current, stricter definitions.
A better understanding of the pathogenesis of CVC-related infections should lead to the development of more effective preventive strategies, including antiseptics with greater and more prolonged antimicrobial activity, and new materials that make CVCs intrinsically resistant to microbial colonization and that do not promote antimicrobial resistance. Because of its critical role in the infection process, bacterial adherence represents a potential target for the development of new preventive strategies, and agents that can block the process of adherence, such as specific bacterial surface adhesin-blocking antibodies, may prove to be effective at preventing infections. In vitro studies have been conducted to assess the effectiveness of new polymer–antibiotic systems in inhibiting bacterial biofilm formation  and in reducing neutrophil activation after surface contact on different biomaterials, thus reducing the risk for biomaterial-mediated inflammatory reactions . Moreover, organisms such as staphylococci, Candida spp. and some others produce a microbial biofilm that helps them to survive on the surfaces of foreign bodies in the bloodstream. The development of biofilm involves intercellular signaling molecules that serve in a communication system termed quorum sensing. Quorum sensing enables population density control of gene expression . Molecules that inhibit quorum sensing signal generation among organisms could block microbial biofilm formation and prevent catheter colonization .
CRBSIs, as a consequence of the use of CVCs, are associated with significant morbidity, mortality and additional medical costs. Nevertheless, most CVC-related infections are preventable, and preventive strategies should aim at achieving maximal antiseptic barrier precautions during catheter insertion, catheter site maintenance, and hub handling. However, new technologies that have already been proven to be effective in clinical trials in preventing CVC infections, particularly those intended for short-term use, should be considered in clinical practice. Moreover, many of these new technologies have proven to be not only effective but also cost-effective.
catheter-related bloodstream infection
chlorhexidine and silver sulfadiazine
central venous catheter
- M-EDTA :
minocycline and EDTA.
The work of the authors is supported by grants from Ricerca Corrente e Finalizzata, Ministry of Health and from Programma Nazionale di Ricerca sull'AIDS, Istituto Superiore di Sanità, Italy.
- Centers for Disease Control and Prevention: Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep 2002,51(RR-10):1-29.Google Scholar
- Mermel LA: New technologies to prevent intravascular catheter-related bloodstream infections. Emerg Infect Dis 2001, 7: 197-199.PubMed CentralView ArticlePubMedGoogle Scholar
- Richet H, Hubert B, Nitemberg G, Andremont A, Buu-Hoi A, Ourbak P, Galicier C, Veron M, Boisivon A, Bouvier AM: Prospective multicenter study of vascular-catheter-related complications and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol 1990, 28: 2520-2525.PubMed CentralPubMedGoogle Scholar
- Collignon PJ: Intravascular catheter associated sepsis: a common problem. The Australian Study on Intravascular Catheter Associated Sepsis. Med J Aust 1994, 161: 374-378.PubMedGoogle Scholar
- Garland JS, Alex CP, Mueller CD, Otten D, Shivpuri C, Harris MC, Naples M, Pellegrini J, Buck RK, McAuliffe TL, Goldmann DA, Maki DG: A randomised trial comparing povidone-iodine to a chlorhexidine gluconate impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001, 107: 1431-1437.View ArticlePubMedGoogle Scholar
- Bonawitz SC, Hammell EJ, Kirkpatrick JR: Prevention of central venous catheter sepsis: a prospective randomized trial. Am Surg 1991, 57: 618-623.PubMedGoogle Scholar
- Maki DG, Cobb L, Garman JK, Chapiro JM, Ringer M, Helgerson RB: An attachable silver-impregnated cuff for prevention of infection with central venous catheters: a prospective randomized multicenter trial. Am J Med 1988, 85: 307-314.View ArticlePubMedGoogle Scholar
- Flowers RHD, Schenzer KJ, Kopel RF, Fish MJ, Tucker SI, Farr BM: Efficacy of an attachable subcutaneous cuff for the prevention of intravascular catheter-related infection: a randomized, controlled trial. JAMA 1989, 261: 878-883. 10.1001/jama.261.6.878View ArticlePubMedGoogle Scholar
- Smith HO, DeVictoria CL, Garfinkel D, Anderson P, Goldberg GL, Soeiro R, Elia G, Runowicz CD: A prospective randomized comparison of an attached silver-impregnated cuff to prevent central venous catheter-associated infection. Gynecol Oncol 1995, 58: 92-100. 10.1006/gyno.1995.1189View ArticlePubMedGoogle Scholar
- Dahlberg PJ, Agger WA, Singer JR, Yutuc WR, Newcomer KL, Schaper A, Rooney BL: Subclavian haemodialysis catheter infections: a prospective randomized trial of an attachable silver impregnated cuff for prevention of catheter-related infections. Infect Control Hosp Epidemiol 1995, 16: 506-511.View ArticlePubMedGoogle Scholar
- Groeger JS, Lucas AB, Coit D, LaQuaglia M, Brown AE, Turnbull A, Exelby P: A prospective, randomized evaluation of the effect of silver impregnated subcutaneous cuffs for preventing tunnelled chronic venous access catheter infections in cancer patients. Ann Surg 1993, 218: 206-210.PubMed CentralView ArticlePubMedGoogle Scholar
- Greenfild JI, Sampath L, Popiskis SJ, Brunnert SR, Stylianos S, Modak S: Decreased bacterial adherence and biofilm formation on chlorexidine and silver sulfadiazine impregnated central venous catheters implanted in swine. Crit Care Med 1995, 23: 894-900. 10.1097/00003246-199505000-00018View ArticleGoogle Scholar
- Kamal GD, Pfaller MA, Rempe LE, Jebson PJ: Reduced intravascular catheter infection by antibiotic bolding. JAMA 1991, 265: 2364-2368. 10.1001/jama.265.18.2364View ArticlePubMedGoogle Scholar
- Maki DG, Stolz SM, Wheeler S, Mermel LA: Prevention of central venous catheter-related infection by use of an antiseptic impregnated catheter. A randomized, controlled trial. Ann Intern Med 1997, 127: 257-266.View ArticlePubMedGoogle Scholar
- Raad I, Darouiche R, Dupuis J, Abi-Said D, Gabrielli A, Hachem R, Wall M, Harris R, Jones J, Buzaid A, Robertson C, Shenaq S, Curling P, Burke T, Ericsson C: Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infection: a randomized, double-bind trial. The Texas Medical Center Catheter Study Group. Ann Intern Med 1997, 127: 267-274.View ArticlePubMedGoogle Scholar
- Bach A, Bohrer H, Motsh J, Martin E, Geiss HK, Sonntag HG: Prevention of bacterial colonization of intravenous catheters by antiseptic impregnation of polyurethane polymers. J Antimicrobial Chemother 1994, 33: 969-978.View ArticleGoogle Scholar
- Veenstra DL, Saint S, Saha S, Lumeley T, Sullivan SD: Efficacy of antiseptic-impregnated central venous catheters in preventing catheter related bloodstream infection: a meta-analysis. JAMA 1999, 281: 261-267. 10.1001/jama.281.3.261View ArticlePubMedGoogle Scholar
- Bach A, Schmidt H, Bottiger B, Schreiber B, Bohrer H, Motsch J, Martin E, Sonntag HG: Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters. J Antimicrob Chemoter 1996, 37: 315-322.View ArticleGoogle Scholar
- Logghe C, Van Ossel C, D'Hoore W, Ezzedine H, Wauters G, Haxhe JJ: Evaluation of chlorexidine and silver sulfadiazine impregnated central venous catheters for the prevention of bloodstream infection in leukaemia patients: a randomized controlled trial. J Hosp Infect 1997, 37: 145-156. 10.1016/S0195-6701(97)90184-5View ArticlePubMedGoogle Scholar
- Raad I, Darouiche R, Hachem R, Mansouri M, Bodey GP: The broad-spectrum activity and efficacy of catheter coated with minocycline and rifampin. J Infect Dis 1996, 173: 418-424.View ArticlePubMedGoogle Scholar
- Bassetti S, Hu J, D'Agostino RB Jr, Sherertz RJ: Prolonged antimicrobial activity of a catheter containing chlorhexidine-silver sulfadiazine extends protection against catheter infections in vivo. Antimicrob Agents Chemoter 2001, 45: 1535-1538. 10.1128/AAC.45.5.1535-1538.2001View ArticleGoogle Scholar
- Oda T, Hamasaki J, Kanda N, Mikami K: Anaphylactic shock induced by an antiseptic-coated central venous catheter. Anesthesiology 1997, 87: 1242-1244. 10.1097/00000542-199711000-00031View ArticlePubMedGoogle Scholar
- Stephens R, Mythen M, Kallis P, Davies DW, Egner W, Rickards A: Two episodes of life-threatening anaphylaxis in the same patient to a chlorhexidine-sulphadiazine-coated central venous catheter. Br J Anaesth 2001, 87: 306-308. 10.1093/bja/87.2.306View ArticlePubMedGoogle Scholar
- Crnich CJ, Maki DG: The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices. Clin Infect Dis 2002, 34: 1232-1242. 10.1086/339863View ArticlePubMedGoogle Scholar
- Darouiche RO, Raad II, Heard SO, Thornby JI, Wenker OC, Gabrielli A, Berg J, Khardori N, Hanna H, Hachem R, Harris RL, Mayhall G: A comparison of two antimicrobial impregnated central venous catheters. N Engl J Med 1999, 340: 1-8. 10.1056/NEJM199901073400101View ArticlePubMedGoogle Scholar
- Raad II, Darouiche RO, Hachem R, Abi-Said D, Safar H, Darnule T, Mansouri M, Morck D: Antimicrobial durability and rare ultrastructural colonization of indwelling central catheters coated with minocycline and rifampin. Crit Care Med 1998, 26: 219-224. 10.1097/00003246-199802000-00015View ArticlePubMedGoogle Scholar
- Marciante KD, Veenstra DL, Lipsky BA, Saint S: Which antimicrobial impregnated catheter should we use? Modelling the costs and outcomes of antimicrobial catheter use. Am J Infect Control 2003, 31: 1-8. 10.1067/mic.2003.35View ArticlePubMedGoogle Scholar
- Tambe SM, Sampath L, Modak SM: In vitro evaluation of the risk of developing bacterial resistance to antiseptics and antibiotics used in medical devices. J Antimicrob Chemother 2001, 47: 589-598. 10.1093/jac/47.5.589View ArticlePubMedGoogle Scholar
- Ranucci M, Isgro G, Giomarelli PP, Pavesi M, Luzzani A, Cattabriga I, Carli M, Giomi P, Compostella A, Digito A, Mangani V, Silvestri V, Mondelli E, Catheter Related Infection Trial (CRIT) Group: Impact of oligon central venous catheters on catheter colonization and catheter-related bloodstream infection. Crit Care Med 2003, 3: 52-59. 10.1097/00003246-200301000-00008View ArticleGoogle Scholar
- Liu WK, Tebbs SE, Byrne PO, Elliott TS: The effects of electric current on bacteria colonizing intravenous catheters. J Infect 1993, 27: 261-269.View ArticlePubMedGoogle Scholar
- Raad I, Hachem R, Zermeno A, Dumo M, Bodey GP: In vitro antimicrobial efficacy of silver iontophoretic catheters. Biomaterials 1996, 17: 1055-1059. 10.1016/0142-9612(96)85905-9View ArticlePubMedGoogle Scholar
- Segura M, Alvarez-Lerma F, Tellado JM, Jimenez-Ferreres J, Oms L, Rello J, Baro T, Sanchez R, Morera A, Mariscal D, Marrugat J, Sitges-Serra A: A clinical trial on the prevention of catheter-related sepsis using a new hub model. Ann Surg 1996, 223: 363-369. 10.1097/00000658-199604000-00004PubMed CentralView ArticlePubMedGoogle Scholar
- Luna J, Masdeu G, Perez M, Claramonte R, Forcadell I, Barrachina F, Panisello M: Clinical trial evaluating a new hub device designate to prevent catheter-related sepsis. Eur J Clin Microbiol Infect Dis 2000, 19: 655-662. 10.1007/s100960000346View ArticlePubMedGoogle Scholar
- Halpin DP, O'Byrne P, Mc Entee G, Hennessy TP, Stephens RB: Effects of a Betadine connection shield on central venous catheters sepsis. Nutrition 1991, 7: 33-34.PubMedGoogle Scholar
- Mendelson MH, Short LJ, Schechter CB, Meyers BR, Rodriguez M, Cohen S, Lozada J, DeCambre M, Hirschman SZ: Study of needleless intermittent intravenous access system for peripheral infusions: analysis of staff patient, and institutional outcomes. Infect Control Hosp Epidemiol 1998, 19: 401-406.View ArticlePubMedGoogle Scholar
- Danzig LE, Short LJ, Collins K, Mahoney M, Sepe S, Bland L, Jarvis WR: Bloodstream infections associated with a needleless intravenous infusion system in patients receiving home infusion therapy. JAMA 1995, 273: 1862-1864. 10.1001/jama.273.23.1862View ArticlePubMedGoogle Scholar
- Cookson ST, Ihrig M, O'Mara EM, Denny M, Volk H, Banerjee SN, Hartstein AI, Jarvis WR: Increased bloodstream infection rates in surgical patients associated with variation from recommended use and care following implementation of a needleless device. Infect Control Hosp Epidemiol 1998, 19: 28-31.View ArticlePubMedGoogle Scholar
- Kellerman S, Shay DK, Howard J, Goes C, Feusner J, Rosenberg J, Vugia DJ, Jarvis WR: Bloodstream infections in home infusion patients: the influence of race and needleless intravescular devices. J Pediatr 1996, 129: 711-717.View ArticlePubMedGoogle Scholar
- Do AN, Ray BJ, Banerjee SN, Illian AF, Barnett BJ, Pham MH, Hendricks KA, Jarvis WR: Bloodstream infection associated with needleless devices use and the importance of infection control practices in the home health care setting. J Infect Dis 1999, 179: 442-448. 10.1086/314592View ArticlePubMedGoogle Scholar
- Seymour VM, Dhallu TS, Moss HA, Tebbs SE, Elliot TS: A prospective clinical study to investigate the microbial contamination of a needleless connector. J Hosp Infect 2000, 45: 165-168. 10.1053/jhin.2000.0726View ArticlePubMedGoogle Scholar
- Rackoff WR, Weiman M, Jakobowski D, Hirschl R, Stallings V, Bilodeau J, Danz P, Bell L, Lange B: A randomized, controlled trial of the efficacy of a heparin and vancomycin solution in preventing central venous catheter infection in children. J Pediatr 1995, 127: 147-151.View ArticlePubMedGoogle Scholar
- Shwartz C, Henrickson KJ, Roghmann K, Powell K: Prevention of bacteremia attributed to luminal colonization of tunnelled central venous catheter with vancomycin susceptible organisms. J Clin Oncol 1990, 8: 591-597.Google Scholar
- Raad II, Hanna HA: Intravascular catheter-related infections. New horizons and recent advances. Arch Intern Med 2002, 162: 871-878. 10.1001/archinte.162.8.871View ArticlePubMedGoogle Scholar
- Henrickson KJ, Axtell RA, Hoover SM, Kuhn SM, Pritchett J, Kehl SC, Klein JP: Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solutions: a randomized, multicenter, double-blind trial. J Clin Oncol 2000, 18: 1269-1278.PubMedGoogle Scholar
- Centers for Disease Control and Prevention: Recommendations for preventing the spread of vancomycin resistance. Recommendations of the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 1995,44(RR-12):1-13.Google Scholar
- Raad I, Buzaid A, Rhyne J, Hachem R, Darouiche R, Safar H, Albitar M, Sherertz RJ: Minocycline and etylenediaminetetraacetate for the prevention of recurrent vascular catheter infections. Clin Infect Dis 1997, 25: 149-151.View ArticlePubMedGoogle Scholar
- Chatzinikolaou I, Zipf TF, Hanna H, Umphrey J, Roberts WM, Sherertz R, Hachem R, Raad I: Minocycline-ethylenediamine tetracetate lock solution for the prevention of implantable port infections in children with cancer. Clin Infect Dis 2003, 36: 116-119. 10.1086/344952View ArticlePubMedGoogle Scholar
- Raad II, Luna M, Khalil SA, Costerton JW, Lam C, Bodey GP: The relationship between the thrombotic and infectious complications of central venous catheters. JAMA 1994, 271: 1014-1016. 10.1001/jama.271.13.1014View ArticlePubMedGoogle Scholar
- Timsit JF, Farkas JC, Boyer JM, Martin JB, Misset B, Renaud B, Carlet J: Central vein catheter-related thrombosis in intensive care patients: incidence, risk factors, and relationship with catheter-related sepsis. Chest 1998, 113: 165-171.View ArticleGoogle Scholar
- Pierce CM, Wade A, Mok Q: Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children. Intensive Care Med 2000, 26: 967-972. 10.1007/s001340051289View ArticlePubMedGoogle Scholar
- Randolph AG, Cook DJ, Gonzales CA, Andrew M: Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis of randomised controlled trials. Chest 1998, 113: 165-171.View ArticlePubMedGoogle Scholar
- Donelli G, Francolini I, Piozzi A, Di Rosa R, Marconi W: New polymer-antibiotic systems to inhibit bacterial biofilm formation: a suitable approach to prevent central venous catheter-associated infections. J Chemother 2002, 14: 501-507.View ArticlePubMedGoogle Scholar
- Schmidt S, Haase G, Csomor E, Lutticken R, Peltroche-Llacsahuanga H: Inhibitor of complement, Compstatin, prevents polymer-mediated Mac-1 up-regulation of human neutrophils independent of biomaterial type tested. J Biomed Mater Res 2003, 66A: 491-499. 10.1002/jbm.a.10031View ArticleGoogle Scholar
- Parsek MR, Val DL, Hanzelka BL, Cronan JE Jr, Greenberg EP: Acyl homoserine-lactone quorum-sensing signal generation. Proc Natl Acad Sci USA 1999, 96: 4360-4365. 10.1073/pnas.96.8.4360PubMed CentralView ArticlePubMedGoogle Scholar
- Davies DG, Parsek MR, Pearson JP, Iglewski BH, Costerton JW, Greenberg EP: The involvement of cell-to-cell signals in the development of a bacterial biofilm. Science 1998, 280: 295-298. 10.1126/science.280.5361.295View ArticlePubMedGoogle Scholar