Needleless connectors (NCs) are an important component of the intravenous system. .. study have found a similar relationship with 2 positive-pressure MV- NCs [9–12]. Nosocomial bacteremia caused by antibiotic-resistant gram- negative. Needleless Connectors and Bacteremia: Is There a Relationship? By Marilyn Hanchett, RN, PhD. Abstract. Needleless connectors, used today as integral. The needleless closed system (NCS) has been disseminated in several to clarify the relationship between the internal jugular vein and the common carotid artery was the development of any CVC-RBSI, which included either bacteremia or . Disinfection of needleless catheter connectors and access ports with alcohol.
Those attending the focus groups used a variety of MV-NCs. Surveillance for HA-BSIs at all collaborating hospitals was conducted by their infection preventionists IPs using the same ie, CDC definitions, data collection processes, and methods during all study periods.
To evaluate factors responsible for switching from SS-NC to MV-NC, collaborators were asked who had made the decision at their facility and how the decision had been made. Data were provided by IPs at 5 hospitals 4 academic and 1 community hospitalincluding 16 ICUs, hospital-wide hospital Cand 1 adult oncology ward hospital D.
Drivers for NC change. Often, the decision to change from SS- to MV-NC was made by occupational health, product evaluation, or other committees, without infection control personnel input. In trials simulating clinical use, septal membranes of connectors were inoculated with E. Microorganisms suspended in the intraluminal fluid path of antimicrobial connectors were rapidly killed.
For 5 species, there was a 5.
These simulation experiments show that needleless connectors readily acquire an internal biofilm when microorganisms gain access to the internal fluid path and that biofilm formation allows an exponential buildup of internal contamination, with shedding back into the fluid path and downstream sufficient to cause bacteremia.
Incorporation of nanoparticle silver into the lining surfaces of the novel connector kills microorganisms in the fluid pathway and prevents internal biofilm formation, even with high levels of introduced contamination and continuous fluid flow. This technology deserves to be evaluated in a prospective, randomized clinical trial to determine its capacity to prevent catheter-associated bloodstream infection.
More thanintravascular device-related bloodstream infections BSIs occur in the United States each year, the majority caused by central venous catheters CVCs [ 1 ]. Microorganisms cause CVC-related infection when they gain access to the surface of the implanted device where they can establish a biofilm [ 45 ], allowing sustained surface colonization and, ultimately, dissemination into the bloodstream.
With short-term intravascular devices—peripheral intravenous catheters, arterial catheters, and noncuffed and nontunneled CVCs—most catheter-related BSIs originate from skin of the insertion site and gain access extraluminally and occasionally intraluminally [ 6—8 ].
With long-term devices—cuffed and tunneled CVCs, totally implanted central venous ports, and peripherally inserted central venous catheters PICCs —intraluminal contaminants are the major cause of device-related BSI [ 9—13 ].
Needleless valved connectors for CVCs have come into near-universal use throughout the United States as part of the national movement to reduce the risk to health care workers of biohazardous sharps injuries and exposure to bloodborne viruses, such as human immunodeficiency virus, hepatitis B virus, and hepatitis C virus, following the Occupational Safety and Health Administration's Needlestick Safety and Prevention Act of [ 14—16 ].
A recent meta-analysis has shown that these devices have reduced the incidence of biohazardous needlestick injuries in health care workers [ 17 ]. Unfortunately, over the past 15 years a growing number of reports have suggested that valved needleless connectors are associated with significantly increased risks of CVC-associated BSI [ 18—27 ]. In most of these reports, the adoption of a new Luer-activated, valved needleless connector by a hospital or home care infusion therapy program—usually replacing a splitseptum connector—has been associated with an abrupt and significant increase in the incidence of nosocomial BSI, particularly CVC-associated BSIs.
Multiple manufacturers' valved connectors have been implicated in these reports. In a number of institutions, increased rates of BSI persisted despite intensified efforts to achieve a high level of compliance with infection control practices to prevent CVC-associated BSI, including routinely vigorously disinfecting the membranous septum of the connector before actuation and entry, and BSI rates decreased only after discontinuing use of the new valved connector [ 18—27 ].
Frequent handling and access of catheter hubs, needless connectors, and injection ports has been shown to put patients at increased risk of CVC-associated primary BSI [ 1820—2228 ], presumably because they facilitate entry ofmicroorganisms into the connector and fluid path. In support of this hypothesis, studies have shown a high incidence of biofilm formation on the interior surface of valved connectors that have been used clinically [ 29 ].
Although needleless connectors and injection ports are recognized sites of access for microbial contamination, no national standard exists defining the best and recommended form of antiseptic preparation to prevent microbial entry when the needleless connector or injection port is accessed.
Although studies have examined the efficacy of various disinfectants to remove microorganisms from the membranous surface of needleless connectors or injection ports [ 2830—32 ], there have been no randomized clinical trials that have prospectively examined the efficacy of various approaches to disinfection of connectors for prevention of CVC-related BSI.
Disinfection of Needleless Connector Hubs: Clinical Evidence Systematic Review
Most importantly, numerous studies have shown that if there is significant contamination of the membranous septum prior to actuation, conventional disinfection may fail to prevent entry of microorganisms [ 2830—36 ].
It seems clear that there is an urgent need to develop new technologies that can implicitly reduce the risk of contamination of needleless connectors and associated BSI. We report in vitro studies of a novel antimicrobial luer-activated connector, with a nanoparticle-silver coating of the entire surface, to ascertain its capacity to resist internal fluid contamination and biofilm formation and potential to confer protection against catheterassociated BSI.
Methods The novel antimicrobial needleless connector. The novel antimicrobial connector evaluated in this study V-Link; Baxter Healthcare is an adaptation of the company's nonmedicated single-use, disposable, luer-activated, valved connector constructed of polycarbonate Clearlink; Baxter Healthcarewhich is designed to connect an administration set or extension set to a vascular catheter and provide needleless access for administration of fluid or withdrawal of blood specimens.
NC are used on virtually all intravascular devices in the USA; they provide an easy access point for syringe or tubing attachment and have now become the central access point for all connections.
Yet, despite providing some level of safety, concerns over infection related to NC contamination exist. Surface design, gaps around valve closure surface, segmented fluid pathway with dead space, differing internal mechanisms, clear or obscured visibility, variable blood reflux, clamping sequences, and different flushing instructions, depending on the type of NC, all play a part in the level of risk associated with the device. Before the advent of NC, clinicians had an intuitive understanding that prior to penetrating the septum with the needle the septum required disinfection.
Current surface disinfection of NC is not necessarily intuitive. As a result, the disinfection process remained intuitive. With the changes to the access point using direct luer connection through the NC, the intuitive sense to disinfect the surface prior to access is lost; many clinicians fail to realize the consequences of this breech in aseptic technique [ 4 — 6 ].
Nursing Research and Practice
Disinfection of the exposed surface of the NC is necessary to avoid contamination and subsequent intraluminal biofilm formation and protect patients from infection. The results of the groundbreaking Keystone initiative demonstrated the effect of five measures, known as the Central Line Bundle, on the improvement of outcomes during insertion of central venous catheters [ 64].
However, despite the successes of the insertion bundle, full compliance more than seven years later is still lacking, with reported compliance rates at one institution ranging from 0. Disinfection of the NC access site was not included in the insertion related central line bundle. To reach the goal of zero, consideration must be given for the pathogenesis of catheter related infections and an investigation into current human factors of catheter management preventing achievement of this goal.
While many experts agree that application of the insertion bundle is one of the best ways to prevent insertion-related infection, the bundle does not address NC, aseptic access, or any postinsertion catheter usage issues. A Pennsylvania study reported that Contamination of the catheter directly through the catheter hub has been confirmed through published studies [ 1213— ].
These studies found that bacteria identified on external hub surfaces were also present in biofilm sampled from random locations within the needless connector. Research performed at one institution revealed that patient skin flora was not the source of catheter related bloodstream infections in any of their cases; all infections in this study originated from the catheter hub [ 6]. Infections later in the life of the catheter develop from improper catheter manipulation, failure to perform hand hygiene, inadequate time to clean NC, inadequate training, and poor access and exit site management [ 267, ].
This common break in aseptic technique sets the stage for biofilm formation within NC and catheters and increases the potential for delayed infection of both central and peripheral catheters [ 146068, ]. The results of the Pennsylvania Patient Safety Advisory Report and independent biofilm sampling of NC suggest that more attention is needed for aseptic access and maintenance practices [ ]. According to the Epic3 Evidence-Based Guidelines for Preventing Healthcare Infections, disinfection is defined as the use of chemical or physical methods to reduce the number of pathogenic microorganisms on surfaces to a level at which they are not able to cause harm, but which does not usually destroy spores [ 53 ].
These guidelines further state that disinfection methods used in combination with cleaning blood or other debris off the surface as disinfectants have limited ability to penetrate organic material [ 8 ]. The Association for Professionals in Infection Control APIC defines disinfection as a process to eliminate microorganisms accomplished with the use of liquid chemicals or pasteurizing; process works best by having proper contact time and dilution of disinfection agent [ ].
Goal The goal of this review is to assess current literature related to disinfection of NC to establish recommendations that promote aseptic access, reducing infection risk for the patient. Search Methodology The purpose of this systematic review was to evaluate the supporting evidence for disinfection practices of NC, catheter hub, stopcock, and side ports that reduce the transfer of microorganisms through intravascular device access.
Since no RCTs were found, lower level evidence including clinical and in vitro laboratory studies was reviewed, as long as these included reporting of quantitative data. Additional studies were cross-referenced through manual search. Conference posters and abstracts were included in the review. Manufacturers websites of disinfection ports and two manufacturers Excelsior Medical, Neptune, NJ; Ivera Medical Corporation, San Diego, CA were contacted directly requesting all published materials and posters on disinfection products.
There were no identified formal published systematic reviews of the effectiveness of NC disinfection practices, indicating a knowledge gap in this area. Search results were evaluated by title, abstract, and content.
Selected papers were subjected to full-text assessment. Initial selection process and critique was performed by one researcher NMwith evidence rating performed by two researchers independently NM and JFwith any disagreement in quality rating resolved by discussion.
Inclusion criteria consisted of publications meeting search terms and topic requirements under sub groupings: Exclusion criteria were i nonresearch papers, ii studies of adult, pediatric, or neonatal increasingly important role patients not inclusive of intravascular device disinfection practices, iii primary populations outside acute care, iv publications not translated into English, v studies prior to Results The systematic review of these topics yielded a total of papers and abstracts.
After initial review articles did not meet eligibility requirements and were removed.
Of the studies 67 were graded according to the strength of the study. The study results and ratings of the literature are included in Tables 1 — 5 and Figure 1with recommendations are represented in Table 6.
Disinfecting agents and devices literature.
Sources of contamination literature. Education and compliance literature. Table 6 Figure 1 3. Because catheters provide an open conduit into the vasculature, a NC is attached, via luer threaded connection, to the integrated hub end of the catheter establishing a closed system.
Studies reflecting benefits of closed systems with NC have trended toward demonstration of protection for catheter and hub colonization [ 4]. In a prospective controlled study by Rosenthal and Maki and multicenter prospective cohort by Rangel-Frausto et al.
NC used as a closed system must be weighed with consideration for potential negative factors of design features, poor aseptic practices, and lack of disinfection that all contribute to risk of infection [ 2, ]. Any puncture through the protective skin barrier creates a portal for bacteria to enter the body.