Infection remains the leading complication that is associated with intravascular access devices. Despite continuous research efforts and advances in technology, the rate of central venous catheter infections has remained relatively constant over the past decade. This article focuses on four pertinent aspects of central venous access infection: microbial etiology and pathogenesis, diagnosis, prevention, and treatment. An update of the scientific literature in this area will aid clinicians in their patient care practices and serve to identify unanswered questions.
Get full access to this article
View all access options for this article.
References
1.
1. Hospital Infection Control Practices Advisory Committee, Centers for Disease Control and Prevention. Guidelines for prevention of intravascular-device-related infections. Infect Control Hosp Epidemiol1996;17:438–73.
2.
2. Maki DG, Stolz SM, Wheeler S, et al. Prevention of central venous catheter-related bloodstream infection by use of an antiseptic-impregnated catheter: a randomized, controlled trial. Ann Intern Med1997;127:257–66.
3.
3. CDC NNIS System. National Nosocomial Infections Surveillance (NNIS) Report, Data Summary from October 1986-April 1997, Issued May 1997. Am J Infect Control1997;25:477–87.
4.
4. Mermel LA.Bacteriology, safety and prevention of infection associated with continuous intravenous infusions. Bloods Coagulation Fibrinolysis1996;7(Suppl 1):S45–S51.
6. Gosbell IB.Central venous catheter-related sepsis: epidemiology, pathogenesis, diagnosis, treatment and prevention. Intensive Care World1994;11:55–8.
7.
7. Mermel LA.Defining intravascular-catheter-related infections: a plea for uniformity. Nutrition1997;13(Suppl 1):2S–4S.
8.
8. Krzywda EA.Central venous access-catheters, technology and physiology. Med Surg Nurs1998;7:132–9.
9.
9. Orr ME, Ryder MA.Vascular access devices: perspectives on designs, complications, and management. Nutr Clin Pract1993;8:145–52.
10.
10. Linares J, Dominguez A, Martin R.Current laboratory techniques in the diagnosis of catheter-related infections. Nutrition1997;13(Suppl 1):10S–14S.
11.
11. Maki DG, Weise CE, Sarafin HW.A semiquantitative culture method for identifying intravenous catheter-related infections. N Engl J Med1977;296:1305–9.
12.
12. Sherertz RJ, Raad II, Balani A, et al. Three year experience with sonicated vascular cultures in a clinical microbiology laboratory. J Clin Microbiol1990;28:76–82.
13.
13. Blot F, Schmidt E, Nitenberg G, et al. Earlier positivity of central-venous versus peripheral-blood cultures is highly predictive of catheter-related sepsis. J Clin Microbiol1998;36:105–9.
14.
14. Raad I, Dans S, Khan A, et al. Impact of central venous catheter removal on the recurrence of catheter-related coagulase-negative staphylococcal bacteremia. Infect Control Hosp Epidemiol1992;13:215–21.
15.
15. Quillici N, Audibert G, Conroy MC, et al. Differential quantitative blood cultures in the diagnosis of catheter-related sepsis in intensive care units. Clin Infect Dis1997;25:1066–70.
16.
16. Fan ST, Teoh-Chan CH, Lau KF.Evaluation of central venous catheter sepsis by differential quantitative culture. Eur J Clin Microbiol Infect Dis1989;8:142–4.
17.
17. Armstrong CW, Mayhall CC, Miller KB, et al. Clinical predictor of infection of central venous catheters used for TPN. Infect Control Hosp Epidemiol1990;11:71–8.
18.
18. Wing EJ, Norden CW, Shadduck RK, et al. Use of quantitative bacteriologic technique to diagnose catheter-related sepsis. Arch Intern Med1979;139:482–3.
19.
19. Maki DG.Infections caused by intravascular device pathogenesis, strategies for prevention. Royal Society of Medicine Services Ltd, London, 1991.
20.
20. Sitges-Serra A.Hub colonization as the initial step in outbreaks of catheter-related sepsis due to coagulase-negative staphylococci during parenteral nutrition. J Parenteral Enteral Nutr1984;8:668–72.
21.
21. Linares J, Sitges-Serra A, Garau J, et al. Pathogenesis of catheter sepsis: a prospective study with quantitative and qualitative cultures of catheter hub and segments. J Clin Microbiol1985;21:357–60.
22.
22. Raad I, Costerton W, Sabharwal U, et al. Ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization and duration of placement. J Infect Dis1993;168:400–7.
23.
23. Banerjee SN, Emori TG, Culver DH, et al. Secular trends in nosocomial primary bloodstream infection in the United States, 1980–1989, National Nosocomial Infection Surveillance (NNIS) System. Am J Med1991;91(Suppl 3B):86S–9S.
24.
24. Pallares R, Dick R, Wenzel RP, et al. Trends in antimicrobial utilization at a tertiary teaching hospital during a 15-year period (1978–1992);InfectControl Hosp Epidemiol1993;14:376–82.
25.
25. Edmiston CE.Prosthetic device infections in surgery. IN Problems in General Surgery: Surgical Sepsis 1993 and Beyond, Nichols RL, Nyhus LM (eds). JB Lippincott, Philadelphia, 1993, pp 444–68.
26.
26. Schwank S, Rajacic Z, Zimmeril W, et al. Impact of bacterial biofilm formation on in-vitro and in-vivo activities of antibiotics. Antimicrob Agents Chemother1998;42:895–8.
27.
27. Souli M, Giamarellou H.Effects of slime produced by clinical isolates of coagulase-negative staphylococci on activities of various antimicrobial agents. Antimicrob Agents Chemother1998;42:939–41.
28.
28. Anwar H, Strap JL, Costerton JW.Establishment of aging biofilms: possible mechanism of bacterial resistance to antimicrobial therapy. Antimicrob Agents Chemother1992;36:1347–51.
29.
29. Schaberg DR.Major trends in the microbial etiology of nosocomial infection. Am J Med1991;91(Suppl 3B):72S–5S.
30.
30. John JF, Barg NL.Staphylococcus aureus. IN Hospital Epidemiology, Mayhall CG (ed). Williams & Wilkins, Philadelphia, 1996, pp 271–90.
31.
31. Greene JN.Catheter-related complications of cancer therapy. Infect Dis Clin N Am1996;10:255–95.
32.
32. Steinberg JP, Clark CC, Hackman BO.Nosocomial and community-acquired Staphylococcus aureus bacteremias from 1980 to 1993: impact of intravascular devices and methicillin resistance. Clin Infect Dis1996;23:255–9.
33.
33. Shay DK, Maloney SA, Montecalvo M, et al. Epidemiology and mortality risk of vancomycin-resistant enterococcal bloodstream infections. J Infect Dis1995;172:993–1000.
34.
34. Edmonds MB, Ober JF, Weinbaum DL, et al. Vancomycin-resistant Enterococcus faecium bacteremia: risk factors for infection. Clin Infect Dis1995;20:1126–33.
35.
35. Karanfil LV, Murphy M, Josephson A, et al. A cluster of vancomycin-resistant Enterococcus faecium in an intensive care unit. Infect Control Hosp Epidemiol1992;13:195–200.
36.
36. Boyce JM, Opal SM, Chow JW, et al. Outbreak of multidrugresistant Enterococcus faecium with transferable vanB class vancomycin resistance. J Clin Microbiol1994;32:1148–53.
37.
37. Graninger W, Ragette R.Nosocomial bacteremia due to Enterococcus faecalis without endocarditis. Clin Infect Dis1992;15:49–57.
38.
38. Ena J, Dick R, Wenzel RP, et al. The epidemiology of intravenous vancomycin usage in a university hospital. A 10-year study. JAMA1993;269:598–602.
39.
38a. Smith TL, Pearson ML, Wilcox KR, et al. Emergence of vancomycin resistance in Staphylococcus aureus. N Engl J Med1999;340:493–501.
40.
39. Elishoov H, Or R, Strauss N, et al. Nosocomial colonization, septicemia, and Hickman/Broviac catheter-related infections in bone marrow transplant recipients: a 5-year prospective study. Medicine1998;83–101.
41.
40. McNeil MM.Candida. IN Hospital Epidemiology, Mayhall CG (ed). Williams & Wilkins, Philadelphia, 1996, pp 408–19.
42.
41. Pfaller MA, Cabezudo I, Hollis R, et al. The use of biotype and DNA fingerprinting in typing Candida albicans from hospitalized patients. Diagn Microbiol Infect Dis1990;13:481–9.
43.
42. Moro ML, Maffei C, Manso E, et al. Nosocomial outbreaks of systemic candidosis associated with parenteral nutrition. Infect Control Hosp Epidemiol1990;11:27–35.
44.
43. Lee W, Bumie JP, Matthews RC, et al. Hospital outbreaks with yeast. J Hosp Infect1991;18(Suppl A):237–49.
45.
44. Nguyen MH, Peacock JE, Tanner DC, et al. Therapeutic approaches in patients with candidaemia: evaluation in a multicenter, prospective observational study. Arch Intern Med1995;155:2429–35.
46.
45. Maki DG, Rhame FS, Mackel DC, et al. Nationwide epidemic of septicemia caused by contaminated intravenous products. Am J Med1976;60:471–85.
47.
46. Krzywda E, Andris D, Edmiston CE, et al. Hickman catheter sepsis: efficacy of antibiotic lock therapy. Infect Control Hosp Epidemiol1995;16:596–8.
48.
47. Trooskin SZ, Mikulaschek AW.Biomaterials used for catheters. IN Implantation Biology, Greco RS (ed). CRC Press, Boca Raton, FL, 1994, pp 267–86.
49.
48. Raad I, Davis S, Becker M, et al. Low infection rate and long durability of nontunnelled silastic catheters: a safe and cost effective alternative for long-term venous access. Arch Intern Med1993;153:1791–6.
50.
49. Groeger JS, Lucas AB, Thaler HT, et al. Infectious morbidity associated with long-term use of venous access devices in patients with cancer. Ann Intern Med1993;119:1168–74.
51.
50. Howell PB, Walters PE, Donowitz GR, et al. Risk factors for infection of adult patients with cancer who have tunnelled central venous catheters. Cancer1995;75:1367–74.
52.
51. Mermel LA.Prevention of intravascular-catheter related infections. Infect Dis Clin Practice1994;3:391–8.
53.
52. Taber SW, Bergamini TM.Long-term venous access: indications and choice of site and catheter. Sem Vasc Surg1997;10:130–4.
54.
53. Band JD, Maki DG.Infections caused by arterial catheters used for hemodynamic monitoring, Am J Med1979;67:735–41.
55.
54. Bock SN, Lee RE, Fisher B, et al. A prospective randomized trial evaluating prophylactic antibiotics to prevent triple lumen catheter-related sepsis in patients treated with immunotherapy. J Clin Oncol1990;8:161–9.
56.
55. Al-Sibai MB.The value of prophylactic antibiotics during insertion of long-term indwelling silastic right atrial catheters in cancer patients. Cancer1987;60:1891–5.
57.
56. Ranson MR, Oppenheim BA, Jackson A, et al. Double-blind placebo controlled study of vancomycin prophylaxis for central venous catheter insertion in cancer patients. J Hosp Infect1990;15:95–102.
58.
57. McKee R, Dunsmuir R, Whitby M, et al. Does antibiotic prophylaxis at the time of catheter insertion reduce the incidence of catheter-related sepsis in intravenous nutrition?J Hosp Infect1985;6:419–25.
59.
58. Stillman RM, Soliman F, Garcia L, et al. Etiology of catheter-associated sepsis: correlation with thrombogenicity. Arch Surg1977;112:1497–9.
60.
59. Press OW, Ramsey PG, Larson EB, et al. Hickman catheter infections in patients with malignancies. Medicine1984,63:189–99.
61.
60. Raad II, Luna M, Khalil SAM, et al. The relationship between the thrombotic and infectious complications of central venous catheters. JAMA1994;271:1014–6.
62.
61. Timsit JF, Farkas JC, Boyer JM, et al. Central vein catheter-related thrombosis in intensive care patients. Incidence, risk factors, and relationship with catheter-related sepsis. Chest1998;114:207–13.
63.
62. Brun-Buisson C, Abrouk F, Legrand P, et al. Diagnosis of central venous catheter-related sepsis: critical level of quantitative tip cultures. Arch Intern Med1987;147:873–7.
64.
63. Collignon PJ, Soni N, Pearson IY, et al. Is semiquantitative culture of central vein catheter tip useful in the diagnosis of catheter-associated bacteremia?J Clin Microbiol1986;24:532–5.
65.
64. Richet H, Hubert B, Nitemberg G, et al. Prospective multicenter study of vascular catheter-related complication and risk factors for positive central-catheter cultures in intensive care unit patients. J Clin Microbiol1990;28:2520–5.
66.
65. Ryder MA.Peripheral access options. Surg Oncol Clin N Am1995;153:1791–6.
67.
66. Bernard RW, Stahl WM.Subclavian vein catheterization: a prospective study. I. Noninfectious complications. Ann Surg1971;173:184–90.
68.
67. Fuch RC, Gustafson ME, King JT, et al. Assessment of catheter-associated infection risk with the Hickman right atrial catheter. Infect Control1984;5:226–30.
69.
68. Lee RB, Buckner M, Sharp KW.Do multi-lumen catheters increase central venous catheter sepsis compared to single-lumen catheters?Trauma1988;28:1472–5.
70.
69. McCarthy MC, Shives JK, Robison RJ, et al. Prospective evaluation of single and triple lumen catheters in TPN. JPEN1987;11:259–62.
71.
70. Clark-ChristoffN, Watters VA, Sparks W, et al. Use of triple lumen subclavian catheters for administration of TPN. JPEN1992;16:403–7.
72.
71. Farkas JC, Liu N, Bleriot JP, et al. Single versus triple-lumen catheter-related sepsis: a prospective randomized study in a critically ill population. Am J Med1992;93:277–82.
73.
72. Ma TY, Yoshinaka R, Banaag A, et al. TPN via multilumen catheters does not increase the risk of catheter-related sepsis: a randomized, prospective study. Clin Infect Dis1998;27:500–3.
74.
73. Wurzel CL, Halom K, Feldman JG, et al. Infection rates of Broviac-Hickman catheters and implantable venous devices. Am J Dis Child1988;142:536–40.
75.
74. Gyves J, Ensminger W, Niederhuber J, et al. A totally implanted injection port system for blood sampling and chemotherapy administration. JAMA1984;251:2538–41.
76.
75. Lokick JJ, Bothe AJ, Benotti P, et al. Complications and management of implanted venous access catheters. J Clin Oncol1985;3:710–7.
77.
76. Kapper-Klunne MC, Degener JE, Stijnen T, et al. Complication from long-term indwelling central venous catheters in hematologic malignancy patients with special reference to infection. Cancer1989;64:1747–52.
78.
77. Andris DA, Krzywda EA.Central venous access. clinical practice issues. Nurs Clin N Am1997;32:719–40.
79.
78. Widmer AF.Intravenous-related infections. IN Prevention and Control of Nosocomial Infections, Wenzel RP (ed). Williams & Wilkins, Philadelphia, 1997, pp 771–805.
80.
79. Whitman ED.Complication associated with the use of central venous access devices. Curr Prob Surg1996;33:313–78.
81.
80. Corso F, Wolfe BM.Complications in vascular access devices. Nutr Clin Practice1993;8:143–4.
82.
81. Hoch JR.Management of the complications of long-term venous access. Sem Vase Surg1997;10:135–43.
83.
82. Lecciones JA, Lee JW, Navarro EE, et al. Vascular catheter-associated fungemia in patients with cancer: analysis of 155 episodes. Clin Infect Dis1992;14:875–83.
84.
83. Miller SJ, Dickerson RN, Graziani AA, et al. Antibiotic therapy of catheter infections in patients receiving home parenteral nutrition. JPEN1990;14:143–7.
85.
84. Buchman AL, Moukarzel A, Goodson B, et al. Catheter-related infections associated with home parenteral nutrition and predictive factors for the need for catheter removal in their treatment. JPEN1994;18:297–302.
86.
85. Hawkey PM.The origins and molecular basis of antibiotic resistance. Brit Med J1998;317:657–60.
87.
86. Flynn PM, Shenep JL, Stokes DC, et al. In situ management of confirmed central venous catheter-related bacteremia. Pediatr Infect Dis1987;6:729–34.
88.
87. McCarthy A, Rao JS, Byrne M, et al. Central venous catheter infections treated with teicoplanin. Eur J Hematol1998;59(Suppl 62):15–17.
89.
88. Benoit JL, Carandang G, Sitrin M, et al. Intraluminal antibiotic treatment of central venous catheter infection in patients receiving nutrition at home. Clin Infect Dis1995;21:1286–8.
90.
89. Messing B, Peitra-Cohen S, Debure A, et al. Antibiotic-lock technique: a new approach to optimal therapy for catheter-related sepsis in home-parenteral nutrition patients. JPEN1988;12:185–9.
91.
90. Rao JS, O'Meara A, Harvey T, et al. A new approach to the management of Broviac catheter infection. J Hosp Infect1992;22:109–16.
92.
91. Andris D, Krzywda E, Edmiston CE, et al. Elimination of intraluminal colonization by antibiotic lock (AL) in silastic catheters. Nutrition1998;14:427–32.
93.
92. Sitges-Serra A, Girvent M.Elimination of intraluminal colonization by antibiotic lock in silicone vascular catheters. Nutrition1998;14:715–6.
94.
93. Ascher DP, Shoupe BA, Maybee D, et al. Persistent catheter-related bacteremia clearance with antibiotics and urokinase. J Pediatr Surg1993;28:627–9.
95.
94. Jones GR, Konsler GK, Dunaway RP.Urokinase in the treatment of bacteremia and candidemia patients with right atrial catheters. Am J Infect Control1996;24:160–6.
96.
95. Jones GR, Konsler GK, Dunaway RP, et al. Prospective analysis of urokinase in the treatment of catheter sepsis in pediatric hematology-oncology patients. J Pediatr Surg1993;28:350–7.
97.
96. Atkinson JB.A prospective randomized trial of urokinase as an adjuvant in the treatment of proven Hickman catheter sepsis. J Pediatr Surg1998;33:714–6.
98.
97. Martinon-Torres F, Rodriquez-Nunez A, Pekarikova J, et al. Is heparin daily flushing useful to decrease the incidence of catheter-related infections?Chest1998;114:1498–9.
99.
98. Keohane PP, Attrill H, Northover J, et al. Effect of catheter tunnelling and a nutrition nurse on catheter sepsis during parenteral nutrition: a controlled trial. Lancet1983;2:1388–90.
100.
99. Faubion WC, Wesley JR, Khaldi N, et al. TPN catheter sepsis: impact of the team approach. JPEN1986;10:642–5.
101.
100. Mermel LA, McCormick RD, Springman, SR, et al. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters, a prospective study utilizing molecular subtyping. Am J Med1991;91(Suppl 3B):197–205.
102.
101. Raad II, Hohn DC, Gilbreath J, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol1994;15:231–8.
103.
102. Bjornson HS, Colley R, Bower RH, et al. Association between microorganism growth at the catheter insertion site and colonization of the catheter in patients receiving TPN. Surgery1982;92:720–7.
104.
103. Maki DG, McCormack KN.Defatting catheter insertion sites in TPN is of no value as an infection control measure. Am J Med1987;83:833–8.
105.
104. LeVeen HH, LeVeen RF, LeVeen EG.The mythology of povidone-iodine and the development of self-sterilizing plastics. Surg Gynecol Obstet1993;176:183–9.
106.
105. King TC, Price PB.An evaluation of iodophors as skin antiseptics. Surg Gynecol Obstet1963;116:361–5.
107.
106. Strand CL, Wajsbort RR, Sturmann K.Effect of iodophor vs iodine tincture skin preparation on blood culture contamination rate. JAMA1993;269:1004–6.
108.
107. Maki DG, Ringer M, Alvarado CJ.Prospective randomized trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet1991;338:339–43.
109.
108. De Cicco M, Chiaradia V, Veronesi A, et al. Source and route of microbial colonization of parenteral nutrition catheters. Lancet1989;2:1258–61.
110.
109. Bozzetti F, Terno G, Bonfanti G, et al. Prevention and treatment of central venous catheter sepsis by exchange via a guidewire: a prospective controlled trial. Ann Surg1983;198:48–52.
111.
110. Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-arterial catheters. N Engl J Med1992;327:1062–8.
112.
111. Circeo L, McGee W, Brown RB.Management of infections in adult intensive care units. Part II. Infect Dis Clin Practice1994;3:254–9.
113.
112. Maki DG.Infections due to infusion therapy. IN Hospital Infection. Bennett JV, Brachman PS (eds). Little, Brown and Co, Boston, 1992, pp 849–98.
114.
113. Conly JM, Grieve K, Peters B.A prospective random study comparing transparent and dry gauze dressings for central venous catheters. J Infect Dis159:310–5.
115.
114. Hoffmann KK, Weber DJ, Samsa GP, et al. Transparent polyurethane film as an intravenous catheter dressing: a metaanalysis of the infection risk. JAMA1992;267:2072–5.
116.
115. Madeo M, Martin CR, Turner C, et al. A randomized trial comparing Arglaes (a transparent dressing containing silver ions) to Tegaderm (a transparent polyurethane dressing) for dressing peripheral arterial catheters and central vascular catheters. Intensive Crit Care Nurs1998;14:187–91.
117.
116. Babycos CR, Barracos A, Mancuso J, et al. Collodion as a safe, cost-effective dressing for central venous catheters. South Med J1990;83:1286–8.
118.
117. Petrakis S, Rodvien R, Garmhausen LW, et al. The effect of biopatch antimicrobial dressing for insertion site management of indwelling central venous catheters (Abstract). Intravenous Nursing Society, Denver, CO, 1994.
119.
118. Sitges-Serra A, Hernandez R, Maestro S, et al. Prevention of catheter sepsis: the hub. Nutrition1997;13(Suppl 1):30S–5S.
120.
119. Salzman MB, Rubin LG.Relevance of the catheter hub as a portal for microorganisms causing catheter-related bloodstream infections. Nutrition1997;13(Suppl 1):15S–7S.
121.
120. Maki DG, Botticelli JT, LeRoy ML, et al. Prospective study of replacing administration sets for intravenous therapy at 48-vs 72-hour intervals. JAMA1987;258:1777–81.
122.
121. Danzig LE, Short LJ, Collins K, et al. Bloodstream infections associated with a needleless intravenous infusion system in patients receiving home infusion therapy. JAMA1995;273: 1862–4.
123.
122. Larson EL, Cheng G, Choo JTE, et al. In vitro survival of skin flora in heparin locks and needleless valve infusion devices. Heart & Lung1993;22:459–62.
124.
123. Do AN, Ray BJ, Banerjee SN, et al. Bloodstream infections associated with needleless device use and the importance of infection-control practices in the home care setting. J Infect Dis1999;179:442–8.
125.
124. Adams KS, Zehrer CL, Thomas W.Comparison of a needleless system with conventional heparin lock. Am J Infect Control1993;21:263–9.
126.
125. Flowers RH, Schwenzer KJ, Kopel RF, et al. Efficacy of an attachable subcutaneous cufffor the prevention of intravascular catheter-related infection. JAMA1989;261:878–83.
127.
126. Maki DG, Cobb L, Garman K, et al. An attachable silver-impregnated cufffor prevention of infection with central venous catheters: a prospective, randomized, multicenter trial. Am J Med1988;85:307–14.
128.
127. Groeger JS, Lucas AB, Coit D, et al. A prospective, randomized evaluation of the effect of silver impregnated subcutaneous cuffs for preventing tunneled chronic venous access catheter infections in cancer patients. Ann Surg1993;218:206–10.
129.
128. Kamal GD, Pfaller MA, Rempe LE, et al. Reduced intravascular catheter infection by antibiotic bonding: a prospective, randomized, controlled trial. JAMA1991;265:2364–6.
130.
129. Ciresi DL, Albrecht RM, Volkers PA, et al. Failure of antiseptic bonding to prevent central venous catheter-related infection and sepsis. Am Surg1996;62:61–2.
131.
130. Pemberton LB, Ross V, Cuddy P, et al. No difference in catheter sepsis between standard and antiseptic central venous catheters: a prospective randomized trial. Arch Surg1996;131:986–9.
132.
131. Pearson ML, Abrutyn E.Reducing the risk for catheter-related infections: a new strategy. Ann Intern Med1997;127:304–6.
133.
132. Veenstra DL, Saint S, Saha S, et al. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection. JAMA1999;281:261–7.
134.
133. Raad I, Darouiche R, Dupuis J, et al. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: a randomized, double-blind trial. Ann Intern Med1997;127:267–74.
135.
134. Darouiche RO, Raad II, Heard SO, et al. A comparison of two antimicrobial-impregnated central venous catheters. N Engl J Med1999;340:1–8.
136.
135. Wenzel RP, Edmond MB.The evolving technology of venous access. N Eng J Med1999;340:48–50.
137.
136. McNair TJ, Dudley HAF.The local complications of intravenous therapy. Lancet1959;2:365–8.
