458


Table 1. Blood Culture or Intraluminal Catheter Colonization With and Without Use of Antiseptic Barrier Caps Reference Study Design


13


Quasi-experimental, single-center


Blood culture contamination drawn through peripherally inserted central catheters before use of antiseptic barrier caps


2.5% (10/400) 14


Quasi-experimental, multi-center


Colonization of intraluminal catheter blood before use of antiseptic barrier caps in a hospital system


12.4% (40/323)


Colonization of intraluminal catheter blood before use of antiseptic barrier caps in one hospital


12.5% (15/120) 15


Quasi-experimental, single-center


Blood culture contamination drawn through central venous catheters before use of antiseptic barrier caps in high-risk patients


2.0% (110/9,267)


Blood culture contamination drawn through central venous catheters before use of antiseptic barrier caps in general oncology patients


3.7% (576/15,730)


Leonard A. Mermel


Outcome Measures and Contamination Rates


Blood culture contamination drawn through peripherally inserted central venous catheters after routine use of antiseptic barrier caps


0.5% (1/222)a


Colonization of intraluminal catheter blood with routine use of antiseptic barrier caps in a hospital system


5.5% (28/507)b


Colonization of intraluminal catheter blood with routine use of antiseptic barrier caps in one hospital


6.2% (22/354)


Blood culture contamination drawn through central venous catheters with routine use of antiseptic barrier caps in high-risk patients


0.7% (64/9,415)d


Blood culture contamination drawn through central venous catheters before use of antiseptic barrier caps in general oncology patients


1.7% (113/6,587)þ


Note. RR, risk ratio; CI, confidence interval. aRR, 0.18; 95% CI, 0.02–1.37; P = 0.10. bP < .001. cP = .01 when comparing before barrier cap use and with barrier cap use; P = .003 when comparing with barrier cap use and after discontinued barrier cap use. dP < .001.


significant reductions in these infections when unique antiseptic barrier caps are used.11,12 Thus, one would expect a commensu- rate reduction in blood culture contamination. In the peer- reviewed literature, 3 studies assessed this issue and found a reduction in intraluminal colonization or blood culture contami- nation (Table 1).13–15 In these studies, no data were provided regarding contamination of simultaneously obtained, percutane- ously-drawn, blood cultures. Notably, the use of antiseptic barrier caps is not without complications; pediatric patients have swal- lowed these devices.16 Blood cultures collected through a short-term peripheral intra-


venous catheter during insertion in pediatric17 and adult patients18 have a significantly greater risk of contamination compared to per- cutaneously-drawn cultures. Blood cultures drawn during central venous catheter insertion in an intensive care unit have a signifi- cantly higher risk of contamination compared to percutaneously- drawn cultures; however, contamination of blood cultures drawn during arterial catheter insertion was not significantly different than percutaneously-drawn cultures.19 From this review, it is evident that (1) a multimodal program


can significantly reduce catheter-drawn blood culture contamina- tion; (2) the use of antiseptic barrier caps can reduce the risk of catheter-drawn blood culture contamination; and (3) blood


cultures should not be obtained during insertion of short-term peripheral intravenous catheters or central venous catheters. No published studies have assessed contamination rates when percu- taneously-drawn blood cultures are done with technologies that divert an initial aliquot of blood compared with catheter-drawn cultures when antiseptic barrier caps are used and cultures are obtained from the catheter hub or from a new needleless connector after the old connector is discarded. It is important to remember that catheter colonization is not static


— it is a continuous process.


Catheter lumens can become colonized over time,20 which can lead to a bloodstreaminfection. As such, catheter-drawn blood cultures may reveal such colonization before a true bloodstream infection is evident or may reveal colonization in a patient who had recent or transient bacteremia from the colonized catheter that was cleared and undetected by percutaneously-drawn cultures. In situ diagno- sis of catheter-related bloodstream infection, in contradistinction to the less-specific central-line–associated bloodstream infection, requires catheter-drawn and percutaneously-drawn cultures.1 Basedonthe publishedliterature, bloodcultures shouldbe


obtained percutaneously when possible. Definitive in situ diagnosis of catheter-related bloodstream infection requires catheter-drawn cultures,which should be obtained froma catheter hub after removal of the old needleless connector that was protected with an antiseptic


Colonization of intraluminal catheter blood after discontinued use of antiseptic barrier caps in one hospital


12.6% (33/261)c


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