Goetz, 1998

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CVCrBSI rates and site on General wards

In the general ward setting: The Subclavian site is associated with less CVC colonizations that either the Internal Jugular or the Femoral site. There is no difference in CVCrBSI rates. ICU patients were excluded.

Level of Evidence: 2^-(Cohort study with a high risk of Bias)

Citation/s: Goetz AM, et al. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Contol Hosp Epidemiol 1998;19:842-845.
Lead author's name and fax: Robert R Muder. Infectious diseases section. VA Medical center. Pittsburgh. USA.

Three-part Clinical Question: Is the incidence of CVC related infection in ward patients affected by insertion site.

Search Terms: see summary

The Study: Cohort Study. 300 CVCs.

The Study Patients: All patients in general medical or surgical wards in a single general hospital. Prospective study. Patients followed-up until catheter removal, transfer to critical care or long term care units, or discharge from the hospital.

Exposure of Interest: Type of catheter (single or multiple lumen), site of insertion. For the purposes of this CAT we shall only consider the impact of different site.

The Outcome: CVCrBSI, catheter colonization, IV site wound infection.
Can't tell if the subjects were defined and similar in other important ways. The exposures and outcomes were either objective or measured blind. Follow-up was long enough; follow-up was complete enough.

The Evidence:

Internal Jugular vs. Subclavian

		catheter colonization
		Present		Absent
		Number	Proportion	Number	Proportion
Type of catheter	Int Jug	10	0.14	62	0.86
Type of catheter	Sub Cl	8	0.06	129	0.94
Relative Risk:		2.38	95% CI:	2.13 to 2.62
Number Needed to Harm:		12
Chi Square		2.93

Femoral vs. Subclavian

		Colonization
		Present		Absent
		Number	Proportion	Number	Proportion
Site	Fem	18	0.20	73	0.80
Site	Sub Cl	8	0.06	129	0.94
Relative Risk:		3.39	95% CI:	3.02 to 3.76
Number Needed to Harm:		7
Chi Square		9.18

Comments:

No significant difference in CVCrBSI rates between the sites.

1. Do the methods allow accurate testing of the hypothesis? No. We are unable to determine the patient’s baseline characteristics to assess equal exposure to other risks of CVCrBSI between site groups. Definitions for CVCrBSI were not standard (they used peripheral BC match with either tip culture OR iv wound site).

2. Do the statistical tests correctly test the results to allow differentiation of statistically significant results? Yes.

3. Are conclusions valid in light of the results? The authors state that after cox regression only the femoral site was associated with catheter contamination – however contamination was defined as catheter colonization OR clinical infection.

4. Did results get omitted, and why? Can not tell

5. Did they suggest areas of further research? No

6. Did they make any recommendations based on the results and were they appropriate? Avoid the femoral approach if possible. Appropriate give the results.

7. Is the study relevant to my clinical practice? Possibly. Although ICU catheters excluded, ICU staff are often asked to insert CVCs into ward patients.

8. What level of evidence does this study represent? 2^-.

9. What grade of recommendation can I make on this result alone? none

10. What grade of recommendation can I make when this study is considered along with other available evidence? N/A

11. Should I change my practice because of these results? Possibly if your approach of choice in ward patients is the femoral one (unlikely).

12. Should I audit my current practice because of these results? If the above applies.

Appraised by: Dr Chris Cairns. Consultant. ICU. Stirling Royal Infirmary. UK ; 02 June 2005
Email: Chris.Cairns@fvah.scot.nhs.uk

Kill or update By: June 2010

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