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To the Editors: Catheter-related bloodstream infections associated with the use of central venous catheters (CVCs) are a major source of morbidity in US intensive care units,¹ accounting for approximately 80 000 infections annually. To prevent catheter-related bloodstream infections, national evidence-based guidelines published in 1996 recommended maximal barrier precautions (MBPs) (ie, mask, sterile gloves, gown, and large sterile drape) and skin antisepsis during CVC insertion.² In 2001, the Agency for Healthcare Research and Quality supported an evidence-based review of best hospital safety practices, listing MBPs among the highest priorities.³ The 2002 update of national guidelines prioritized MBP use and skin antisepsis with 2% chlorhexidine gluconate (CHG),⁴ but physician adherence to recommendations supporting use of MBPs and CHG remains unknown.

Methods
Surveys were mailed to 1000 US internists selected randomly from the American College of Physicians-American Society of Internal Medicine membership. Initial surveys were mailed in June 2002, followed by up to 2 additional mailings to nonrespondents. Adherence to MBP or skin antisepsis (used during 90% of CVC insertions) was defined using previous criteria.⁵ Respondents adherent to skin antisepsis during CVC insertion also identified the specific agent they used. Frequency of other practices was also assessed, including insertion into the subclavian vein and use of CVCs impregnated or coated with antimocrobial agents (recommended) as well as administration of systemic antimicrobial prophylaxis during CVC insertion (strongly recommended against).^{3, 5}

Results
Five hundred twenty-six physicians (53%) responded. Among the 178 (34%) who had inserted at least 1 CVC in an intensive care unit during the past year, all were internists. Nearly half were general internists (50.6%); the 3 most common subspecialties were critical care medicine (16.1%), cardiology (12.6%), and nephrology (5.8%). The majority (51.2%) had inserted >50 CVCs during their careers, with 25.6% inserting >200 CVCs. Use of individual MBP components varied greatly. Nearly all wore sterile gloves (99.4%), but respondents were less adherent to the other MBP components (sterile gown, 72.2%; mask, 66.3%; large sterile drape, 35.0%). Adherence to all MBP components was very low (28.2%), and did not vary by physician specialty or CVC experience. Many respondents used draping materials not specifically recommended (eg, small drape provided in the CVC kit [87.6%], sterile towels [73.5%]).

Almost all (98.9%) adhered to use of any skin antiseptic agent, of which povidone/iodine was the most commonly used (88.4%). Less often used were CHG (8.7%), povidone/iodine with alcohol (1.7%), and povidone/iodine with CHG (1.1%).

Few respondents (17.0%) inserted CVCs into the subclavian vein for 90% or more of patients, and even fewer (16.7%) used CVCs impregnated or coated with antimicrobial agents for 90% or more of patients. Use of systemic antimicrobial prophylaxis at the time of CVC insertion was reported by only 2.3% of physicians.

Comment
While evidence and expert opinion support MBPs and use of CHG to prevent catheter-related bloodstream infections, these US internists reported infrequent use of these practices during CVC insertion. There are important variations in use of components of MBPs, with the large sterile drape being least used. Since the effect of individual components of MBPs on prevention of catheter-related bloodstream infections has not been studied, current best practice requires use of all MBP components. Few respondents reported cleaning the CVC insertion site with CHG, which became available in the United States in 2000. Expert opinion endorsed the use of CHG prior to the survey mailing¹; because further supportive evidence for CHG was published only 1 month prior to mailing of the survey,⁶ sufficient time might not have elapsed to allow the information to influence practice.

This study identified infrequent insertion into the subclavian vein and infrequent use of CVCs impregnated or coated with antomicrobial agents. Because there are some contraindications to these latter approaches, it is difficult to determine whether the reported practices were ideal or fell short of the recommended standard.

To our knowledge, this study is the first to assess current adherence to MBPs and use of CHG among a national sample of physicians. Given the infrequent use of evidence-based optimal practice, it is important to identify barriers to adherence.⁵ Overcoming these barriers has the potential to prevent catheter-related bloodstream infections and improve patient safety.

Lewis Rubinson, MD; Edward F. Haponik, MD
Division of Pulmonary and Critical Care Medicine

Albert W. Wu, MD, MPH
Division of General Internal Medicine

Gregory B. Diette, MD, MHS
Division of Pulmonary and Critical Care Medicine
Johns Hopkins University School of Medicine
Baltimore, Md

1. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132:391-402. [published correction appears in Ann Intern Med. 2000;133:5]. FREE FULL TEXT 2. Pearson ML, Hospital Infection Control Practices Advisory Committee. Guideline for prevention of intravascular device-related infections. Infect Control Hosp Epidemiol. 1996;17:438-473. WEB OF SCIENCE | PUBMED 3. Shojania KG, Duncan BW, McDonald KM, Wachter RM. Making Health Care Safer: A Critical Analysis of Patient Safety Practices: Evidence Report/Technology Assessment No. 43. Rockville, Md: Agency for Healthcare Research and Quality; 2001. AHRQ Publication 01-E058. 4. O'Grady NP, Alexander M, Dellinger EP, et al, Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep. 2002;51(RR-10):1-29. PUBMED 5. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? a framework for improvement. JAMA 1999;282:1458-1465. FREE FULL TEXT 6. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002;136:792-801. FREE FULL TEXT

JAMA. 2003;290:2802.

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