Editorial
What does really affect the colonization of needleless connectors?
¿Qué afecta realmente a la colonización de los conectores sin aguja?
a Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
b Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain
c Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain
d CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "97" "paginaFinal" => "98" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "María Guembe, María Jesús Pérez-Granda" "autores" => array:2 [ 0 => array:4 [ "nombre" => "María" "apellidos" => "Guembe" "email" => array:1 [ 0 => "mariaguembe@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "María Jesús" "apellidos" => "Pérez-Granda" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Cardiac Surgery Postoperative Care Unit, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "CIBER Enfermedades Respiratorias-CIBERES (CB06/06/0058), Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Qué afecta realmente a la colonización de los conectores sin aguja?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The study published by Delgado et al., in the present issue of Enfermedades Infecciosas y Microbiología Clínica entitled: “Positive pressure needleless connectors did not increase rates of catheter hub colonization respecting the use of neutral pressure needleless connectors in a prospective randomized trial”, demonstrates that the use of positive-pressure nedleeless connectors (NCs) did not result in significantly more hub colonization rates respect to neutral-pressure NCs (13.4% vs. 14.6%).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> This could mean that maybe not only the NCs’ design or the valve type is relevant, but also other factors unrelated to the NCs, such as NC design, correct hub manipulation, and NC disinfection.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Closed NCs have proven useful in the prevention of hub contamination and their use is recommended by the IDSA Guidelines.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2,3</span></a> However, when central venous catheters (CVCs) are inserted for more than 8 days, infection can occur by an intra-luminal route (66%) because of hub contamination. Hub colonization after manipulation is responsible for 29–60% of catheter-related infections.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The key point in hub contamination relays on biofilm formation. Biofilms begin to form on CVCs within hours after catheter insertion by developing a conditioning layer with plasma proteins, platelets and neutrophils attached, to which bacteria can easily adhere.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Hub colonization can be conservatively detected (without NCs removal) by superficial cultures (combination of skin and hub cultures).<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3,6</span></a> However, scrubbing the internal surface of hubs carries the risk of biofilm dislogde to the bloodstream causing infection. Recently, flushing withdrawn NCs has been demonstrated to be an alternative and safer diagnostic technique for detecting hub colonization in combination with skin superficial cultures.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The main issue regarding NCs’ colonization relays on its design, which is still under discussion, as Delgado et al. demonstrate in their study.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> There are several <span class="elsevierStyleItalic">in vitro</span> and <span class="elsevierStyleItalic">in vivo</span> studies assesing whether the type of valve systems of NCs are the main reasons for the potential colonization of these devices. Originally, positive-pressure-valve NCs demonstrated to be associated to lower colonization rates. Schilling et al. demonstrated in a prospective and comparative study that those CVCs capped with a single-valve or positive-pressure-valve NCs had lower catheter occlusion rates that those capped with a standard device (<5% vs. 12.7%). However, they did not find differences in infection rates between different NCs groups. They found that lower infection rates were more related to the use of heparinized saline.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> Yebenes et al. demonstrated that positive-pressure valve NCs had significantly lower hub colonization rates than conventional caps used for radial arterial catheters inserted into critically ill patients (2.4% vs. 20.5%, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.03).<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> In addition, an <span class="elsevierStyleItalic">in vitro</span> study comparing 8 different NCs showed that 3 positive-displacement mechanical valves were associated with the ingress of significantly fewer microorganisms compared with other devices.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> However, current Prevention Guidelines recommend the use of neutral-valve NCs, as they demonstrated to prevent occlusions and infections.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11–13</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In the multicenter surveillance study for health-care associated bloodstream infections (HA-BSI) it was demonstrated that HA-BSI rate increased significantly when split septum NCs were replaced by mechanical valve NCs (6.15 vs. 9.49 BSIs per 1000 CVC days, <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0.001).<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> In addition, Yebenes et al. demonstrated in an <span class="elsevierStyleItalic">in vitro</span> study, that the barrier effect of disinfectable NCs was adversely affected by incorrect handling.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Moreover, another <span class="elsevierStyleItalic">in vitro</span> study showed that the optimal scrubbing technique for NC disinfection was scrubbing an access port in a straight line using an alcohol cotton swab, applying a force that was almost equal to an arterial compression haemostasis to the access port, and repeating this procedure once using a new cotton swab.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Finally, an observational before-after trial in an oncology unit, central line-associated bloodstream infection was reduced from 2.3 to 0.3 infections/1000 CVC days (<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.03) when hub care was changed from cleaning with alcohol wipes to using alcohol-impregnated port portectors.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Therefore, there is not a single main factor associated to hub colonization, but to the set of several factors composed of correct handling, valve design, and NC disinfection with alcohol.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In addition, the design of the NC is important not only to reduce colonization, but also to prevent occlusions in the catheter and to protect healthcare personnel from punctures and sprays, especially when handling cytostatics. Therefore, it is important to know the design of the connector (access type-Split-septum, preferably fluid laminar flow to avoid turbulences, type of displacement, as well as other specifications: dead space, compatibility, etc.).<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> Thus, the occlusion of the catheter is related to the NC design, being the anti-reflux valves those that have been shown to be related to less reflux in <span class="elsevierStyleItalic">in vitro</span> studies and, therefore, they are recommended when long-term CVCs are used.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a> Another important factor of NC is the dead space of the connector, specially when they are inserted in newborns. Also, dialysis catheters need to use high flows.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, the role of NCs in the pathogenesis of catheter hub colonization is still under discussion. There are several <span class="elsevierStyleItalic">in vitro</span> and <span class="elsevierStyleItalic">in vivo</span> studies trying to demonstrate whether type of valve or NC design are intrinsically involved in the appearance of infection. However, not only these factors could be associated to hub contamination, but also other extrinsic factors. It is also mandatory to monitor not only catheter infections but also obstructions. We must know the NC design and it is needed to assess the lack of complications by clinical studies.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Positive Pressure Needleless Connectors did not increase rates of catheter hub colonization respecting the use of Neutral Pressure Needleless Connectors in a prospective randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Delgado" 1 => "J.A. Capdevila" 2 => "G. Sauca" 3 => "J. Méndez" 4 => "A. Rodriguez" 5 => "J.C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 6 | 3 | 9 |
| 2024 September | 11 | 16 | 27 |
| 2024 August | 19 | 8 | 27 |
| 2024 July | 13 | 9 | 22 |
| 2024 June | 11 | 4 | 15 |
| 2024 May | 15 | 3 | 18 |
| 2024 April | 19 | 8 | 27 |
| 2024 March | 27 | 9 | 36 |
| 2024 February | 25 | 5 | 30 |
| 2024 January | 14 | 9 | 23 |
| 2023 December | 8 | 9 | 17 |
| 2023 November | 14 | 10 | 24 |
| 2023 October | 21 | 10 | 31 |
| 2023 September | 11 | 3 | 14 |
| 2023 August | 9 | 5 | 14 |
| 2023 July | 16 | 12 | 28 |
| 2023 June | 25 | 24 | 49 |
| 2023 May | 33 | 18 | 51 |
| 2023 April | 40 | 4 | 44 |
| 2023 March | 14 | 7 | 21 |
| 2023 February | 14 | 2 | 16 |
| 2023 January | 11 | 9 | 20 |
| 2022 December | 17 | 4 | 21 |
| 2022 November | 17 | 8 | 25 |
| 2022 October | 17 | 8 | 25 |
| 2022 September | 8 | 12 | 20 |
| 2022 August | 14 | 7 | 21 |
| 2022 July | 9 | 8 | 17 |
| 2022 June | 11 | 10 | 21 |
| 2022 May | 15 | 9 | 24 |
| 2022 April | 12 | 10 | 22 |
| 2022 March | 11 | 19 | 30 |
| 2022 February | 9 | 6 | 15 |
| 2022 January | 15 | 4 | 19 |
| 2021 December | 11 | 7 | 18 |
| 2021 November | 8 | 6 | 14 |
| 2021 October | 7 | 8 | 15 |
| 2021 September | 8 | 10 | 18 |
| 2021 August | 10 | 4 | 14 |
| 2021 July | 13 | 9 | 22 |
| 2021 June | 12 | 7 | 19 |
| 2021 May | 14 | 7 | 21 |
| 2021 April | 31 | 12 | 43 |
| 2021 March | 16 | 8 | 24 |
| 2021 February | 9 | 7 | 16 |
| 2021 January | 12 | 6 | 18 |
| 2020 December | 9 | 3 | 12 |
| 2020 November | 9 | 7 | 16 |
| 2020 October | 10 | 6 | 16 |
| 2020 September | 10 | 5 | 15 |
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