Kaur, Surinder Jaspal, Sukhminderjit Singh BajwaAbstract


Introduction: Central venous catheters (CVCs) are inserted to critically ill patients admitted in intensive care units for hemodynamic monitoring and administration of medications and nutrition. Objectives: To assess the bacteriological prole among critically ill patients with open versus closed central venous catheter access system. Methodology: The present study was carried out as a randomized, prospective, parallel group design. The ethical clearance was obtained from Institute Ethics Committee of Gian Sagar Medical College and Hospital, Ram Nagar. All the patients admitted in the Intensive Care Unit (ICU) and needed central line catheter were included in study. Patients with any positive culture of urine, surgical drains uid, respiratory secretions and or evidence of positive culture like wound swab culture, pleural uid etc. were excluded from study. Patients were randomized into two groups (200 in each group) by using sequentially numbered, sealed, opaque envelopes. Training protocol and observational checklist for nurses regarding CVC care was prepared and validated. Written informed consent was taken from relatives of patients. Data was collected from patients by using socio-demographic and clinical prole sheet and data related to CVC such as date of CVC insertion, type and site of CVC insertion, signs of local and systemic infection was done till the termination of CVC. In experimental group closed catheter access system (Luer-access split septum) was used while in control group, open access system -three way system was used. If any patient developed fever, blood culture, urine culture and tracheal secretions were sent for culture and sensitivity. Collected data was analyzed for descriptive and inferential statistics. Results: In experimental group 37.1% had positive blood culture whereas in control group all the patients had positive blood culture. This shows the signicant impact of intervention i.e. the prevalence of positive blood culture was signicantly lesser in experimental group than control group(X2-58.305, p= 0.0001). Gram -ve bacilli E.coli and Klebsiella pneumoniae was present in both groups in the same proportion. Closed catheter access system (Luer access split septum) had better efcacy in prevention of catheter related blood stream infection.

Key Words: Catheter related blood stream infection (CRBSI); Luer access split septum connectors; Three way connectors; Prevention of CRBSI

Correspondence Address

Prof Davinder Kaur

Principal, Gian Sagar College of Nursing, Ram Nagar




Globally among hospitalized patients more that 1.4 Million suffer from complications associated with hospital acquired infections (HAI) and 7-12% acquires HAI at any given time. 1 Catheter related bloodstream infections (CRBSI), ventilator-associated pneumonia (VAP) , Catheter associated urinary tract infection (CAUTI), and surgical site infection (SSI) are most important and frequently occurring infections among admitted patients.2,3 Blood stream infections account for 14% of the hospital acquired infections and Central venous catheters (CVCs) are found to be the most common cause.4For the administration of l i fe supportive medications, total parenteral nutrition, hemodynamic monitoring and collection of blood samples CVCs are inserted to critically ill patients admitted in intensive care units.5,6Pathogenic microorganisms can gain entry into bloodstream at the time of insertion of the catheter due to contact between organism with its external surfaces. Contamination of catheter hub, administration of contaminated uids, and contamination of guide wire and handling o f i n f u s i o n l i n e s m a y l e a d t o microorganism colonization.2,7Bacterial contamination of CVC can be minimized with closed access system because the catheter connection is not open to air during the change of  infusion  site  which s ignicantly decreases infection. 8 Researchers recommended that needleless access ports should be used on all lumens as compared to open access systems for prevention of CRBSI.9

Infection control specialists have emphasized that nurses are the key personnel for maintenance and care of venous access devices in daily clinical practice and they should be educated so that the incidence of CRBSI should be minimized. 1 0 Hence, researcher has undertaken this study with the aim to assess Bacteriological prole with open versus closed central venous catheter access system among critically ill patients admitted in Intensive Care Unit.

Material and methods

This was a randomized, prospective, parallel group, t r ial that assessed bacteriological prole among critically ill patients with open versus closed central venous catheter access system. All patients who were admitted in Intensive Care Unit (ICU) at Gian Sagar Medical College and Hospital, RamNagar, Dist Patiala, Punjab and need central line catheter were the accessible population during the period of July, 2015-February, 2017. Patients having central venous catheter at any site were included in trial. Patient with positive culture of urine, surgical drain , respiratory secretions, wound swab, pleural uid etc. were excluded from the study. Consecutive sampling technique was used for selecting sample. Sample size was 200 in each group. P a t i e n t s w e r e r a n d o m i z e d i n t o experimental and control group by using sequentially numbered, sealed, opaque envelopes. In experimental group closed catheter access system (Luer-access split septum) & in control group open access system -three-way system was used. After extensive review of l i terature and consultation with experts data collection tool was prepared which included Socio- demographic and clinical prole sheet. Tool included age, sex, diagnosis; type of CVC intervention, site of insertion and list of administered antibiotics and clinical sheet included sign of local infection, vital signs (blood pressure, pulse rate, respiratory rate and temperature), laboratory investigations (Total leukocyte count, Differential leukocyte count, blood culture, tracheal secretion culture, urine culture). Training protocol regarding care of patient with CVC and prevention of CRBSI was prepared based on standard guidelines by Centre for Diseases Control and prevention (CDC). Observational checklist was prepared to evaluate practices of nurses. Data collection tool, training protocol and observational checklist got validated by experts in eld of nursing, anesthesia and microbiology. All nurses posted in ICUs were trained for optimal care of patients with CVC before beginning of the study in their convenient time by using power point presentation and demonstration. Care practices of the staff nurses regarding care of central line  were  observed  by  using  o b s e r v a t i o n a l c h e c k l i s t i n n o n – participatory observations. Permission for carrying out the study  was  sought  from H O D o f A n e s t h e s i a a n d M e d i c a l Superintendent of GSMC&H, Ram Nagar. Ward in charges of ICU & ICCU were informed regarding study. Data was collected from ICU, ICCU of GSMC&H, Ram Nagar on all days during study period. Selection/ Screening of patients after meeting inclusions & exclusion criteria was done (420 patients were assessed for eligibility).Base line routine investigations – total leukocyte count, differential leukocyte count, blood culture, urine culture, tracheal secretion culture was done. Written consent was obtained from each enrolled patient/ their relative if patient was unconscious. Patient information sheet was lled for every patient. Patient’s details were entered in the data collection tool by researcher herself. Daily monitoring of patients done for assessment of local signs of inammation and systemic signs of infection till the CVC was in situ. If patient developed fever, then 10 ml blood was collected aseptically from peripheral vein and central venous catheter for blood culture. Urine and tracheal secretion culture was also sent. Two patients in experimental group and six patients in control group were lost to follow up due to LAMA (Leave Against Medical Advice). Collected data was analyzed by using SPSS version 20 for descriptive and inferential statistical.


In experimental group 25% patients were in age group 51-60 yrs and in control group 26 % were in age group of 61-70 yrs. Two third patients were male i.e. 66% & 57% in e x p e r i m e n t a l a n d c o n t r o l g r o u p respectively (Table 1) Both the groups were homogenous. (P >0.05 as per chi-square test).


Table 1: Demographic profile of patients enrolled in both groups





Demographic profile

Experimental (E) group Control group (C)
(n – 200) n (%) (n – 200) n (%) X 2 , df, p- value
1 Age(yrs)
≤ 30 32(16) 25(12.5)
31 – 40 19(9.5) 17(8.5)
41 – 50 22(11) 28(14)
51   – 60

61   – 70





4.245, 5,

0.515 NS

> 70 34(17) 39(19.5)
2 Gender
Male 132(66) 115(57.5) 3.059,1,
Female 68(34) 85(42.5) 0.080 NS

NS – Non signicant (p>0.05)

Mean ± SD (Range) Age in years (E) 54.3 ± 18.0 (18.0 –92.0) (C) 55.9 ± 17.8 (18.0 – 100.0)

More than 70% patients have jugular line and triple lumen central venous catheter. In both groups majority patients had triple lumen CVC catheters (93.5% & 91% respectively) and very few have double lumen. Distribution of patients was found to be homogenous in both groups. (Table2) Maximum  patients  have  cardiac diseases i.e. Coronary artery disease, Hypertension, triple  vessel  disease  and  underwent gastrointestinal surgeries in both groups. Cephalosporin and penicillin group antibiotics were administered to maximum patients in both groups.

Fig 1 depicts signs of infection faced by patients. Redness, inammation, fever and chills present in both groups but in control group more patients have signs of infection as compared to experimental group.

Table 2 : Clinical profile of patients enrolled in both groups






Clinical variables

Experimental group

(n – 200)

n (%)

Control group (n – 200)

n (%)

X 2 , df, p- value


Site of insertion  



1.345 # , 2,

0.578  NS





0.874,  1,

0.350  NS

Jugular 141(70.5) 146(73.0)
Subclavian 59(59.5) 53(26.5)
Femoral 0(0.0) 1(0.5)
2 Type of
Double lumen Triple lumen 13(6.5)






#   –   Fisher’s exact test                        NS – Non signicant (p>0.05)

Fig 1: Complications faced by patients in both groups

There was no signicant difference (p.>0.05) in baseline vital parameters ( Blood pressure, pulse rate and respiratory rate ) of patients among experimental group and control group as revealed by t- test. All patients have temperature within range of 96.0 -105.8 in experimental group and 95.6- 104.2 in control group.

Table 3 depicts that 37.1% had positive blood culture and 62.9% had sterile blood culture in experimental group whereas, in control group, 100% had positive blood culture. There was highly signicant (X2- 58.305, p= 0.0001) difference in blood culture results, as an impact of intervention positive blood culture was witnessed less in experimental group than control group.

Gram-ve bacilli E.coli and Klebsiella pneumoniae were present in both groups in the same proportion. Positive urine culture and tracheal culture proportions was almost similar in both groups

Table 3 Result of blood culture among patients in both groups


Blood culture


F(n- 126)

Experimental group (n -62) Control group     (n –



X2(df) p -value

n(%) n(%)
Sterile 39 39(62.9) 58.3(1)0.0001
Positive 87 23(37.1) 64(100.0)
E.coli 74 19 (82.6) 55 (85.9)  



13 4(17.4) 9(14.1)

***- signicant at p<0.0001        $       – Yate’s corrected


  should be used and three way connectors Central venous catheters (CVC) are should be avoided.12 These guidelines inserted in critically ill patients and essential to the modern practices. CVC enables hemodynamic monitoring, collection of blood samples, administration of life supporting medicines and total parenteral nutrition5 , 6 Central Venous catheter related bloodstream infections (CRBSIs) signicantly increases mortality, morbidity as well as treatment expenses worldwide and listed among signicant complications associated with CVC related to CVC and closed catheter access system (Luer access Split septum) have been published and are being practiced in all the developed nations. Prevention of CRBSI is a major concern in intensive care units across the globe. The present study was done to compare the efcacy of closed catheter access system (Luer access Split Septum) and open catheter access system (three way connector) for prevention of CRBSI among critically ill patients p l a c e m e n t . 1 1 – 1 3 C R B S I r e d u c t i o n admitted in ICUs and to evaluate interventions were focused on infection surveillance and insertion bundle, maintenance and removal i.e. injection ports should be cleaned with alcohol and needleless adaptors for injection ports bacteriological prole of CRBSI.

For the proper execution of the study design, all nurses working in ICUs were trained for optimal care of patient with CVC and prevention of CRBSI as they are the key health care personnels for patient care in ICUs. Hadaway 10reported that when nurses gain experience and overcome the challenges of using the closed access system, i.e needleless system, infection rates will be less.

In present study, it had been found that both negative bacteria, 26% have gram-positive bacteria and 12.3% have fungi. Lin etal18 (2015) also identied pathogens which caused CRBSI following bundle care, and found Gram-ve bacteria (38%) to be most common, and followed by gram +ve bacteria (34.7%) and Candida spp. he groups were homogenous in terms of(24%).Abirami4 identied Klebsiella socio-demographic status, site of insertion, clinical diagnosis, type of insertion as per X2test(p>0.05). Mean age was 54.3±18.0 in experimental group and 55.9±17.8 in control group. Both the groups had maximum male patients. Similar ndings p n e u m o n i a e a n d s t a p h y l o c o c c u s epidermidis in CVC tip culture. Vading et al19 2018 found the most common gram- negative species, Klebsiella pneumoniae (KP) and Escherichia coli (EC) that cause invasive infections. Many studies reported were also reported by Mallikarjun14 and similar ndings regarding presence of gram Patil etal 201115 that mean age of patient’s negative organisms but Bhavana 1 6 , were 51.25yrs and maximum patients were

Mozaffari etal20 and Gahlotetal reported male. Bhavna etal16 also reported that that Staphylococcus aureus , gram +ve patients having CRBSI belong to age group of 51-60yrs and mean age for males was 43.48 yrs and females 42.87out of which 70% was males and 30% was females

Present study revealed that there was highly organism were isolated, followed by Candida tropicalis. Templeton 200821 reported staphylococci coagulase negative with a rate of 28%.were isolated in CRBSI positive culture. Krishnan et al22 2010 signicant (X2-58.305, p value -0.0001) difference in blood culture among patients in both groups. In experimental group 37.1% patients have positive and 62.9% patients have sterile blood culture but in found Gram-positive cocci (27%) and gram-negative bacilli (56%) caused CRBSI. CRBSI proportion caused by Gram-negative bacilli was lower in western hospitals.control group all patients have positive

Rosenthal VD9 et al reported that CVC blood culture. Gram-ve bacilli E.Coli and Klebsiella pneumoniae was present in both groups in the same proportion thus non- signicant p-value 0.966 was calculated. It probably happened as gram-ve infections are very common in ICUs. Oberai et al 20167 also found Klebsiella pneumonia as common isolated bacteria in CRBSI and CVC colonization. Jia, Yu and Lu17 reported similar ndings of blood culture of CRBSI positive patients that 61.7% have gram- associated bacteremia during use of the closed system was signicantly lower than during the use of the open system. To ll the gap between knowledge and practice regarding CLABSI/CRBSI prevention, educational programmes should be imparted routinely and nurses should use evidence-based practices.23

Based upon above ndings it was concluded that open access system (Luer access system) had better efcacy in prevention of catheter associated blood stream infections as compared to open access system (three way connectors). Nurses should have strict compliance to infection control prevention bundles in intensive care units. Training of all health care personals should be mandatory to reduce health care associated infections and to improve prognosis of patients .It was recommended that hospitals administrators should ensure implementation of infection control protocols according to CDC guidelines and mandatory training of staff nurses to prevent CRBSI in ICUs. Closed catheter access system ( Luer access split septum) should be used for CVC as well for peripheral venous lines to reduce blood stream infections in hospital which possibly reduce morbidity, mortality and hospital cost of patients.


  1. WHO 2002. Prevention of hospital acquired infections. A practical guide. 2nd Edition. [Online]. Accessed on 2 Jan, 2017 Available from:URL: sources/publications/whocdscsreph2 00212.pdf
  2. Ramasubramanian V, IyerV,SewlikarS, Desai A. Epidemiology of health care infection- An Indian perspective on surgical site infection and catheter related blood stream infection.lJBAMR 2014; 3(4):46-63. Accessed on 6 Aug 2016 Available on 2014%2046-63.pdf.
  1. Mukhopadhyay C. Infection control in Intensive care Units’. Indian J Respir Care2018;7(1):14-21. Accessed on 5th Dec 2018 Available from: p?2018/7/1/14/224410.
  1. Abirami IE, Venkatesan P, Shanmugam P, Sattar SBA. Catheter related bloodstream infections (CRBSI) Intensive Care Unit patients in a tertiary care hospital, Indian J Microbiol Res, 2017;4(2):138-43. Accessed on 5 Dec 2018 Availale on:https://www.innovativepublication

.com/journal-article-le/4278 .

  1. Chopdekar K, Chande C, Chavan S, Veer P, Wabale V, Vishwakarma K etal. Central venous catheter-related blood stream infection rate in critical care units in a Tertiary Care, Teaching Hospital in Mumbai. Indian J Med Microbiol, 2011;29 (2):169-71. Accessed on 5 may 2015. Available from: ubmed/21654114.
  2. Gahlot R, Nigam C, Kumar V, Yadav G, Anupurba S. Catheter related bloodstream infections, Int J CritIllnInj Sci 2014;4(2) :162-67. Accessed on 10 March, 2016, Available from: icles/PMC4093967/
  3. Oberai L, Pallavi P, Chatrath, V, Devi
  4. Microbial prole and risk factors of central venous catheter associated blood stream infections in Tertiary care hospital, Amritsar.Int J Med Res Rev 2016; 4( 8):1437-42. Accessed on 30 Oct 2018. Available from: IJMRR/article/view/911/2250
  1. Akagi S, Matsubara H, Ogawa A, Kayai Y, Hisamatsu K, Miyaji K . Prevention of catheter related infections using a closed hub system in patients with pulmonary artery hypertension, Circulation J 2007; 71(4): 559-64. Accessed on 22 May 2013 Available from: d/17384460
  2. Rosenthal VD, Maki DG. Prospective study of the impact of open and closed infusion systems on rates of central venous catheter associated bacteremia, AJIC 2004; 32(3 ):135-41 Accessed on 22 May 2013 Available from: d/15153924
  3. Hadaway L, Richardson D. Needleless Connectors, J InfusNurs 2010; 33(1):23-31. Accessed on 7 July 2018. Available from: e/article/pii/S1552885511700344
  4. Narendranath V, Nandakumar BS, SaralaKS, Epidemiology of hospital- acquired infections in a tertiary care teaching hospital in India: a cross- sectional study of 79401 inpatients. Int J Community Med Public Health. 2017Feb;4(2):335-339. Accessed on 7 July 2018 Available from: cmph/article/view/411
  5. Longmate AG, Ellis KS, Boyle L, Maher S, Cairns CJS, Lloyd SM
  1. Elimination of central-venous- catheter related bloodstream infections from the intensive care unit,BMJ Qual Saf 2011; 20(2):174-80.Accessed on 22 May 2013 Available from: ubmed/21303772
  1. Dasgupta S, Das S, ChawanNS, Hazra A.Nosocomial infections in the intensive care unit: risk factors, outcome,and associated pathogens in a public tertiary teaching hospital of eastern India.Indian J Crit care Med2015 Jan;19(1):14-20. Accessed on 6 Dec 2018. Available from: d/25624645
  2. Millikaran RV. Catheter related bloodstream infections (CRBSI) in intensive care units: a prospective study of its rate, microbiological prole and associated factors. Int J Microbiol Res2018;10(4):1117-11 Accessed on 2 Jan 2019. Available from:l es/articles/10_4_1_IJMR.pdf.
  3. Patil HV, Patil VC, Ramteerthkar MN, Kulkarni RD. Central venous catheter related bloodstream infections in the intensive care unit. Indian JCrit care Med 201;15(4):213-
  4. Accessed on 22 May 2014 Available from: d/22346032
  5. Bhavna C, Nagarathnamma T, Ambica R. Study of Central line associated blood stream infections (CLABSIs) and central line related blood stream infections(CRBSIs) in a tertiary hospital, Bangalore, India.Int JcurrMicrobiol AppSci.2018; 7(5): 697-07. Accessed on 5 Dec 2018. Available from: C.%20Bhavana,%20et%20al.pdf
  1. Jia L, Yu H, Lu J, Zhang Y, Cai Y, Liu Epidemiological characteristics and risk factors for patients with catheter-related bloodstream infections in intensive care unit. Zhonghua Yi Xue Za Zhi 2015 10; 95(9):654-8.
  2. Lin KY, Cheng A, Chang YC, Hung,MC, Wang JT, Sheng WHetal. Central line associated bloodstream infections among critically –ill patients in the era of bundle care.J Microbiol, Immunol Infect 2017 Jun; 50(3): 339-48. Accessed on 5 Dec 2018 Available from: d/25976044
  3. Vading M, Nauclér P, Kalin M , Giske CG. Invasive infection caused by Klebsiella pneumoniae is a disease affecting patients with high comorbidity and associated with high long-term mortality.PLoS ONE2018;13(4): e0195258. Viewed on 2 December 2018, Available from 195258
  4. Mozaffari K, Bakhshandeh H, Khalaj H, SoudiH.Incidence of catheter related infections in hospitalized cardiovascular patients. Respcardiovascumed 2013;2(2): 99 Accessed on 5 Dec 2018. Available from: icles/PMC4253759/
  5. Templeton A, Schlegel M, Fleisch F, RettenmundG, SchobiB, Henz S Multilumen central venous catheters increase risk for catheter related blood stream infection: prospective surveillance study.Infection2008Aug;36(4): 322-
  6. Accessed on 5 Dec 2018 Available from: d/18663408
  7. Gopalakrishnan R, Sureshkumar Changing Trends in Antimicrobial Susceptibility and Hospital Acquired Infections Over an 8Year Period in a Tertiary Care Hospital in Relation to Introduction of an Infection Control Programme. JAPI. 2010Dec;58:25-
  8. Accessed on 5 Dec 2018. Available form: d/21563610.
  9. Esposito MR, GuillariA, Angelillo Knowledge, attitudes, and practice on the prevention of central line- associated bloodstream infections among nurses in oncological care: A cross-sectional study in an area of southern Italy. PLoS One2017Jun;30(6):e0180473.,e01804 73.doi:10.1371/journal.pone.018047.