The results of the Pennsylvania Patient Safety Advisory Report and independent biofilm sampling of NC suggest that more attention is needed for aseptic access and maintenance practices [109]. NC are used on virtually all intravascular devices in the USA; they provide an easy access point for syringe or tubing attachment and have now become the central access point for all connections. (19) S. Schilling, D. Doellman, N. Hutchinson, and B. R. Jacobs. S161S165, 1998. curos connector disinfecting needleless jet caps strips 3m iv cap misc supplies connector clave luer needleless lock preciousarrows De Muynck et al.. (18) D. Macklin, J Assoc Vasc Access, vol. After insertion of a catheter, introduction of microorganisms occurs primarily from two routes: the skin/insertion track or through the lumen of the catheter [15, 124127]. A BEME systematic review: BEME Guide No. 
(3) J. D. Brown, H. A. Moss, and T. S. Elliott. 
Intraluminal contamination and subsequent colonization become more prominent with longer dwell times [110, 147]. education and compliance for infection prevention. Poster and abstract presentations on disinfecting caps/port protectors. Achieving zero CoN CLBSI in the NICU,, (16) J. Lee, Disinfection cap makes critical difference in central line bundle for reducing CLABSIs,, (17) B. Lopansri, I. Nicolescu, J. Parada, A. Tomich, J. Belmares, and P. Schereckenberger, Microbial colonization of needleless intravenous connectors and the male luer end of IV administration sets: does the partner matter?, (18) D. Maslak, D. Rossettini, L. Trento, and M. Leone, Catheter maintenance in the home parenteral nutrition patient = reduced CRBSIs,, (19) S. McCalla, J. Greco, M. Warren, P. Byrne, and J. Bogetti, Integrated delivery system of disinfection cap and flush syringe, plus staff education, reduce bloodstream infections and treatment costs,, (20) M. Moore, K. Gripp, H. Cooper, and R. Almeida, Providence Sacred Heart Medical Center: impact of port protectors on incidence of central line infections,. curos needleless 3m disinfecting cff1 With NC, these questions arise: is disinfection always performed prior to access? infection, infection prevention, catheter related infections, CLABSI, bloodstream infections, bacteremia, sepsis, and cross-infection. This report is based on an electronic systematic literature search and review of published materials from Pubmed, Medline, Scopus, Ovid, jStor, CINAHL, Cochrane, Athens, and ScienceDirect by cross-referencing these key terms for years 1977December 2014. 
(22) M. Pavia, Testing elimination of an infection prevention device from catheter bundle and potential effect on overall catheter bloodstream infection rate,, (23) M. Pittiruti, Port protectors and educational intervention: the key to zero central line-associated bloodstream infection: a randomized controlled trial,, (24) A. Pong, C. Salgado, M. Speziale, P. Grimm, and C. Abe, Rady Children's Hospital San Diego, reduction of central line associated bloodstream infection (CLABSI) in a neonatal intensive care unit with use of access site disinfection caps,, (25) P. Posa, Improving IV connector disinfection by using human factors engineering to identify effective, nurse-friendly solutions,, (26) M. Pratt and M. Leone, Coram specialty infusion services. A. Ascenzi, and I. Berkowitz. (9) J. M. Costello, D. F. Morrow et al., (10) ECRI Institute, Evaluation: needleless connectors,. Disinfection of the NC access site was not included in the insertion related central line bundle. The goal of any effective infection prevention program is zero CLABSIs. Nancy L. Moureau was responsible for the study design, searches and selection of publications, analysis of selected studies, and drafting of the paper. In a prospective controlled study by Rosenthal and Maki and multicenter prospective cohort by Rangel-Frausto et al., open systems compared to closed systems resulted in major reductions in catheter related infections [120]. (28) J. Oto, H. Imanaka, M. Konno, E. Nakataki, and M. Nishimura. Application of alcoholic chlorhexidine to disinfect skin for central line insertions and now, more and more with peripheral catheter insertions, is helping to reduce bacterial ingress to the bloodstream. Part 2: patient controlled analgesia,, D. D. McMahon, Evaluating new technology to improve patient outcomes: a quality improvement approach,, S. Cicalini, F. Palmieri, and N. Petrosillo, Clinical review: new technologies for prevention of intravascular catheter-related infections,, S. T. Cookson, M. Ihrig, E. M. O'Mara et al., Increased bloodstream infection rates in surgical patients associated with variation from recommended use and care following implementation of a needleless device,, J. S. Soothill, K. Bravery, A. Ho, S. Macqueen, J. Collins, and P. Lock, A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: a pediatric single center before/after study on a hemopoietic stem cell transplant ward,, S. Sannoh, B. Platace et al. Brown, Autonomy and Self-efficacy as influencing factors in nurses' behavioral Intention to disinfect needleless intravenous systems,, J. M. Jardim, R. A. Lacerda, N. D. J. D. Soares, and B. K. Nunes, Evaluation of practices for the prevention and control of bloodstream infections in a government hospital,, Y. J. Hsu, K. Weeks, T. Yang, M. D. Sawyer, and J. JCM MED223 Chemin de Bellevue,
curos cap disinfecting 3m caps needleless connector connectors box cff1 icu clear woundcareshop pole strips Results. 21, supplement 5, pp. (15) W. Jarvis, C. Murphy, K. Hall et al.. (16) N. Khalidi, D. S. Sovacevich, L. F. Papke-ODonnell, and I. Btaiche. Access catheter connections with sterile devices only [, Antimicrobial caps/port protectors may be effectively used for passive continuous hub disinfection on needleless connections in accordance with manufacturer instructions, in conjunction with frictional antiseptic wiping between applications and access [, Ensure compliance with hand hygiene, gloving and aseptic practices prior to any contact with intravenous devices and add-on equipment [, Establish and educate all clinical staff on a standard protocol to disinfect catheter hubs, needleless connectors and ports prior to and after each access [, Provide consistent and varied staff education on consequences of poor technique along with clinical reminders of best practice [, Establish regular surveillance of compliance for disinfection of intravascular devices prior to access with reporting of results to each care unit [, Establish a formal process to evaluate new technology and needleless connector designs [, Implement a multimodal quality improvement infection prevention program that applies guidelines and recommendations to all intravascular practices [, L. Hadaway, Needleless connectors: Improving practice, reducing risks,, I. F. Btaiche, D. S. Kovacevich, N. Khalidi, and L. F. Papke, The effects of needleless connectors on catheter-related bloodstream infections,, W. R. Jarvis, C. Murphy, K. K. Hall et al., Health care-associated bloodstream infections associated with negative- or positive-pressure or displacement mechanical valve needleless connectors,, E. Bouza, P. Muoz, J. Lpez-Rodrguez et al., A needleless closed system device (CLAVE) protects from intravascular catheter tip and hub colonization: a prospective randomized study,, C. Chernecky and J. Waller, Comparative evaluation of five needleless intravenous connectors,, A. Sitges-Serra, Strategies for prevention of catheter-related bloodstream infections,, W. Jarvis, Choosing the best design for intravenous needleless connectors to prevent healthcare-associated bloodstream infections,, N. P. O'Grady, M. Alexander, L. A. Burns et al., Guidelines for the prevention of intravascular catheter-related infections,, V. Chopra, S. Krein, R. Olmstead, N. Safdar, and S. Saint, Prevention of central line-associated bloodstream infections: brief update review, in, J. M. D. Marschall, L. A. D. O. S. Mermel, M. M. D. M. P. H. Fakih et al., Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update,, INS, Infusion nursing standards of practice,, S. Z. Menyhay and D. G. Maki, Disinfection of needleless catheter connectors and access ports with alcohol may not prevent microbial entry: the promise of a novel antiseptic-barrier cap,, S. Simmons, C. Bryson, and S. Porter, Scrub the hub: cleaning duration and reduction in bacterial load on central venous catheters,, M. DeVries, P. S. Mancos, and M. J. Valentine, Reducing bloodstream infection risk in central and peripheral intravenous lines: Initial data on passive intravenous connector disinfection,, M. B. Salzman and L. G. Rubin, Relevance of the catheter hub as a portal for microorganisms causing catheter-related bloodstream infections,, D. P. Halpin, P. O'Byrne, G. McEntee, T. P. J. Hennessy, and R. B. Stephens, Effect of a Betadine connection shield on central venous catheter sepsis,, A. T. Stotter, H. Ward, A. H. Waterfield, J. Hilton, and A. J. Sim, Junctional care: the key to prevention of catheter sepsis in intravenous feeding,, M. Pittiruti, Port protectors and educational intervention: the key to zero central line-associated bloodstream infectiona randomized controlled trial, in, S. Z. Menyhay and D. G. Maki, Preventing central venous catheter-associated bloodstream infections: development of an antiseptic barrier cap for needleless connectors,, N. Moureau and R. Dawson, Passive disinfection product effectiveness study, in, M. B. Salzman, H. D. Isenberg, and L. G. Rubin, Use of disinfectants to reduce microbial contamination of hubs of vascular catheters,, M. B. Salzman, H. D. Isenberg, J. F. Shapiro, P. J. Lipsitz, and L. G. Rubin, A prospective study of the catheter hub as the portal of entry for microorganisms causing catheter-related sepsis in neonates,, M. Ryder, Access site and hub disinfection: in vitro testing of a novel device, in, A. L. Casey, S. Burnell, H. Whinn, T. Worthington, M. H. Faroqui, and T. S. J. Elliott, A prospective clinical trial to evaluate the microbial barrier of a needleless connector,, J. P. Kennedy, R. A. Lasher, D. Solomon, and R. W. Hitchcock, Disinfection of male luer style connectors for prevention of catheter related bloodstream infections using an isopropyl alcohol dispensing cap,, M.-O. 
In both the Kaler laboratory and the Ruschman randomized experimental design studies, using a 15 second and 60 second scrub respectively, disinfection with 70% alcohol eliminated all microorganisms [173, 181]. curos disinfecting needleless fsa Even with the success of the Central Line Bundle on CLABSI reductions, a majority of hospitals remain well above zero for infections. Stango and associates reported a 50% reduction in CLABSIs and a savings of $464,440 per year after alcoholic cap implementation [184]. guidelines and recommendations for infection prevention with disinfection. 2, pp. 
The goal of this review is to assess current literature related to disinfection of NC to establish recommendations that promote aseptic access, reducing infection risk for the patient. (13) G. K. Frampton, P. Harris, K. Cooper et al.. (16) J. M. Jardim, R. A. Lacerda et al.. (17) I. S. Jeong, S. M. Park, J. M. Lee, J. Y. These studies found that bacteria identified on external hub surfaces were also present in biofilm sampled from random locations within the needless connector. Julie Flynn performed grading of selected publications and contributed to second paper revision. All NC consist of a septum, a fluid pathway and a mechanism for activation; the design, space, volume, and human factors all affect how easy a product is to use and disinfect, and may also act as contributors to the potential risk of catheter associated bloodstream infection [3, 69, 150, 155, 157, 158]. Effective disinfection of a NC is influenced by several factors including: ability to clean the NC surface, the amount and position of grooves or gaps present, and the roughness or smoothness of the septum [1, 3, 7, 69, 150, 154156]. catheter cap, access port, disinfecting cap, antimicrobial cap, hub protection cap, and port protector. Clearly there are human factors working against disinfection of hubs prior to access requiring engineered solutions such as passive disinfecting cap strips hanging on intravenous pump poles, supply dispensers of alcohol wipes at the bedside, or on the intravenous pump to ensure greater, even 100% compliance with disinfection each and every time [91, 170]. Since no RCTs were found, lower level evidence including clinical and in vitro (laboratory) studies was reviewed, as long as these included reporting of quantitative data. Heard, Who let the bugs in?, J. C. Ybenes, R. Martinez, M. Serra-Prat et al., Resistance to the migration of microorganisms of a needle-free disinfectable connector,, J. D. Brown, H. A. Moss, and T. S. J. Elliott, The potential for catheter microbial contamination from a needleless connector,, B. W. Trautner and R. O. Darouiche, Catheter-associated infections: pathogenesis affects prevention,, J.-C. Lucet, J. Hayon, F. Bruneel, J.-L. Dumoulin, and M.-L. Joly-Guillou, Microbiological evaluation of central venous catheter administration hubs,, R. M. Donlan, Biofilms and device-associated infections,, R. M. Donlan and J. W. Costerton, Biofilms: survival mechanisms of clinically relevant microorganisms,, R. Donlan, Biofilms on central venous catheters: is eradication possible? in, M. Ryder, G. Hamilton, M. Hamilton, and G. James, Bacterial transfer through needlefree connectors: comparison of nine different devices, in, A. Sitges-Serra, J. Linares, J. L. Perez, E. Jaurrieta, and L. Lorente, A randomized trial on the effect of tubing changes on Hub contamination and catheter sepsis during parenteral nutrition,, C. Len, F. lvarez-Lerma, S. Ruiz-Santana et al., Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study,, M. Leone and L. R. Dillon, Catheter outcomes in home infusion,, I. Raad, W. Costerton, U. Sabharwal, M. Sacilowski, E. Anaissie, and G. P. Bodey, Ultrastructural analysis of indwelling vascular catheters: a quantitative relationship between luminal colonization and duration of placement,, E. Perez, M. Williams, J. T. Jacob et al., Microbial biofilms on needleless connectors for central venous catheters: comparison of standard and silver-coated devices collected from patients in an acute care hospital,, R. W. Loftus, H. M. Patel, B. C. Huysman et al., Prevention of intravenous bacterial injection from health care provider hands: the importance of catheter design and handling,, J. L. Holroyd, D. A. Paulus, K. H. Rand, F. K. Enneking, T. E. Morey, and M. J. 126150, 2010. Sweet, A. Cumpston, F. Briggs, M. Craig, and M. Hamadani, Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit,, G. Schears, Cap the connector: save the patient, in, M. Pratt and M. Leone, Coram spcialty infusion services: an evaluation of the effectiveness of intravenous disinfection caps in the prevention of CVAD infections in parenteral nutrition, in, D. Maslak, D. Rossettini, L. Trento, and M. Leone, Maintenance in the home parenteral nutrition patient = reduced CRBSIs, in, H. Contreras, Use of disinfection cap/flush syringe combination to address bloodstream infection and related issues, in, S. McCalla, J. Greco, M. Warren, P. Byrne, and J. Bogetti, Integrated delivery system of disinfection cap and flush syringe, plus staff education, reduce bloodstream infections and treatment costs, in, B. Bor, C. Johnson, and C. Noble, It takes a village to prevent central venous catheter infections and promote safety of patients, in, G. Kaye and T. Anthony, Weiss memorial hospital: new disinfection cap achieves joint commission compliance for valve disinfection not achievable with alcohol prep pads, in, M. Pavia, Testing elimination of an infection prevention device from catheter bundle and potential effect on overall catheter bloodstream infection rate, in, S. Sumner, K. C. Merrill, L. Linford, and C. Taylor, Decreasing CLABSI rates and cost following implementation of a disinfectant cap in a tertiary care hospital,, B. Danielson, S. Williamson, G. Kaur et al., Decreasing the incidence of central line-associated blood stream infections using alcohol-impregnated port protectors (AIPPS) in a neonatal intensive care unit, in, J. Kelleher, R. Almeida, H. Cooper, and S. Stauffer, Providence sacred heart medical center and children's hospital: achieving zero CoN CLBSI in the NICU, in, M. Moore, K. Gripp, H. Cooper, and R. Almeida, Providence sacred heart medical center: impact of port protectors on incidence of central line infections, in, A. Dobin, Broward Health Coral Springs Medical Center: bloodstream infections eliminated by use of plastic cap for disinfecting needleless connectors, in, D. G. Maki, M. Ringer, and C. J. Alvarado, Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters,, M. K. Muffly, M. L. Beach, Y. C. Isaac Tong, and M. P. Yeager, Stopcock lumen contamination does not reflect the full burden of bacterial intravenous tubing contamination: analysis using a novel injection port,, M. A. Luebke, M. J. Arduino, D. L. Duda et al., Comparison of the microbial barrier properties of a needleless and a conventional needle-based intravenous access system,, M. DeVries, P. Mancos, and M. Valentine, Improving catheter cleaning and maintenance in central and peripheral lines, in, P. Posa, Improving IV connector disinfection by using human factors engineering to identify effective, nurse-friendly solutions, in, M. Pittiruti, H. Hamilton, R. Biffi, J. MacFie, and M. Pertkiewicz, ESPEN guidelines on parenteral nutrition: central venous catheters (access, care, diagnosis and therapy of complications),, N. L. Moureau and R. B. Dawson, Keeping needleless connectors clean, part 1,, H. P. Loveday, J. Aseptic technique is the foundation for safe delivery of intravenous medications and solutions. 
Any intravascular access point with a surface open to the environment requires disinfection prior to use, as it acts as the immediate portal of entry for intraluminal contaminants [23, 99, 113, 127, 133, 144, 150152]. BEME Guide No. Overall, the evidence base for the effectiveness of various disinfection strategies is low level, resulting in recommendations compiled from the available publications. (17) B. S. Nil-Weise, T. J. Daha, P. J. van den Broek. Disinfection points to gain access to intravenous or intravascular devices may include tubing side ports, direct catheter connections, stopcocks with needle free caps, NC of various types (split septum, mechanical valves, positive pressure valves, zero, or neutral connectors), traditional silicone septum, or other forms of access integrated with the catheter or tubing. cap disinfecting curos needleless connector 3m disinfectants cleaners The central line bundle checklist is used as evidence to demonstrate compliance with safety practices during insertion, but the aspect of day to day management is not addressed in the bundle. In the research by Hong et al., a 5 second scrub with alcoholic chlorhexidine fully disinfected NC surfaces treated with Pseudomonas Aeruginosa [179]. 
Measurement of compliance with hub disinfection is challenging, requiring direct observation of the action unless disinfection caps/ports are used on all NC hubs as a form of verification. Exclusion criteria were(i)nonresearch papers,(ii)studies of adult, pediatric, or neonatal increasingly important role patients not inclusive of intravascular device disinfection practices,(iii)primary populations outside acute care,(iv)publications not translated into English,(v)studies prior to 1984. Disinfection of a catheter hub prior to flushing or prior to the administration of medications is required for all aseptic access, yet in the Karchmer study, 31% of clinicians did not even attempt to disinfect, even when under active observation [1, 64, 88, 114]. Research of Macias and associates with 2% chlorhexidine in 70% isopropyl alcohol on skin proved an added substantive effect, even against freshly introduced organisms, for up to 24 hours, establishing this agent as a superior disinfecting agent when longer action is needed, in comparison with single agents of 70% isopropyl alcohol, 10% povidone iodine and 10% sodium hypochlorite [172]. (23) J. C. Ybenes, R. Martnez, M. Serra-Prat et al.. (24) J. C. Ybenes, L. Vidaur, M. Serra-Prat, J. M. Sirvent, J. Batlle, M. Motje, A. Bonet, and M. Palomar, (1) F. Alasmari, N. Kittur, A. Russo et al., Impact of alcohol impregnated protectors on incidence of catheter-associated blood stream infections,, (2) T. Antony and M. Levin, MacNeal Hospital: engineered device dramatically improves efficacy leading to fewer CLABSIs,, (3) B. Bor, C. Johnson, and C. Noble, It takes a village to prevent central venous catheter infections and promote safety of patients,. This common break in aseptic technique sets the stage for biofilm formation within NC and catheters and increases the potential for delayed infection of both central and peripheral catheters [14, 60, 68, 112, 116]. Why disinfect? The Holroyd in vitro study at University of Florida compared the single use of this cleansing cap with 70% alcohol to traditional 70% alcohol wipes [151].
Moro reported hub colonization in only 3.5% (21/607), but found that this group was responsible for severe systemic infections more frequently [128]. In Wright et al.s study at NorthShore University HealthSystem, a four University Hospital system, the intervention with 70% alcohol disinfection caps reported CLABSI rates declining from 1.42/1000 catheter days (16/11,540) to 0.69 (13/18,972) with a 95% confidence interval, based on 799 enrolled patients, representing a statistically significant decrease [26]. 
Research that replicates solid studies provides a stronger foundation for evidence-based practice and should be encouraged. Surface design, gaps around valve closure surface, segmented fluid pathway with dead space, differing internal mechanisms, clear or obscured visibility, variable blood reflux, clamping sequences, and different flushing instructions, depending on the type of NC, all play a part in the level of risk associated with the device. More and more studies are demonstrating lack of compliance with hub disinfection despite educational initiatives and better disinfection agents. Its design and operation improves work efficiency by saving time, gestures, swabbing devices and increased safety. needleless medneteurope Clones, J. Munoz, M. Montecalvo, and B. Parvez, A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection,, J. S. Smith, G. Irwin, M. Viney et al., Optimal disinfection times for needleless intravenous connectors,, M. E. Rupp, S. Yu, T. Huerta et al., Adequate disinfection of a split-septum needleless intravascular connector with a 5-second alcohol scrub,, J. H. Macias, V. Arreguin, J. M. Munoz, J. Early concerns over needle safety for healthcare workers led to the creation of products that provide needle-free access. Vast improvements have been made in the reduction of CLABSIs attributed to insertion procedures. The purpose of this systematic review was to evaluate the supporting evidence for disinfection practices of NC, catheter hub, stopcock, and side ports that reduce the transfer of microorganisms through intravascular device access. needleless maxplus tru swab carefusion Primary areas of focus for disinfection of access sites are the point where the sterile syringe or tubing contacts the site, as in the top septum surface, and the threads or side surfaces [7, 143, 154]. New products or technology should be transitioned into a healthcare facility only after a complete evaluation of both the research and the performance of the product to determine the impact of the change on patient outcomes [71, 97, 98, 149, 160, 162166]. Passive disinfection caps reduce guess work, provide clinicians with a point of use solution, and reduce contamination. Randomized controlled studies are needed to rigorously evaluate the efficacy of disinfection practices and antiseptic hub protectors in preventing patient infection. 
(14) J. P. Kennedy, R. A. Lasher, D. Solomon, and R. W. Hitchcock. While policies for disinfection of access devices are a first step, methods to validate actual practice and patient safety must be integrated into hospital culture. Once contamination occurs, bacteria attach to the inner lumen of the catheter, begin to grow and form biofilm, making successful eradication extremely difficult [6, 2830, 113, 127, 133, 140142, 144, 195].
