[Impact of abdominal ultrasound on the identification of the site of infection in the emergency department - Analysis whether it makes sense to perform abdominal ultrasound examination for the identfication of the site of infection if medical history and clinical examination do not indicate an abdominal focus.] / Bedeutung der Abdomen-Sonografie zur Infektfokussuche in der Notaufnahme.

Introduction A very high number of patients presenting in emergency departments suffer from an unknown infection or rather fever. If diagnostic imaging is necessary ultrasound can be performed. Whether ultrasound is superior to medical history and clinical examination considering the significantly enhanced technology in recent years and hence has to be performed in patients without abdominal symptoms with non-obvious focus cannot be answered by review of the literature. The objective of this study was to evaluate the relevance of abdominal ultrasound in the determination of the site of infection and to analyse whether an abdominal ultrasound for the identification of the source of infection is dispensable in patients in whom history and clinical examination do not indicate an abdominal focus. Methods All patients undergoing an ultrasound between 2013/04 and 2013/07 in the emergency department of the university hospital of Regensburg were retrospectively analysed. 500 abdominal ultrasound examinations were performed for identifying an abdominal site of infection. These cases were analysed whether medical history and clinical examination were indicating an abdominal focus. Furthermore, on the basis of patient record and medical report the result of the performed ultrasound, final diagnosis, clinical parameters (lab results, fever) were retrospectively analysed. Results Based on the medical report in 208 (41.6 %) of the 500 reviewed cases there has been an abdominal focus. In 122 of these patients (59.0 %) abdominal ultrasound identified the abdominal focus correctly. In 206 patients (99.0 %) medical history and in 152 patients (73.1 %) clinical examination indicated an abdominal focus. A subgroup analysis regarding immunocompromised patients revealed that in 25 of 38 patients (65.8 %) an abdominal focus was determined via abdominal ultrasound. In patients with unremarkable medical history and clinical examination (23 examinations) no abdominal focus could be found via abdominal ultrasound. Discussion An urgent examination of the abdomen via ultrasound is dispensable in patients in whom history (provided complete history) and clinical examination (i.e. particularly no immunosuppression) do not indicate an abdominal focus.

Etiologies and outcomes of acute liver failure in Germany.

BACKGROUND & AIMS: Acute liver failure (ALF) is a severe form of acute liver injury that can progress to multiple organ failure. We investigated causes and outcomes of ALF. METHODS: Eleven university medical centers in Germany were asked to report patients with (primary) severe acute liver injury (sALI) (international normalized ratio [INR] >1.5 but no hepatic encephalopathy) and primary ALF (INR >1.5 with overt hepatic encephalopathy) treated from 2008 to 2009. Data were analyzed from 46 patients with sALI and 109 patients with ALF. RESULTS: The most frequent etiologies of primary ALF were non-acetaminophen drug-induced (32%), indeterminate (24%), and viral (21%); acetaminophen ingestion was the cause of ALF in only 9% of patients. The support of a ventilator was required by 44% of patients with ALF, vasopressors by 38%, and renal replacement by 36%. Seventy-nine patients with ALF (72%) survived until hospital discharge, 38 (35%) survived without emergency liver transplantation (ELT), and 51 received ELT (47%); 80% of patients who received ELT survived until discharge from the hospital. CONCLUSIONS: In Germany, drug toxicity, indeterminate etiology, and viral hepatitis appear to be the major causes of primary ALF, which has high mortality. Patients with ALF are at great risk of progressing to multiple organ failure, but 80% of patients who receive ELT survive until discharge from the hospital.

Volcano-like intermittent bleeding activity for seven years from an arterio-enteric fistula on a kidney graft site after pancreas-kidney transplantation: a case report.

INTRODUCTION: We report the first case of a patient who underwent simultaneous kidney and pancreas transplantation and who then suffered from repeated episodes of severe gastrointestinal bleeding over a period of seven years. Locating the site of gastrointestinal bleeding is a challenging task. This case illustrates that detection of an arterio-enteric fistula can be very difficult, especially in technically-challenging situations such as cases of severe intra-abdominal adhesions. It is important to consider the possibility of arterio-enteric fistulas in cases of intermittent bleeding episodes, especially in transplant patients. CASE PRESENTATION: A 40-year-old Caucasian man received a combined pancreas-kidney transplantation as a result of complications from diabetes mellitus type I. Thereafter, he suffered from intermittent clinically-relevant episodes of gastrointestinal bleeding. Repeat endoscopic, surgical, scintigraphic, and angiographic investigations during his episodes of acute bleeding could not locate the bleeding site. He finally died in hemorrhagic shock due to arterio-enteric bleeding at the kidney graft site, which was diagnosed post-mortem. CONCLUSIONS: In accordance with the literature, we suggest considering the removal of any rejected transplant organs in situations where arterio-enteric fistulas seem likely but cannot be excluded by repeat conventional or computed tomography-angiographic methods. Arterio-enteric fistulas may intermittently bleed over many years.

Collection of annotated data in a clinical validation study for alarm algorithms in intensive care--a methodologic framework.

INTRODUCTION: Monitoring of physiologic parameters in critically ill patients is currently performed by threshold alarm systems with high sensitivity but low specificity. As a consequence, a multitude of alarms are generated, leading to an impaired clinical value of these alarms due to reduced alertness of the intensive care unit (ICU) staff. To evaluate a new alarm procedure, we currently generate a database of physiologic data and clinical alarm annotations. METHODS: Data collection is taking place at a 12-bed medical ICU. Patients with monitoring of at least heart rate, invasive arterial blood pressure, and oxygen saturation are included in the study. Numerical physiologic data at 1-second intervals, monitor alarms, and alarm settings are extracted from the surveillance network. Bedside video recordings are performed with network surveillance cameras. RESULTS: Based on the extracted data and the video recordings, alarms are clinically annotated by an experienced physician. The alarms are categorized according to their technical validity and clinical relevance by a taxonomy system that can be broadly applicable. Preliminary results showed that only 17% of the alarms were classified as relevant, and 44% were technically false. DISCUSSION: The presented system for collecting real-time bedside monitoring data in conjunction with video-assisted annotations of clinically relevant events is the first allowing the assessment of 24-hour periods and reduces the bias usually created by bedside observers in comparable studies. It constitutes the basis for the development and evaluation of "smart" alarm algorithms, which may help to reduce the number of alarms at the ICU, thereby improving patient safety.

A new miniaturized system for extracorporeal membrane oxygenation in adult respiratory failure.

INTRODUCTION: Mortality of severe acute respiratory distress syndrome in adults is still unacceptably high. Extracorporeal membrane oxygenation (ECMO) could represent an important treatment option, if complications were reduced by new technical developments. METHODS: Efficiency, side effects and outcome of treatment with a new miniaturized device for veno-venous extracorporeal gas transfer were analysed in 60 consecutive patients with life-threatening respiratory failure. RESULTS: A rapid increase of partial pressure of arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) from 64 (48 to 86) mmHg to 120 (84 to 171) mmHg and a decrease of PaCO2 from 63 (50 to 80) mmHg to 33 (29 to 39) mmHg were observed after start of the extracorporeal support (P < 0.001). Gas exchange capacity of the device averaged 155 (116 to 182) mL/min for oxygen and 210 (164 to 251) mL/min for carbon dioxide. Ventilatory parameters were reduced to a highly protective mode, allowing a fast reduction of tidal volume from 495 (401 to 570) mL to 336 (292 to 404) mL (P < 0.001) and of peak inspiratory pressure from 36 (32 to 40) cmH2O to 31 (28 to 35) cmH2O (P < 0.001). Transfusion requirements averaged 0.8 (0.4 to 1.8) units of red blood cells per day. Sixty-two percent of patients were weaned from the extracorporeal system, and 45% survived to discharge. CONCLUSIONS: Veno-venous extracorporeal membrane oxygenation with a new miniaturized device supports gas transfer effectively, allows for highly protective ventilation and is very reliable. Modern ECMO technology extends treatment opportunities in severe lung failure.

[Quality management: implementation of the "in-hospital" emergency protocol into clinical routine]. / Qualitätsmanagement: Implementierung des "In-Hospital"-Notfallprotokolls in die klinische Praxis.

BACKGROUND AND PURPOSE: Outcome after in-hospital resuscitation with survival rates between 14-17% still remains poor. Structured documentation of in-hospital cardiac arrest especially in Germany is rare and inhomogeneous. Documentation of in-hospital emergency situations (I-ES) may help to develop organizational structures, to collect information of treatment after resuscitation and therefore, improve patient's outcome. The aim of this study was to evaluate the documentation quality and user's acceptance after the implementation of an in-house emergency (IHE) protocol used by the authors' internal medicine emergency team (ET). METHODS: Analysis of IHE protocols and discharge letters of 65 patients between August 2004 and December 2007 at a university medical center. RESULTS: The IHE protocol was used in 65% of all emergency calls with a completion rate of 80% of all available documentation categories. Especially documentation of drugs given, their dosage and the general course of action was incomplete. In 25% the discharge letters did not contain information about the I-ES. CONCLUSION: Implementation of the authors' IHE protocol, designed in close accordance with the DIVI (German Interdisciplinary Association of Intensive Care and Emergency Medicine) out-of-hospital emergency protocol, helps to collect important data in I-ES. Usage of the protocol resulted in better documentation of emergency situations in contrast to the information found in discharge letters alone. Nevertheless, documentation of I-ES still needs to be improved, especially concerning the completeness of records.

Outcome in a large unselected series of patients with acute pancreatitis.

BACKGROUND/AIMS: The objective of this study was to assess the outcome in a large unselected population of patients with acute pancreatitis treated at a single university center. METHODOLOGY: We performed a retrospective analysis of 364 patients with acute pancreatitis and evaluated outcome, morbidity and mortality in relation to different treatment modalities. RESULTS: 238 patients suffered from interstitial-edematous pancreatitis, 126 patients from the necrotizing form. ICU treatment was necessary for 174 patients (48%). Minimally-invasive CT guided drainage techniques were used in 73 patients (20%) with pancreatic necroses but also in seven patients with edematous pancreatitis (2%), which showed extrapancreatic tissue necrosis. The overall hospital mortality was 14% (5.5% for patients with edematous pancreatitis vs. 30% for patients with necrotizing pancreatitis). CONCLUSIONS: In patients with the edematous form a small subpopulation showed peripancreatic tissue necrosis without necrosis of the pancreas itself, which was related to higher mortality rates than expected for patients with edematous pancreatitis. Regarding therapeutic procedures interventional treatment modalities should be considered as alternative treatment modalities.

Cardiac arrest: composition of resuscitation teams and training techniques: results of a hospital survey in German-speaking countries.

BACKGROUND: The long-term outcome of patients requiring cardiopulmonary resuscitation depends heavily on swift and appropriate care. The aim of this study was to obtain data on the composition and training of resuscitation teams in specialist departments for internal medicine and anesthesiology. METHODS: Between October 2006 and February 2007, 440 questionnaires were sent to departments for anesthesiology and internal medicine in Germany (hospitals with more than 300 beds) and to university hospitals in Switzerland and Austria. RESULTS: The response rate was 38%. Of 166 participating hospitals, 152 have an emergency team. Resuscitation training (RT) takes place in 111 hospitals. Ninety-two hospitals (55%) hold a course more than once a year. Of those hospitals with RT, 86% use a simulation dummy, 77% conduct theoretical tutorials, and 65% follow a fixed algorithm. CONCLUSION: The majority of hospitals that participated in this survey have an emergency team in place and organize resuscitation training for their medical personnel. The training varies greatly, however, in frequency, size of group, and qualification of the trainer. Implementation of standardized training for and management of in-hospital resuscitation measures might further hone staff skills and therefore improve the long-term outcome for the patients concerned.

Recovery from respiratory failure after decompression laparotomy for severe acute pancreatitis.

We present three cases of patients (at the age of 56 years, 49 years and 74 years respectively) with severe acute pancreatitis (SAP), complicated by intra-abdominal compartment syndrome (ACS) and respiratory insufficiency with limitations of mechanical ventilation. The respiratory situation of the patients was significantly improved after decompression laparotomy (DL) and lung protective ventilation was re-achieved. ACS was discussed followed by a short review of the literature. Our cases show that DL may help patients with SAP to recover from severe respiratory failure.

Significance of scintigraphy for the localisation of obscure gastrointestinal bleedings.

AIM: To determine the role of scintigraphy in patients with gastrointestinal (GI) bleeding of unknown localisation. METHODS: We performed retrospective analyses on 92 patients receiving scintigraphies from 1993 to 2000 in the University of Regensburg hospital, which were done for localisation of GI bleeding as a diagnostic step after an unsuccessful endoscopy. In addition to the scintigraphies, further diagnostic steps such as endoscopy, angiography or operations were performed. In some of the scintigraphies with negative results, a provocation test for bleeding with heparinisation was carried out. RESULTS: 73% of all scintigraphies showed a positive result. In 4.5% of the positive results, the source was located in the stomach, in 37% the source was the small bowel, in 25% the source was the right colon, in 4.5% the source was the left colon, and in 20% no clear localisation was possible. Only 4% of all scintigraphies were false positive. A reliable positive scintigraphy was independent of the age of the examined patient. A provocation test for bleeding with heparin resulted in an additional 46% of positive scintigraphies with a reliable localisation in primary negative scintigraphies. CONCLUSION: Our results show that scintigraphy and scintigraphy with heparin provocation tests are reliable procedures. They enable a reliable localisation in about half of the obscure GI-bleeding cases. Scintigraphy is superior to angiography in locating a bleeding. It is shown that even in the age of video capsule endoscopy and double-balloon enteroscopy, scintigraphy provides a reliable and directed localization of GI bleeding and offers carefully targeted guidance for other procedures.

Pumpless extracorporeal lung assist: a 10-year institutional experience.

BACKGROUND: Pumpless extracorporeal lung assist (PECLA) was developed to support pulmonary function in patients with severe respiratory insufficiency. METHODS: Since 1996, 159 patients with an age ranging from 7 to 78 years were provided with a PECLA system. Fifteen patients were referred to us by air or ground transport after insertion of the system in a peripheral hospital. RESULTS: Main underlying lung diseases were acute respiratory distress syndrome (70.4%) and pneumonia (28.3%). Pumpless extracorporeal lung assist lasted for 0.1 to 33 days, mean 7.0 +/- 6.2 days; cumulative experience was greater than 1,300 days. Successful weaning and survival to hospital discharge was achieved in 33.1% of patients after a mean PECLA support of 8.5 +/- 6.3 days. During PECLA therapy, 48.7% of patients died, mainly as a result of multiorgan failure after a mean interval of 4.8 +/- 5.1 days. Inability to stabilize pulmonary function was noted in 3% of patients only. After PECLA, 30-day mortality was 13.6%. In a subgroup analysis, best outcome was obtained in patients after trauma. CONCLUSIONS: Pumpless extracorporeal lung assist is a simple and efficient method to support patients with deteriorating gas exchange for prolonged periods to allow the lung protective ventilation and transportation. Best indication for use of PECLA is severe hypercapnia and moderate hypoxia.

Pharmacokinetics of meropenem during intermittent and continuous intravenous application in patients treated by continuous renal replacement therapy.

OBJECTIVE: The clinical effect of beta-lactam antibiotics depends on the time of drug concentration above the minimal inhibitory concentration (MIC) for a susceptible bacterium. Continuous infusion (CI) of beta-lactams such as meropenem may therefore be a more rational approach than intermittent bolus injections (IB). The aim of this study was to test whether CI of meropenem achieves effective drug concentrations comparable to IB in patients treated by continuous renal replacement therapy (CRRT). DESIGN: Prospective, randomised cross-over study. SETTING: Twelve-bed medical intensive care unit (ICU). PATIENTS AND INTERVENTIONS: Six ICU patients were randomised to receive either meropenem 1 g IB every 12 h or a 0.5 g i.v. loading dose followed by 2 g i.v. CI over 24 h. After 2 days, regimens were crossed over. Meropenem pharmacokinetics were determined on days 2 and 4. MEASUREMENTS AND RESULTS: Peak serum concentration [median (25% and 75% quartiles)] after short infusion of 1 g meropenem were 62.8 (51.4; 85.0) mg/l, trough levels at 12 h were 8.1 (4.5; 18.7) mg/l, and serum half-life was 5.3 (5.1; 7.0) h. Steady-state concentrations during CI were 18.6 (13.3; 24.5) mg/l. The AUCs during either treatment were comparable and determined as 233 (202; 254) mg/l*h (IB) and 227 (182; 283) mg/l*h (CI), respectively. Four hours after IB, drug concentrations dropped below CI steady-state concentrations. CONCLUSION: Appropriate antibacterial concentrations of meropenem in patients with CRRT are easily achievable with CI. CI may be an effective alternative dosing regimen to IB. A prospective comparison of the clinical efficacy of the two dosage regimens is warranted.

Ischemic-like cholangiopathy with secondary sclerosing cholangitis in critically ill patients.

OBJECTIVES: Sclerosing cholangitis in critically ill patients (SC-CIP) is a newly described entity of severe biliary disease with progression to liver cirrhosis. The mechanisms leading to this form of cholangiopathy with stricture formation and complete obliteration of bile ducts are unknown. PATIENTS AND METHODS: In the last 2 yr, sclerosing cholangitis was diagnosed in 26 patients during or after their stay on the intensive care unit by ERCP and/or liver histology. Complete patient records were available for 17 patients. Histological evaluations of liver biopsies and of four explanted livers, parameters of cardiovascular and respiratory conditions, treatment modalities, and accompanying infections were analyzed to find further hints for the pathomechanisms leading to SC-CIP. RESULTS: With the beginning of cholestasis, the earliest endoscopic findings were intrahepatic biliary casts with impairment of the biliary flow and subsequent biliary infection, in most cases with Enterococcus faecium. Liver biopsy confirmed cholangitis and histology of explanted livers revealed ulcerated biliary epithelium with hemorrhagic exudates in the bile ducts. In the further course, progressive sclerosis with formation of multiple strictures of the bile ducts was observed. All patients suffered severe respiratory insufficiency with the need for mechanical ventilation (40.7+/-32.9 days). The PaO2/FiO2 ratio until beginning of cholestasis was 150.5+/-43.1. Half of the patients (9/17) were treated with high-frequency oscillatory ventilation and 12/17 patients by intermittent prone positioning. All patients required catecholamines for hemodynamic stabilization. CONCLUSIONS: SC-CIP is a severe and in most cases rapidly progressive complication of intensive care patients. Ischemic injury of the biliary tree with the formation of biliary casts and subsequent ongoing biliary infection due to multiresistant bacteria seem to be major pathogenic mechanisms in the development of this new entity of sclerosing cholangitis.

Abdominal ultrasound in the intensive care unit: a 3-year survey on 400 patients.

OBJECTIVE: This study analyzed 400 ultrasound examinations in the ICU to assess the indications of this imaging modality. DESIGN AND SETTING: Retrospective analysis on prospectively collected data on 400 patients in a tertiary care hospital. PATIENTS AND PARTICIPANTS: The observational, prospective, clinical study examined 400 bedside abdominal ultrasound examinations performed in the ICU, of which 2% were performed emergently, 56% urgently, and 42% electively. MEASUREMENTS AND RESULTS: Environmental conditions impaired the examination slightly in 54%, moderately in 27%, and severely in 4%. Total time per study ranged from 1 to 45 min (median 10). New pathological findings were detected in 31% while 33% confirmed already known pathologies. In 53% there was no therapeutic consequence, in 27% treatment was continued based on the sonographic findings, in 10% an intervention was necessary, in 6% other therapeutic changes followed, and in 4% additional evaluation was deemed necessary. In 80% no other imaging test had to be performed. CONCLUSIONS: Ultrasound studies are deemed sufficient in a large proportion of patients and help to avoid other, more elaborate imaging studies. However, more focused indications for studies may help to improve cost-effectiveness.

Frequency and outcome of patients with nonthyroidal illness syndrome in a medical intensive care unit.

Acute and chronic critical conditions are associated with reduced serum levels of free triiodothyronine (FT(3)), free thyroxine FT(4), and thyrotropin, known as nonthyroidal illness syndrome (NTIS). It is still controversial whether these changes reflect a protective mechanism or a maladaptive process during prolonged illness. However, larger studies to determine the prevalence of the NTIS and its association with outcome in medical intensive care units (ICUs) are missing. Complete thyroid hormone levels from 247 of 743 patients admitted to our ICU between October 2002 and February 2004 were retrospectively evaluated. From these patients, Acute Physiology and Chronic Health II scores, ICU mortality, length of stay, mechanical ventilation, and concomitant medication were recorded. Ninety-seven patients (44.1%) had low FT(3) levels indicating an NTIS, either with normal (23.6%) or reduced (20.5%) serum thyrotropin levels. Of 97 patients with NTIS, 24 (23.3%) also showed reduced serum FT(4) levels. The NTIS was significantly associated with Acute Physiology and Chronic Health II scores, mortality, length of stay, and mechanical ventilation. In a multivariate Cox regression analysis, the combination of low FT(3) and low FT(4) was an independent risk factor for survival. Nonthyroidal illness syndrome is frequent at a medical ICU. A reduction of FT(4) together with FT(3) is associated with an increase in mortality and might reflect a maladaptive process, thereby worsening the disease.

Risk factors for mortality in severe upper gastrointestinal bleeding.

BACKGROUND AND AIMS: Factors related to mortality after upper gastrointestinal (GI) bleeding may differ in importance in high- and low-risk populations. This retrospective study was undertaken to define risk factors of mortality in patients needing endoscopy for upper gastrointestinal bleeding at a tertiary care centre. PATIENTS/METHODS: Three hundred and sixty-two patients with upper gastrointestinal bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication and laboratory data were retrieved from hospital charts and patients who survived and those who died in hospital were compared. RESULTS/FINDINGS: The mean Rockall score was 6.6+/-1.3 with 92.5% of patients belonging to a Rockall high-risk group. In hospital, mortality was 26.5%, with 6.4% of patients dying as a direct consequence of bleeding. Variceal bleeding was associated with a high risk of recurrent bleeding and death. Renal disease, liver disease, coagulopathy and immunosuppression were more frequently found in non-survivors than in survivors. Accordingly, serological tests of renal or liver function and coagulation were more disturbed in non-survivors. On average, heart rate was higher, and blood pressure and haemoglobin levels lower in non-survivors. Heparin, glucocorticoids, and anti-ulcer drugs were more frequently used in patients dying in hospital. By logistic regression analysis, in-patient status at the time of bleeding, renal disease and coagulopathy, as well as glucocorticoid use, were risk factors for hospital mortality. INTERPRETATION/CONCLUSION: In tertiary care, a high mortality rate is observed in upper GI bleeding. Teams involved in treating such patients should be aware of the setting in which treatment is performed and its related risk factors.

Comparison of inpatient and outpatient upper gastrointestinal haemorrhage.

BACKGROUND AND AIMS: Inpatients developing upper gastrointestinal (GI) haemorrhage are at increased risk of death. This study was performed to elucidate differences in inpatients and outpatients. PATIENTS/METHODS: Three hundred and sixty-two patients who needed esophagogastroduodenoscopy for upper GI bleeding were identified from endoscopy charts. Patients' characteristics, bleeding parameters, clinical presentation, pre-existing medication, and laboratory data were compared between patients who were admitted because of upper GI bleeding and patients who developed bleeding while in hospital for other reasons. RESULTS/FINDINGS: Hospital mortality was 39.0% in inpatients vs. 11.1% in outpatients (p<0.01). Death due to bleeding was observed in 9.5% of inpatients vs. 2.5% of outpatients (p<0.01). Whereas peptic ulcer was the most common source of bleeding in both, variceal bleeding was the most common cause of death because of haemorrhage in both. Recurrent bleeding was associated with mortality in outpatients (p<0.001), but not in inpatients (p=0.11). Rates of bleeding recurrence and need for surgery was similar in both groups. Inpatients suffered more often from renal disease, pulmonary disease, diabetes mellitus, coagulopathy, or immunosuppression, and were treated more frequently with acetylsalicylic acid, glucocorticoids and heparin. The frequency of pre-existing disease was higher in inpatients. INTERPRETATION/CONCLUSION: Higher mortality after GI bleeding in inpatients than in outpatients is due to a generally higher prevalence of co-morbidity rather than a single or a few risk factors.

Combined skin disinfection with chlorhexidine/propanol and aqueous povidone-iodine reduces bacterial colonisation of central venous catheters.

OBJECTIVE: Central venous catheter (CVC)-related infections may be caused by micro-organisms introduced from the skin surface into deeper tissue at the time of CVC insertion. The optimal disinfection regimen to avoid catheter-related infections has not yet been defined. This study compares three different approaches. DESIGN: Prospective randomised trial. SETTING: A tertiary care hospital. PATIENTS AND PARTICIPANTS: One hundred nineteen patients scheduled electively to receive 140 CVCs. INTERVENTIONS: Skin disinfection was performed with either povidone-iodine 10% (PVP-iodine), chlorhexidine 0.5%/propanol 70%, or chlorhexidine 0.5%/propanol 70% followed by PVP-iodine 10%. Prior to disinfection, a swab from the site of insertion was taken for culture. CVCs were removed if no longer needed or infection was suspected. All catheters were cultured quantitatively after removal. MEASUREMENT AND RESULTS: Bacteria could be isolated from 20.7% of the catheter tips. Bacterial growth was found in 30.8% of the catheters placed after skin disinfection with povidone-iodine, in 24.4% after disinfection with propanol/chlorhexidine and in 4.7% after disinfection with propanol/chlorhexidine followed by povidone-iodine ( p=0.006). In 15 cases, the same organism was isolated from the skin swab and the catheter tip. Ten of these paired isolates showed the same pattern in a pulsed-field gel electrophoresis analysis. CONCLUSIONS: Skin disinfection with propanol/chlorhexidine followed by PVP-iodine was superior in the prevention of microbial CVC colonisation compared to either of the regimens alone. These results support the concept that catheter infections can originate from bacterial translocation at the time of catheter insertion.