Should we review our prophylaxis approach for increased antibiotic resistance in transrectal prostate biopsy?

INTRODUCTION: This study aims to show the bacteriologic picture of acute prostatitis and bacteremia caused by infective agent after transrectal ultrasound-guided prostate biopsy (TRUSBx) and to determine the resistance rates of the infections in patients undergoing transrectal biopsy and to guide prophylaxis approach before biopsy. METHODOLOGY: The retrospective data of 935 patients who underwent TRUSBx between January 2010 to January 2019 were reviewed. Pre-biopsy urine cultures and antimicrobial susceptibility were obtained. Subsequently, patients admitted to the hospital with any complaint after biopsy were examined for severe infection complications. RESULTS: Of the 430 (61.7%) patients who underwent urine culture before the procedure, 45 (10.5%) had growth; 30 (66.7%) of the growing microorganisms were Escherichia coli. Twenty (44.4%) of all Gram-negative agents in pre-biopsy urine culture were susceptible to quinolone. Post TRUSBx bacteremia was present in 18.2%, urinary system infection in 83.6%, and hospitalization in 61.8% of 55 patients who were admitted to the hospital. In the isolated gram-negative microorganisms, fluoroquinolones resistance in urinary system infections was seen in 40% and bacteremia was seen in 70% of the cases. ESBL-producing Gram-negative bacteria were determined in 40% of infections in blood and 38.5% of urinary system infections in the post biopsy period in the current study. CONCLUSIONS: These high antibiotic resistance rates suggest that we better review our pre-procedure prophylaxis approaches.

Safety and Efficacy of Ethanol for Catheter Salvage and Central Line-Associated Bloodstream Infection Prophylaxis in Polyurethane Catheters in the PICU.

OBJECTIVES: Ethanol lock therapy (ELT) is a potential method of central catheter salvage following central line-associated bloodstream infection (CLABSI) although there is potential risk of catheter damage in polyurethane catheters. Further, there is limited efficacy data across the spectrum of common pediatric catheters, and published ELT protocols describe dwell times that are not feasible for critically ill children. We sought to evaluate the safety and efficacy of ELT in polyurethane catheters using brief (30 min to 2 hr) dwell times in our PICU. DESIGN: Investigational pilot study using historical control data. SETTING: PICU in quaternary care, free-standing children's hospital. INTERVENTIONS: ELT in polyurethane central venous catheters for catheter salvage. RESULTS: ELT with brief dwell times was used in 25 patients, 22 of whom were bacteremic. Ultimately 11 patients, comprising 14 catheters, were diagnosed with a primary CLABSI. The catheter salvage rate in primary CLABSI patients receiving ELT was 92% (13/14) and significantly higher than the salvage rate in patients receiving antibiotics alone (non-ELT) (62%, 39/64; mean difference 0.32, 95% CI [0.14-0.50], p = 0.03). The rate of catheter fracture in all patients receiving ELT was 8% (2/25) while the rate of fracture in the non-ELT group was 13% (8/64; mean difference -0.05, 95% CI [-0.18 to 0.09], p = 0.72). The rate of tissue plasminogen activator (tPA) use in the ELT group was 8% (2/25), whereas the rate of tPA use in the non-ELT group was significantly higher at 42% (26/64; mean difference -0.34, 95% CI [-0.49 to -0.17], p = 0.002). CONCLUSIONS: The use of ELT for catheter salvage and prophylaxis in the PICU is safe in a variety of polyurethane catheters. Dwell times ranging from 30 minutes to 2 hours were effective in sterilizing the catheters while allowing other therapies to continue. This approach may decrease the need for frequent line changes in a medically fragile pediatric population.

Catheter salvage or removal in catheter-related bloodstream infections with Staphylococcus aureus in children with chronic intestinal failure receiving home parenteral nutrition and the use of prophylactic taurolidine catheter lock solution: A descriptive cohort study.

BACKGROUND: Children with chronic IF require long-term home parenteral nutrition (HPN), administered through a central venous catheter. Catheter-related bloodstream infection (CRBSI) with Staphylococcus aureus is known to be a serious infection with a high mortality rate and risk of complications. A standardized protocol on the management of S aureus CRBSIs in children receiving HPN is lacking. The aim of this study is to evaluate the effectiveness and safety of the current management in an HPN expertise center in the Netherlands. METHODS: We performed a retrospective descriptive cohort study between 2013 and 2022 on children 0-18 years of age with chronic IF requiring long-term HPN. Our primary outcomes were the incidence of S aureus CRBSI per 1000 catheter days, catheter salvage attempt rate, and successful catheter salvage rate. Our secondary outcomes included complications and mortality. RESULTS: A total of 74 patients (39 male; 53%) were included, covering 327.8 catheter years. Twenty-eight patients (38%) had a total of 52 S aureus CRBSIs, with an incidence rate of 0.4 per 1000 catheter days. The catheter salvage attempt rate was 44% (23/52). The successful catheter salvage rate was 100%. No relapse occurred, and no removal was needed after catheter salvage. All complications that occurred were already present at admission before the decision to remove the catheter or not. No patients died because of an S aureus CRBSI. CONCLUSION: Catheter salvage in S aureus CRBSIs in children receiving HPN can be attempted after careful consideration by a multidisciplinary team in an HPN expertise center.

Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review.

BACKGROUND: Prophylactic antibiotic therapy is widely used in dermatologic surgery to prevent surgical site infections and bacteremia, which can lead to prosthetic joint infections (PJI) and infective endocarditis (IE) in high-risk populations. OBJECTIVE: To evaluate the incidence of bacteremia, PJI, and IE after dermatologic surgery and assess the current evidence for antibiotic prophylaxis. MATERIALS AND METHODS: A search of the computerized bibliographic databases was performed using key terms from the date of inception to March 21, 2021. Data extraction was performed independently by 2 data extractors. RESULTS: The review resulted in 9 publications that met inclusion criteria, including 5 prospective cohort studies and 4 case reports or case series. The prospective studies reported a wide range of bacteremia incidence (0%-7%) after dermatologic surgery. No cases of PJI resulting directly from cutaneous surgery were identified, and only 1 case series reported IE after various skin procedures. CONCLUSION: These findings suggest a low rate of bacteremia and a lack of direct evidence linking dermatologic surgery to PJI or IE. The scarcity of published data on this topic is a limitation, highlighting the need for further research, particularly randomized controlled trials, to guide antibiotic prophylaxis recommendations.

The addition of doxycycline to fluoroquinolones for bacterial prophylaxis in autologous stem cell transplantation for multiple myeloma.

BACKGROUND: Bacterial prophylaxis with a fluoroquinolone (FQ) during autologous stem cell transplant (ASCT) is common, although not standardized among transplant centers. The addition of doxycycline (doxy) to FQ prophylaxis was previously linked to reduced neutropenic fever and bacteremia in multiple myeloma (MM) patients undergoing ASCT although several confounders were present. We compared the incidence of neutropenic fever and bacteremia between MM patients variably receiving prophylaxis with FQ alone and FQ-doxy during ASCT. METHODS: Systematic retrospective chart review of MM patients who underwent ASCT between January 2016 and December 2021. The primary objective was to determine the effect of bacterial prophylaxis on neutropenic fever and bacteremia within 30 days of ASCT. Multivariable logistic regression for neutropenic fever and univariate logistic regression for bacteremia accounted for differences in subject characteristics between groups. RESULTS: Among 341 subjects, 121 received FQ and 220 received FQ-doxy for prophylaxis. Neutropenic fever developed in 67 (55.4%) and 87 (39.5%) subjects in the FQ and FQ-doxy groups, respectively (p = .005). Bacteremia was infrequent, with 5 (4.1%) and 5 (2.3%) cases developing in the FQ and FQ-doxy groups, respectively (p = .337). Among Gram-negative bacteremia events, 7/7 Escherichia coli strains were FQ-resistant, and 5/7 were ceftriaxone-resistant. CONCLUSION: The FQ-doxy prophylaxis group had fewer cases of neutropenic fever than the FQ group, however, there was no significant difference in bacteremia. High rates of antibiotic resistance were observed. An updated randomized controlled trial investigating appropriate prophylaxis for ASCT in the context of current oncology standards and changing antimicrobial resistance rates is warranted.

Infecciones relacionadas con la asistencia sanitaria en neonatología / Health care-associated infections in neonatology

Las infecciones relacionadas con la asistencia sanitaria (IRAS) son frecuentes en neonatología, pero no existe un consenso en sus definiciones. Esto dificulta la comparación de incidencias entre distintas unidades o la valoración de la eficacia de los paquetes de prevención. Por ello, es que consideramos muy importante lograr un acuerdo en las definiciones y diagnóstico de una de las morbilidades más recurrentes de los neonatos hospitalizados. El presente documento pretende unificar estas definiciones en relación con las infecciones más comunes como son la bacteriemia relacionada con el catéter (BRC), la neumonía vinculada a la ventilación mecánica (NAV) y la infección de la herida quirúrgica (IHQ), así como su abordaje diagnóstico-terapéutico.(AU)

Health care-associated infections are common in neonatology, but there is no consensus on their definitions. This makes it difficult to compare their incidence or assess the effectiveness of prevention bundles. This is why we think it is very important to achieve a consensus on the definitions and diagnostic criteria for one of the most frequent causes of morbidity in hospitalised neonates. This document aims to standardise the definitions for the most frequent health care-associated infections, such as catheter-associated bloodstream infection, ventilator-associated pneumonia and surgical wound infection, as well as the approach to their diagnosis and treatment.(AU)

Central Line-Associated Bloodstream Infection Misclassifications-Rethinking the Centers for Disease Control and Prevention's Central Line-Associated Bloodstream Infection Definition and Its Implications.

Centers for Medicare and Medicaid Services imparts financial penalties for central line-associated bloodstream infections (CLABSIs) and other healthcare-acquired infections. Data for this purpose is obtained from the Centers for Disease Control and Prevention (CDC)'s National Health Safety Network. We present examples of misclassification of bloodstream infections into CLABSI by the CDC's definition and present the financial implications of such misclassification and potential long-term implications.

Epidemiology and preventability of hospital-onset bacteremia and fungemia in 2 hospitals in India.

OBJECTIVE: Studies evaluating the incidence, source, and preventability of hospital-onset bacteremia and fungemia (HOB), defined as any positive blood culture obtained after 3 calendar days of hospital admission, are lacking in low- and middle-income countries (LMICs). DESIGN, SETTING, AND PARTICIPANTS: All consecutive blood cultures performed for 6 months during 2020-2021 in 2 hospitals in India were reviewed to assess HOB and National Healthcare Safety Network (NHSN) reportable central-line-associated bloodstream infection (CLABSI) events. Medical records of a convenience sample of 300 consecutive HOB events were retrospectively reviewed to determine source and preventability. Univariate and multivariable logistic regression analyses were performed to identify factors associated with HOB preventability. RESULTS: Among 6,733 blood cultures obtained from 3,558 hospitalized patients, there were 409 and 59 unique HOB and NHSN-reportable CLABSI events, respectively. CLABSIs accounted for 59 (14%) of 409 HOB events. There was a moderate but non-significant correlation (r = 0.51; P = .070) between HOB and CLABSI rates. Among 300 reviewed HOB cases, CLABSIs were identified as source in only 38 (13%). Although 157 (52%) of all 300 HOB cases were potentially preventable, CLABSIs accounted for only 22 (14%) of these 157 preventable HOB events. In multivariable analysis, neutropenia, and sepsis as an indication for blood culture were associated with decreased odds of HOB preventability, whereas hospital stay ≥7 days and presence of a urinary catheter were associated with increased likelihood of preventability. CONCLUSIONS: HOB may have utility as a healthcare-associated infection metric in LMIC settings because it captures preventable bloodstream infections beyond NHSN-reportable CLABSIs.

Use of 2% taurolidine lock solution for treatment and prevention of catheter-related bloodstream infections in neonates: a feasibility study.

BACKGROUND: Taurolidine lock, a technique used to prevent or treat catheter-related bloodstream infection (CRBSI), is effective in adult and paediatric patients but has been described rarely in neonates. The aim of this descriptive retrospective study, was to determine the feasibility and direct outcomes of prophylactic and therapeutic taurolidine locks in term and preterm neonates. METHODS: We implemented the use of therapeutic taurolidine lock in addition to antibiotic treatment with the aim of catheter salvage in critical neonates with difficult vascular access (group 1). In addition, we introduced taurolidine lock as a preventive measure in neonates with a central venous catheter (CVC) at high risk of developing CRBSI (group 2). Every 24 h (in the treatment group) a 2% taurolidine solution was injected and the catheter locked for at least 120 min, until infection clearance (group 1). In the preventive group, the catheter was locked for 30 min every 48 h until CVC removal (group 2). FINDINGS: Thirty-seven neonates who received taurolidine were included in this study. We did not observe any major adverse events. In group 1 (21 cases), clinical symptom disappearance and bacteraemia clearance were achieved without catheter removal in 18 cases (85.7%); in the other three neonates the catheter was removed shortly after the start of the locks as it was possible to replace the CVC. In group 2 (16 neonates), no CRBSI was observed during the duration of the catheter placement. CONCLUSIONS: In this retrospective study, taurolidine was successfully used in neonates both for prevention and treatment of CRBSI, without major undesired effects. A larger cohort and a randomized clinical trial is warranted in order to establish its efficacy and safety in neonates.

Containment of carbapenem-resistant Enterobacterales colonisations and infections: Results from an integrated infection control intervention in a large hospital trust of northern Italy.

PURPOSE: We describe the results of an infection control intervention, implemented in 4 tertiary hospitals in Romagna, Italy, aiming at containing the spread of carbapenem-resistant Enterobacterales (CRE). METHODS: The intervention consisted of rectal screening in patients at risk for CRE; pre-emptive contact precaution waiting for screening results; timely notification of CRE identification and concomitant computerized alert; contact precaution for confirmed CRE-positive patients. We performed an interrupted time series analysis to compare the incidence of CRE bacteraemia, of other CRE infections, and CRE-positive rectal swabs in the pre and postintervention period (January 2015-July 2017 and August 2017-June 2020, respectively). RESULTS: 4,332 CRE isolates were collected. Klebsiella pneumoniae was the most represented pathogen (n = 3,716, 85%); KPC production was the most common resistance mechanism (n = 3,896, 90%). The incidence rate of CRE bacteraemia significantly decreased from 0.554 to 0.447 episodes per 10.000 patient days in the early postintervention period (P = .001). The incidence rate of other CRE infections significantly decreased from 2.09 to 1.49 isolations per 10.000 patient days in the early postintervention period (P = .021). The monthly number of rectal swabs doubled in the postintervention period and there was a significant reduction trend of CRE-positive swabs, sustained over time (P < .001). CONCLUSIONS: The infection control intervention was successful in containing the spread of CRE infections and colonisations.

Changing culture: An intervention to improve blood culture quality in the emergency department.

OBJECTIVE: Blood cultures (BCs) remain a key investigation in ED patients at risk of bacteraemia. The aim of this study was to assess the effect of a multi-modal, nursing-led intervention to improve the quality of BCs in the ED, in terms of single culture, underfilling and contamination rates. METHOD: The present study was conducted in the ED of a large urban tertiary referral hospital. The study included four phases: pre-intervention, intervention, post-intervention and sustainability periods. A multi-modal intervention to improve BC quality consisting small group education, posters, brief educational videos, social media presence, quality feedback, small group/individual mentoring and availability of BC collection kits was designed and delivered by two senior ED nurses over 7 weeks. Study data comprised rates of single, underfilled and contaminated cultures in each of three 18-week periods: pre-intervention (baseline), post-intervention and sustainability. RESULTS: Over the study period 4908 BC sets were collected during 2347 episodes of care in the ED. Single culture sets reduced from 56.2% in the pre-intervention period to 22.8% post-intervention (P < 0.01) and 18.8% in the sustainability period (P < 0.01). Underfilled bottle rates were also significantly reduced (aerobic 52.8% pre-intervention to 19.2% post-intervention, 18.8% sustainability, anaerobic 46.8% pre-intervention to 23.3% post-intervention, 23.8% sustainability). Skin contaminants were grown from 3.7% of BC sets in the pre-intervention period, improving to 1.5% in the post-intervention period (P < 0.001) and 2.1% in the sustainability period (P = 0.03). Total volume of blood cultured was significantly associated with diagnosis of bacteraemia. CONCLUSION: Significant improvements in BC quality are possible with nursing-based interventions in the ED.

Descriptive epidemiology of central line-associated bloodstream infections at an academic medical center in Iowa, 2019-2022.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) increased nationally during the COVID-19 pandemic. We described CLABSIs at our institution during 2019 to 2022. METHODS: This retrospective observational study examined CLABSIs among adult inpatients at an 866-bed teaching hospital in the Midwest. CLABSI incidence was trended over time and compared to monthly COVID-19 admissions. Manual chart review was performed to obtain patient demographics, catheter-associated variables, pathogens, and clinical outcomes. RESULTS: We identified 178 CLABSIs. The CLABSI incidence (cases per 1,000 line days) tripled in October 2020 as COVID-19 admissions increased. CLABSIs in 2020 were more frequently caused by coagulase-negative staphylococci and more frequently occurred in the intensive care units 7+ days after central line insertion. The CLABSI incidence normalized in early 2021 and did not increase during subsequent COVID-19 surges. Throughout 2019 to 2022, about half of the nontunneled central venous catheters involved in CLABSI were placed emergently. One-quarter of CLABSIs involved multiple central lines. Chlorhexidine skin treatment adherence was limited by patient refusal. CONCLUSIONS: The increase in CLABSIs in late 2020 during a surge in COVID-19 admissions was likely related to central line maintenance but has resolved. Characterizing CLABSI cases can provide insight into adherence to guideline-recommended prevention practices and identify areas for improvement at individual institutions.

[Management of the Central Venous Catheter in Patients Undergoing Hemodialysis Treatment].

Background. Catheter-related bloodstream infection (CRBSI) is defined as the presence of bacteremia originating from a venous catheter and is one of the most common and costly complications, often followed by death and septicemia. Objectives. To evaluate the effectiveness of specific interventions on CRBSI reduction rates and other outcomes. Materials and Methods. The review has been performed by consulting scientific evidence through the PUBMED/MEDLINE database using MeSh terms and Boolean operators. Studies related to the formulated hypothesis have been selected and included. Results. The results showed that thanks to a series of interventions it was possible to decrease the risk of CRBSI and lowered the risk of catheter removal, hospitalization rate and morbidity rate. Discussion and Conclusions. Proper catheter care and follow-up procedures are the first steps in preventing infection. Audit and education of dialysis unit personnel is essential.

Risk factors for catheter-related bloodstream infections in patients with intestinal failure undergoing home parenteral nutrition: a single-center study.

PURPOSE: The incidence and risk factors of catheter-related bloodstream infections (CRBSI) in patients with intestinal failure (IF) have not been established, partly because catheter management methods vary from different facilities. This study aimed to identify the risk factors and incidence rate of CRBSIs in patients with IF who were given prophylactic treatment. METHODS: Sixteen patients with IF who required home parenteral nutrition were enrolled in this study. Prophylactic management of CRBSI included monthly ethanol lock therapy and standardized infection prevention education. The outcomes included the incidence and risk factors of CRBSI. RESULTS: The median incidence rate of CRBSI was 1.2 per 1000 catheter days. Univariate analysis showed that the risk of developing CRBSI was significantly associated with short bowel syndrome (< 30 cm) (p = 0.016). Other relevant findings included a significant negative correlation between serum albumin and CRBSI rate (r = - 0.505, p = 0.046), and past history of mixed bacterial infections was significantly associated with increased CRBSI rate (p = 0.013). CONCLUSION: CRBSIs can still develop despite undergoing prophylactic management. Risk factors for CRBSI include the residual intestinal length, nutritional status, and susceptibility to certain microorganisms.

Protecting patients through surveillance of device-related bacteraemias.

Susan Rowlands, IV Resource Team Lead, The Royal Wolverhampton NHS Trust, susan.rowlands1@nhs.net, was a Silver Award winner in the Vascular Access Nurse of the Year category of the BJN Awards 2023.

A Review of Pediatric Central Line-Associated Bloodstream Infections Reported to the National Healthcare Safety Network: United States, 2016-2022.

Central line-associated bloodstream infections (CLABSIs) are common healthcare-associated infections in pediatrics. Children's hospital CLABSI standardized infection ratios decreased when comparing 2016-2019 (-26%, 95% CI [-31%, -20%]), and increased from 2019 to 2022 (18%, 95% CI [9%, 26%]). Resilient pediatric CLABSI prevention initiatives are needed.

Influence of Care on the Prevention of Bacteremia in Hemodialysis: Systematic Review.

Central venous catheter-related infection is the most common complication in patients on hemodialysis. Nursing care is essential for its maintenance, minimizing risk factors, and avoiding complications, such as bacteremia. A systematic review was conducted to identify the influence of nursing care on the prevention of bacteremia due to hemodialysis catheter. The primary endpoint was the bacteremia rate measured as number of events per 1000 catheter days. The rate of bacteremia in the studies ranged from 0.2 to 5.47 events per 1000 catheter days after the application of nursing care. Several studies have shown a significant reduction in central venous catheter bacteremia with the application of management protocols, appropriate vigilance, and monitoring, as well as the inclusion of the Plan Do Check Act cycle and education.

The impact of central line bundles on the timing of catheter-associated bloodstream infections and their microbiological distribution in critically ill children.

Catheter-associated bloodstream infection, also known as CLABSI, is the most serious consequence of central venous access devices. These infections increase the risk of mortality and morbidity. The use of central line bundles in clinical settings is increasing worldwide with the purpose of lowering the risk of catheter-associated bloodstream infections. In this study, we investigated the effect of implementing a central line bundle for the prevention of CLABSIs, the distribution of pathogens, and the duration of time it took for CLABSIs to develop in patients who had subclavian-inserted central venous catheters. This research project was a cross-sectional study investigation carried out in a pediatric tertiary teaching hospital. Participants consisted of children who had been admitted to the pediatric critical care unit with subclavian catheters during a period of 13 years. We compared the prebundle period with the bundle period for CLABSI specifically focusing on the time to infection, the number of polymicrobial infections, the proportion of Candida parapsilosis, and the percentage of Coagulase-negative staphylococci (CoNS). The "prebundle period" included the period from May 2007 to May 2013, and the "bundle period" included the period from June 2013 to June 2020. Throughout the course of the study, a total of 286 cases of CLABSI were documented. Among these patients, 141 (49.3%) had CLABSIs associated with subclavian catheters. During the prebundle period, 55 CLABSIs were diagnosed in 5235 central line days, with an overall rate of 10.5 CLABSIs per 1000 central line days; after the implementation of central line bundle, 86 CLABSIs were diagnosed in 12,450 CL days, with an overall rate of 3.6 CLABSIs per 1000 CL days. This showed a statistically significantly lower rate in the bundle period (p = 0.0126). In the prebundle period, the mean time to develop CLABSI was 15 days, whereas during the bundle period, the mean time to develop CLABSI was 27.9 days, a significantly longer time to onset (p = 0.001). While the percentage of other microorganisms was not statistically different between the prebundle and bundle periods (p > 0.05), the percentage of C. parapsilosis was significantly higher in the prebundle period (p = 0.001).   Conclusion: The results of this study imply that the use of central line bundles not only reduces the incidence of CLABSI but also delays the time to which CLABSI patients acquire an infection. In addition, as a direct consequence of the CLB, the number of CLABSIs caused by gram-positive cocci did not increase, while the proportion of CLABSIs caused by C. parapsilosis decreased. What is Known: • The most significant negative consequence of central venous access devices is catheter-associated bloodstream infections. • "Care bundles" for CLABSI prevention have been reported to reduce the CLABSI rate. What is New: • Consider what would happen if the "Care bundle" failed to prevent CLABSI. • The findings of this study imply that using central line bundles not only reduces the risk of CLABSI but also extends the time it takes for patients to develop CLABSI. While the number of CLABSIs caused by gram-positive cocci did not increase as a direct result of CLB, the rate of CLABSIs caused by C. parapsilosis, which has recently become a major problem, has decreased.

Moving Beyond Central Line-Associated Bloodstream Infections: Enhancement of the Prevention Process.

The provision of medications and other treatments via intravenous (IV) therapy has provided millions of health care patients with extended benefits. IV therapy, however, is also associated with complications, such as associated bloodstream infections. Understanding the mechanisms of development and the factors that have contributed to the recent increases in such health care-acquired infections assists in formulating new preventive strategies that include the implementation of hospital-onset bacteremia, an innovative model that requires surveillance and prevention of bloodstream infections associated with all types of vascular access devices, expansion of vascular access service teams (VAST), and use of advanced antimicrobial dressings designed to reduce bacterial proliferation over the currently recommended time periods for maintenance of IV catheters.