Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: A prospective study utilizing molecular subtyping. American Journal of Medicine. 1991;91(3B):197S-205S.

Prospective observational study of Swan-Ganz catheters, showing that the great majority of infections come from the insertion site. Other risk factors were use of the jugular insertion site, duration of catheter dwell for more than three days, and lack of full barrier precautions during insertion.

McCarthy MC, Shives JK, Robison RJ, et al. Prospective evaluation of single and triple lumen catheters in total parenteral nutrition. Journal of Parenteral and Enteral Nutrition.1987;11:259.

This prospective study was performed to examine the complications associated with the use of these catheters in patients receiving long-term total parenteral nutrition (TPN). The two groups were comparable with respect to concomitant infections, treatment with antibiotics, and need for intensive care.  However, after five days of catheterization, there was a marked increase in the number of TLC removed because of skin entry site infections. SLC were more likely to be used for the full duration of TPN administration.

Massanari RM. Nosocomial infections in critical care units: Causation and prevention. Critical Care Nursing Quarterly. 1989;11(4):45-57.

Detailed narrative review of the causes and prevention of infections in ICUs, including the properties of specific bacteria that enable them to cause hospital-acquired infection, reservoirs of infection, patient-related factors, and the importance of handwashing, including a summary of several reports of epidemics of infection on ICUs.

Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991;338(8763):339-343.

Randomized controlled trial on a surgical ICU in which 668 catheters were placed with either 10 percent povidone-iodine, 70 percent alcohol, or 2 percent aqueous chlorhexidine disinfection of the site prior to insertion and every other day thereafter. Use of chlorhexidine was associated with the lowest risk or local and bloodstream catheter-related infections.

Maki DG, Alvarado CJ, Hassemer CA, Zilz MA. Relation of the inanimate hospital environment to endemic nosocomial infection. New England Journal of Medicine. 1982;307(25):1562-1566.

A prospective study of the bacteria present in the physical environment in a 56-year-old hospital building which was then repeated when the University of Wisconsin moved into a new building complete with air filters, much improved ventilation, and isolation rooms with separate ventilation.

Larson E. Skin hygiene and infection prevention: More of the same or different approaches? Clinical Infectious Diseases. 1999;29(5):1287-1294.

Review of seven studies published between 1977 and 1995 that examined the relationship between handwashing and hospital-acquired infection. The review concluded that there was a clear causal relationship between hand hygiene and reduced transmission of infections. Recommended practices included use of waterless alcohol-based products rather than detergent-based antiseptics to reduce skin damage.

Groeger JS, Lucas AB, Thaler HT, et al. Infectious morbidity associated with long-term use of venous access devices in patients with cancer. Annals of Internal Medicine. 1993;119:1168.

A prospective observational study was conducted to evaluate infectious morbidity associated with long-term use of venous access devices.  Quantitative microbiologic tests were used to identify device-related bacteremia and fungemia, catheter tunnel infection, pocket infection in implantable port devices, and site infections; number of days the device remained in situ and time until infectious morbidity; vessel or device thrombosis and device breakage.

Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: Effect of site of placement and catheter type. Infection Control and Hospital Epidemiology. 1998;19(11):842-845.

Prospective observational study or the risk factors for colonization of catheters and of catheter-related bloodstream infection over 28 months of all non-tunnelled central venous catheters on medical-surgical wards of a VA hospital. Emergent insertion and choice of the femoral vein for insertion were associated with catheter contamination, and there was a trend for an association between femoral placement and catheter-related bloodstream infection.

Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. New England Journal of Medicine. Oct 1992;327(15):1062-1068.

Controlled trial in adult ICU patients requiring central venous or pulmonary artery catheters for more than three days.  Guide wire exchange was associated with an increased risk of bloodstream infection. Reinsertion at a new site was associated with an increased risk of mechanical complications. Replacement at three days did not reduce the risk of infection.

Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Critical Care Medicine. Oct 2004;32(10):2014-2020.

Prospective cohort study involving all patients with a central venous catheter in a surgical ICU, in which a quality improvement team implemented five interventions: staff education, use of a catheter insertion cart, asking providers daily whether lines could be removed, implementing a checklist to ensure adherence to evidence-based guidelines, and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. The rate of catheter-related bloodstream infections fell from 11.3 per 1,000 catheter-days to zero after implementation of these interventions.