Clinical question

Do central venous catheters in the femoral vein increase the risk of catheter-related bloodstream infections as compared with those placed in the subclavian or internal jugular veins?

Bottom line

The risk of catheter-related bloodstream infections (CRBIs) from nontunneled central venous catheters has decreased in the last decade.This review suggests that there is no difference in risk of CRBIs when comparing catheters placed in femoral sites with those placed in subclavian or internal jugular (IJ) sites, especially when looking at data from more recent studies. LOE = 1a

Reference

Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 2012;40(8):2479-2485.

Study design

Meta-analysis (other)

Funding source

Unknown/not stated

Allocation

Uncertain

Setting

Inpatient (any location)

Synopsis

Current guidelines from the Centers for Disease Control recommend avoiding the femoral vein for central access in adult patients because of a potentially higher risk of CRBI. Two independent investigators searched MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and bibliographies of relevant articles, as well as performed an Internet search, to find randomized controlled trials (RCTs) and cohort studies that examined the risk of CRBIs due to nontunneled central venous catheters placed in the femoral site as compared with those placed in the subclavian or IJ sites. Two RCTs, 8 cohort studies, and data from a Welsh infection control surveillance Web site were selected. Two authors independently extracted data from the selected studies. No formal quality assessment of the studies was performed. Data from the RCTs alone showed no difference in CRBIs between femoral sites and subclavian or IJ sites. Data from all the studies that compared femoral sites to subclavian sites showed no significant difference in the risk of CRBIs. For comparisons of femoral and IJ sites, the overall data favored the IJ site (relative risk of infection with femoral site placement = 1.90; 95% CI, 1.21-2.97; P = .005). However, 2 of the 9 included studies in this analysis were “statistical outliers,” possibly due to unique circumstances in the hospitals in which they were performed, thus limiting their generalizability. When these 2 studies were removed from the analysis, there was no significant difference between femoral and IJ sites. For both comparisons (femoral vs subclavian and femoral vs IJ), there was an interaction between risk of infection and year of study publication, with earlier studies noting a greater risk of infection with femoral sites. Overall, this data confirms a decrease in incidence of CRBIs by more than 50% in the last 10 years. Additionally, study meta-analysis found no difference in the risk of deep venous thrombosis with femoral versus subclavian and IJ sites.