title: Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials.
abstract: BACKGROUND
  When subclavian access is not possible, controversy exists between the internal jugular and femoral sites for the choice of central-venous access in intensive care unit patients.
  
  
  OBJECTIVE
  To compare infection and colonization rates of short-term jugular and femoral catheters.
  
  
  METHODS
  Using data from two multicenter studies, we compared femoral and internal jugular for the risks of catheter-related bloodstream infection, major catheter-related infection, and catheter-tip colonization. We also compared the rates of dressing disruption and skin colonization. We used marginal structural models with inverse probability of treatment weighting to adjust on indication bias.
  
  
  RESULTS
  We included 2,128 patients (2,527 catheters and 19,481 catheter-days). We found no difference in catheter-related bloodstream infection (internal jugular 1.0 vs. femoral 1.1 per 1,000 catheter-days; hazard ratio [HR], 0.63 [0.25-1.63]; P = 0.34), major catheter-related infection (internal jugular 1.8 vs. femoral 1.4 per 1,000 catheter-days; HR, 0.91 [0.38-2.18]; P = 0.34), and colonization (internal jugular 11.6 vs. femoral 12.9 per 1,000 catheter-days; HR, 0.80 [0.25-1.63]; P = 0.15). However, colonization was higher with femoral for female (HR, 0.39 [0.24-0.63]; P < 0.001) and, at the significance limit, catheter maintained for more than 4 days (HR, 0.73 [0.53-1.01]; P = 0.05). The absence of benefit of internal jugular before Day 5 was related to a higher skin colonization at the internal jugular site for catheters removed before Day 5. After the fourth day, dressing disruption became more frequent with femoral catheters and may explain the subsequent risk of catheter colonization. Differences in cutaneous and catheter colonization between internal jugular and femoral was suppressed by the use of chlorhexidine-impregnated dressings.
  
  
  CONCLUSIONS
  Femoral and internal jugular accesses lead to similar risks of catheter infection. Internal jugular might be preferred for female, nonchlorhexidine-impregnated dressings users, and when catheters are left in place more than 4 days. Both sites are acceptable when a subclavian approach is not feasible. Clinical trial registered with www.clinicaltrials.gov (NCT00417235 and NCT01189682).
authors.affiliation: 1 Grenoble 1 (Joseph Fourier) University, U823 "Outcome of Cancers and Critical Illness," Albert Bonniot Institute, La Tronche, France.
authors.forename: Jean-François
authors.initials: JF
authors.lastname: Timsit
authors.forename: Lila
authors.initials: L
authors.lastname: Bouadma
authors.forename: Olivier
authors.initials: O
authors.lastname: Mimoz
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Parienti
authors.forename: Maïté
authors.initials: M
authors.lastname: Garrouste-Orgeas
authors.forename: Serge
authors.initials: S
authors.lastname: Alfandari
authors.forename: Gaétan
authors.initials: G
authors.lastname: Plantefeve
authors.forename: Régis
authors.initials: R
authors.lastname: Bronchard
authors.forename: Gilles
authors.initials: G
authors.lastname: Troche
authors.forename: Remy
authors.initials: R
authors.lastname: Gauzit
authors.forename: Marion
authors.initials: M
authors.lastname: Antona
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Canet
authors.forename: Julien
authors.initials: J
authors.lastname: Bohe
authors.forename: Marie-Christine
authors.initials: MC
authors.lastname: Herrault
authors.forename: Carole
authors.initials: C
authors.lastname: Schwebel
authors.forename: Stéphane
authors.initials: S
authors.lastname: Ruckly
authors.forename: Bertrand
authors.initials: B
authors.lastname: Souweine
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Lucet
mesh_terms: D000368:Aged; D055499:Catheter-Related Infections / Q000209:etiology* / Q000517:prevention & control; D002405:Catheterization, Central Venous / Q000009:adverse effects / Q000379:methods*; D062905:Central Venous Catheters / Q000382:microbiology; D003422:Critical Care / Q000379:methods*; D005260:Female; D005268:Femoral Vein; D005500:Follow-Up Studies; D006801:Humans; D007601:Jugular Veins; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D017063:Outcome Assessment, Health Care; D057216:Propensity Score; D016016:Proportional Hazards Models; D012307:Risk Factors; D016037:Single-Blind Method; D012867:Skin / Q000382:microbiology; D013997:Time Factors