title: Cumulative Evidence of Randomized Controlled and Observational Studies on Catheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis.
abstract: BACKGROUND
  Selection of central venous catheter insertion site in ICU patients could help reduce catheter-related infections. Although subclavian was considered the most appropriate site, its preferential use in ICU patients is not generalized and questioned by contradicted meta-analysis results. In addition, conflicting data exist on alternative site selection whenever subclavian is contraindicated.
  
  
  OBJECTIVE
  To compare catheter-related bloodstream infection and colonization risk between the three sites (subclavian, internal jugular, and femoral) in adult ICU patients.
  
  
  METHODS
  We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, CINAHL, and ClinicalTrials.gov.
  
  
  METHODS
  Eligible studies were randomized controlled trials and observational ones.
  
  
  METHODS
  Extracted data were analyzed by pairwise and network meta-analysis.
  
  
  RESULTS
  Twenty studies were included; 11 were observational, seven were randomized controlled trials for other outcomes, and two were randomized controlled trials for sites. We evaluated 18,554 central venous catheters: 9,331 from observational studies, 5,482 from randomized controlled trials for other outcomes, and 3,741 from randomized controlled trials for sites. Colonization risk was higher for internal jugular (relative risk, 2.25 [95% CI, 1.84-2.75]; I = 0%) and femoral (relative risk, 2.92 [95% CI, 2.11-4.04]; I = 24%), compared with subclavian. Catheter-related bloodstream infection risk was comparable for internal jugular and subclavian, higher for femoral than subclavian (relative risk, 2.44 [95% CI, 1.25-4.75]; I = 61%), and lower for internal jugular than femoral (relative risk, 0.55 [95% CI, 0.34-0.89]; I = 61%). When observational studies that did not control for baseline characteristics were excluded, catheter-related bloodstream infection risk was comparable between the sites.
  
  
  CONCLUSIONS
  In ICU patients, internal jugular and subclavian may, similarly, decrease catheter-related bloodstream infection risk, when compared with femoral. Subclavian could be suggested as the most appropriate site, whenever colonization risk is considered and not, otherwise, contraindicated. Current evidence on catheter-related bloodstream infection femoral risk, compared with the other sites, is inconclusive.
authors.affiliation: 1Critical Care Department, General Hospital Papageorgiou, Thessaloniki, Greece.2Critical Care Department, General Hospital G. Gennimatas, Thessaloniki, Greece.3Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium.4Burns Trauma and Critical Care Research Centre Medical School, University of Queensland, Brisbane, Australia.5Department of Hygiene and Epidemiology, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece.62nd Critical Care Department, Attikon University Hospital, Medical School, University of Athens, Greece.
authors.forename: Kostoula
authors.initials: K
authors.lastname: Arvaniti
authors.forename: Dimitrios
authors.initials: D
authors.lastname: Lathyris
authors.forename: Stijn
authors.initials: S
authors.lastname: Blot
authors.forename: Fani
authors.initials: F
authors.lastname: Apostolidou-Kiouti
authors.forename: Despoina
authors.initials: D
authors.lastname: Koulenti
authors.forename: Anna-Bettina
authors.initials: AB
authors.lastname: Haidich
mesh_terms: D055499:Catheter-Related Infections / Q000453:epidemiology* / Q000209:etiology; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000379:methods*; D005268:Femoral Vein; D006801:Humans; D007362:Intensive Care Units; D007601:Jugular Veins; D064887:Observational Studies as Topic; D016032:Randomized Controlled Trials as Topic; D012307:Risk Factors; D018805:Sepsis / Q000453:epidemiology* / Q000209:etiology; D013350:Subclavian Vein