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The Risk of Catheter-Related Blood Stream Infections: Femoral vs Internal Jugular and Subclavian

Take Home Point(s):

  • There is no recent high quality evidence, after the institution of sterilized technique, to support that femoral vein central lines have a higher rate of catheter-related blood stream infections (CRBIs) or complications (DVT).
  • Preferred selection of the femoral line site for a central line catheter may be appropriate in certain clinical circumstances, such as during emergencies.


Summary:

Current guidelines recommend the avoidance of femoral site selection for central line placement in order to minimize the risk of catheter-related blood stream infection (CRBIs) in hospitalized patients. This recommendation by the CDC is backed by the assignment of its strongest level of evidence (Category 1A). Recent randomized controlled trials (RCTs) and Meta analyses, however, may call this designation into question.

Early cohort studies suggested an increased risk of CRBIs in patients receiving femoral lines versus subclavian or internal jugular (IJ) lines.  The morbidity and mortality of CBRIs is significant, and as a result, many hospitals prioritized bundled measures to decrease their incidence, including standardized sterile technique and instructions to avoid femoral placement of these lines. With increased adherence to barrier methods, chlorhexidine, antimicrobial catheters and the use of ultrasound in central line placement, the overall risk of CRBIs at any site have significantly decreased and prompted investigators to re-examine the role of site selection in preventing CRBIs.

Two recent RCTs independently demonstrated no significant difference in major infection (sepsis) rates between the three sites. Similarly, a Cochrane review and systematic review/meta-analysis reported no significant difference in complications (CRBI or DVT) between the femoral and subclavian or IJ sites. Femoral line colonization, however, was intuitively noted to be increased in morbidly obese patients.

It is important to note, however, that there has been a trend noted in the literature favoring increased infection rates at the femoral catheter site. Meta-regression demonstrated a significant difference in femoral infection rate based on year of publication, with earlier studies reporting higher rates. This suggests that CRBIs from femoral lines are no longer as prominent after the institution of standardized, sterile technique, and are no longer clinically significant in comparison to other sites. One ongoing large RCT at multiple sites in France may shed further light on this discussion.

While this topic is still under investigation, recent evidence suggests that femoral lines may be appropriated selected as the line of choice in the right clinical circumstances, particularly in cases where blind avoidance of these lines may increase patient morbidity, such as during emergencies.

Author: Karolina P. DeAugustinis, MD
Editor(s):
Anthony J. Busti, MD, PharmD, FNLA, FAHA
Date Last Reviewed:
  September 2015

Supporting Guidelines

  • CDC Guidelines for the Prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention

    Avoid using the femoral vein for central venous access in adult patients. (Category 1A)
    Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement. (Category IB)

    • Guideline Rating: 1A 
    • Reference: O'Grady NP, et al: CDC Guidelines for the Prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. 2011

Landmark or Original Studies

  • Marik, P. E., et al. 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. Critical care medicine 2012;40(8):479-2485. PubMed
  • Merrer, J., et al & French Catheter Study Group in Intensive Care. (2001). Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA 2001;286(6):700-707. PubMed
  • Parienti JJ et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008;299(20):2413-22. PubMed

Related Articles & Reviews

    • Timsit J et al. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Resp & Crit Care Med 2013:188(10), 1232-1239. PubMed
    • Ge X, et al. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database Syst Rev. 2012; 3:CD004084. PubMed
    • Welsh Healthcare Associate Infection Programme - critical care annual report: central venous catheter and ventilator associated pneumonia. 2010. Accessed August 22, 2014
    • Nagashima G et al. To reduce catheter-related bloodstream infections: is the subclavian route better than the jugular route for central venous catheterization? J Infect Chemother. 2006; 12(6):363-5. PubMed
    • Lorente L et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005; 9(6):R631-5. PubMed
    • LeMaster CH et al. Infection and natural history of emergency department-placed central venous catheters. Ann Emerg Med. 2010; 56(5):492-7. PubMed
    • Gowardman JR et al. Influence of insertion site on central venous catheter colonization and bloodstream infection rates. Intensive Care Med. 2008; 34(6):1038-45. PubMed
    • Goetz AM et al. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998; 19(11):842-5. PubMed
    • Garnacho-Montero J et al. Risk factors and prognosis of catheter-related bloodstream infection in critically ill patients: a multicenter study. Intensive Care Med. 2008; 34(12):2185-93.  

Other EBM Consult Related Content

    • Procedures: Seldinger Technique for Vascular Line Placement

MESH Terms or Keywords

  • Catheter Related Blood Stream Infections, CRBI, Central Line Infection Risk