*1. Form a HD team*

*3. Use of full-barrier precautions during CVC insertion*

a jugular or femoral site to reduce the risk for infection [29].

*5. Remove unnecessary central venous catheters*

*6. Hygienic management of catheters*

**8.2. Our recommendations for developing countries**

gloves and small drapes) [29].

136 Contemporary Challenges in Endocarditis

*4. Avoid the femoral site*

Bottom Line: Maintain aseptic technique for the insertion of intravascular catheters. Category IA: Maximal sterile barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape) during the insertion of CVCs substantially reduce the incidence of catheterrelated bloodstream infection (CR-BSI) compared with standard precautions (e.g., sterile

Bottom Line: A subclavian site is preferred for infection control purposes, although other factors (e.g., the potential for noninfectious and catheter-operator skill) should be considered for deciding where to place the catheter. Category IA: The site at which a catheter is placed influences the subsequent risk for catheter-related infection and phlebitis. For adults, lower extremity insertion sites are associated with a higher risk of infection than upper extremity sites. As a result, authorities recommend that CVCs be placed in the subclavian site instead of

Bottom Line: Promptly remove any intravascular catheter that is no longer essential. Category IA: One of the most effective strategies for preventing CR-BSIs is to eliminate, or at least reduce, exposure to central venous catheters. The decision regarding the need for a catheter, however, is complex and therefore difficult to standardize into a practice guideline. Nonetheless, to reduce exposure to central venous catheters, the ICU team should adopt a strategy to system-

Minimize the manipulation of the connections and clean the injection sites of the catheter with isopropyl alcohol 70° before its use. Category IA: Another characteristic of this study was that the people in charge of the catheters needed to do an auto-test online, assist to safety meetings before they can be part of the study [32]. This study was performed in 68% of all ICUs in Spain, with a reduction of 50% in the bacteremia related to catheter in a two-year period [19].

In addition to the intervention to reduce the rate of catheter-related bloodstream infection, the ICUs implemented the use of a daily goal to improve clinician-to-clinician communication within the ICU, an intervention to reduce the incidence of ventilator-associated pneumonia, and a comprehensive unit-based safety program to improve the safety culture. The period necessary for the implementation of each intervention was estimated to be 3 months [29].

After analyzing the literature and the results in the different countries and our own experience, we made some recommendations that could help any HD program in developing countries

for reducing their bacteremia incidence, and thus reducing the risk of IE.

atically evaluate daily whether any catheters or tubes can be removed [29].

Theyshouldbe the onlypeople involvedinthe HDprocess.This canbe achievedby online autotest of the use of catheters and the safety recommendations for it. This team must have a leader, whohas tobeinconstanttrainingthroughconferencesandworkshops.Thismustbetransmitted to the whole group, also by training and evaluations. Having a checklist for every procedure could also help reduce errors or omissions in the process. The personnel involved in this HD team must be able to teach all the safety measures for the patient and their family members to avoidinfectionofanyHDaccess.Theymustprovidestandardizedknowledgeabouttopics such asvascularaccess care,handhygiene,risks relatedtocatheteruse,recognizingsignsofinfection, and instructions for access management when away from the dialysis unit.
