Proposed members of the WHO global guidelines for the prevention of bloodstream infections and other infections associated with the use of intravascular catheters

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Background

Numerous reports from WHO and other organizations have clearly identified the increasing endemic burden of healthcare-associated infections (HAIs) and antimicrobial resistant (AMR) infections, which harm patients every day across health care systems in all countries, regardless of income status (1). Key among the most preventable of these are bloodstream infections (BSI) and other infections that are associated with the use of intravascular catheters (IVCs) (2, 3). 

A recent WHO report on IPC highlighted the burden of HAIs and antimicrobial resistance (AMR) and the related harm to both patients and health workers in health care settings. It presented a global situation analysis of the implementation of IPC programmes, as well as an overview of the strategies and resources that are available to improve the situation within countries. The data provided from numerous sources within this report indicate that substantial gaps in the implementation of IPC practices and lack of programmes and infrastructures to support IPC exist in countries. Some gaps and important areas for improvement were also identified in high-income countries, as demonstrated by the COVID-19 pandemic, and documented in a recent OECD-WHO Briefing Paper on IPC, addressing the burden of HAIs and AMR associated with health care in G7 countries (4). Therefore, these reports highlight how much more could and should be done across all WHO regions to ensure the reliable implementation of effective IPC strategies and to realize the potential cost and life-saving benefits that this could bring (1).

Health care-associated BSI (HA-BSI) are particularly notable because: 

1. They are mostly preventable if appropriate insertion, maintenance, and access protocols are followed for IVCs. Analyses pooling together the results of systematic reviews, calculated that implementing IPC interventions can achieve a significant reduction of HAI rates, in particular of catheter-associated BSI, irrespective of a country’s income level (1). 
2. They are often caused by antimicrobial resistant pathogens and thus, difficult to treat. Bloodstream infections due to a range of resistant pathogens that are mostly associated with health care, were found to be the second most frequent cause of the global burdens attributable to and associated with AMR in 2019, causing almost 1.5 million deaths around the world (5). 
3. They have major health impacts for affected patients. In Europe, HA-BSI are the second commonest cause of disability and premature deaths due to HAIs (6). Crude excess mortality due to catheter-related BSIs in adult patients was 23.6% in a study conducted in 25 countries worldwide (7). 
4.  They can evolve to serious deep-seated infectious complications such as bacterial endocarditis, lung abscesses and infectious embolic events to major organs such as the brain and kidneys (8). These complications are often associated with clinical sepsis and septic shock. WHO estimated that mortality among patients affected by health care-associated sepsis was 24.4%, increasing to 52.3% among patients treated in an intensive care unit (9). 
5. They are most often linked to peripheral intravenous catheters (PIVCs), which are the most common form of intravenous access used worldwide. However, HA-BSI have also become increasingly associated with the use of peripherally inserted central venous catheters (PICCs), for which many of the important IPC measures for PIVCs are similarly important (10). 
6. HA-BSI associated with centrally inserted venous catheters (CVCs) are also a key concern, but many of these patients have complex, high-risk medical conditions, such that they require a CVC, and are often managed in healthcare settings such as intensive care units where local care protocols are generally common and many confounding factors are often present (2, 8, 10, 11). 

The prevention of infections and AMR associated with health care is a key priority of several critical WHO resolutions and global strategies, including those on AMR, patient safety, WASH, and others (1). Furthermore, Resolution WHA75.13 on the global strategy for IPC, provides several recommendations to Member States for the improvement of IPC programmes and practices and requests the Director General to develop a global strategy, a global action plan and a monitoring framework on IPC. However, these existing resolutions, strategies and plans are programmatic and strategic documents which are critical but do not contain technical guidance on best practices to be implemented at the point of care to reduce the harm caused by HAI and AMR during health care delivery. Indeed, Resolution WHA75.13 also includes the request of new technical IPC guidelines and implementation resources to support Member States in their improvement efforts (12).

Several public health agencies and medical societies have produced local guidelines regarding the prevention of BSI, in particular those associated with centrally inserted catheters (CVCs). However, these are not always based on a rigorous process of evidence appraisal, and they often vary in their applicability and relevance to different local health systems, particularly in low-and middle-income countries.

This is the first time that the WHO will issue a guideline on this topic of new and existing recommendations on the prevention of BSI and other infections to be developed according to the WHO standards (13). They will be evidence-based and have a global scope based upon a rigorous process guided by the GRADE methodology. The guidelines will be based on a systematic review of the published scientific evidence related to preventive measures to be adopted during the insertion, maintenance, access, and removal of IVCs to provide a practical template for the safe use of these devices to minimize the risk of HA-BSI and other infections.

Role of the Guideline Development Group (GDG)

The guideline development group is made of external experts in the subject area, their main role is the task of developing evidence-based recommendations for the guideline. Members of the GDG participate in the guideline development process and at meetings as individuals and not as representatives of the institutions or organizations with which they are affiliated. The GDG is also responsible for finalizing the scope of the key questions of the guideline. During the guideline development process, GDG members will be called upon to define the priority outcomes which will guide evidence retrievals and reviews, examine the evidence profiles of the quality of evidence, interpret the evidence, and formulate recommendations that will go into the guideline. The provisional list of the GDG members who are experts, front line providers and patient representatives are listed in the document below.  

Download the proposed GDG members' biographies. 

Declarations of interests (DOIs)

WHO Secretariat has received and assessed all the DOIs submitted by the GDG members. In accordance with WHO's policy, all declared interests, even if they do not give rise to a conflict of interest that would warrant partial or total exclusion of the expert concerned, will be disclosed within the Guideline Development Group (GDG) at the beginning of the meeting so that other members are aware of them. Many of the GDG members have extensive research and governmental experience and expertise – and consulting with WHO – in the areas that are the subject of the guideline underdevelopment, which are considered relevant and important for the tasks faced by the GDG.

Process to provide comments on the proposed GDG members

Should you have any comments on the proposed GDG members, please send them to savelives@who.int with the following text in the subject line: Public Comment: WHO Guideline Development Group for the prevention of bloodstream infections and other infections associated with the use of intravascular catheters.

References

1. World Health Organization. (‎2022)‎. Global report on infection prevention and control: executive summary. World Health Organization. https://apps.who.int/iris/handle/10665/354553
2. Adrie C, Garrouste-Orgeas M, Ibn Essaied W, Schwebel C, Darmon M, Mourvillier B, et al. Attributable mortality of ICU-acquired bloodstream infections: Impact of the source, causative micro-organism, resistance profile and antimicrobial therapy. J Infect. 2017;74(2):131-41.
3. Stewardson AJ, Marimuthu K, Sengupta S, Allignol A, El-Bouseary M, Carvalho MJ, et al. Effect of carbapenem resistance on outcomes of bloodstream infection caused by Enterobacteriaceae in low-income and middle-income countries (PANORAMA): a multinational prospective cohort study. Lancet Infect Dis. 2019;19(6):601-10.
4. OECD (2018), Stemming the Superbug Tide: Just A Few Dollars More, OECD Health Policy Studies, OECD Publishing, Paris, https://doi.org/10.1787/9789264307599-en.  
5. Murray CJL, Ikuta KS, Sharara F, Swetschinski L, Robles Aguilar G, Gray A, et al. Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. The Lancet. 2022;399(10325):629-55.
6. Cassini A, Plachouras D, Eckmanns T, Abu Sin M, Blank HP, Ducomble T, et al. Burden of Six Healthcare-Associated Infections on European Population Health: Estimating Incidence-Based Disability-Adjusted Life Years through a Population Prevalence-Based Modelling Study. PLoS Med. 2016;13(10):e1002150.
7. Rosenthal VD, Maki DG, Jamulitrat S, Medeiros EA, Todi SK, Gomez DY, et al. International Nosocomial Infection Control Consortium (INICC) report, data summary for 2003-2008, issued June 2009. Am J Infect Control. 2010;38(2):95-104.e2.
8. Timsit JF, Ruppé E, Barbier F, Tabah A, Bassetti M. Bloodstream infections in critically ill patients: an expert statement. Intensive Care Med. 2020;46(2):266-84.
9. World Health Organization. (‎2020)‎. Global report on the epidemiology and burden of sepsis: current evidence, identifying gaps and future directions. World Health Organization. https://apps.who.int/iris/handle/10665/334216.
10. Rupp ME, Karnatak R. Intravascular Catheter-Related Bloodstream Infections. Infect Dis Clin North Am. 2018;32(4):765-87.
11. O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4 Suppl 1):S1-34.
12. World Health Assembly 75. 2022. Agenda item 14.6. Global Strategy on Infection Prevention and Control. World Health Organization. https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_ACONF5-en.pdf.
13. World Health Organization. WHO handbook for guideline development. 2nd ed. Geneva: World Health Organization; 2014 2014.