In a letter to infection preventionists, Susan Gardner, director of the Office of Surveillance and Biometrics in the Center for Devices and Radiological Health at the Food and Drug Administration (FDA), is informing them about positive displacement needleless connectors and the possible link to several patient deaths associated with bloodstream infections (BSIs).
The FDA is requiring nine companies to conduct a post-market surveillance study on positive displacement needleless connectors to assess whether they may be associated with a higher rate of device-associated bloodstream infections than other types of needleless connectors, and to assess the factors that may contribute to a possible increased risk.
The FDA says it has become aware of information that raises concerns about the safety of positive displacement needleless connectors. These devices are intended for use as an accessory to an intravascular administration set to allow delivery of a wide range of fluids to a patient's vascular system through a cannula inserted into a vein or artery. Needleless connectors may also be referred to as "valves" or "accesses." "Positive displacement" refers to the positive pressure of fluid movement from a reservoir into the lumen of the catheter upon disconnection of an administration set or syringe.
The FDA has received three reports of death associated with BSIs and positive displacement needleless connectors. Infection control authorities are also concerned about positive displacement connectors and the devices association with BSI. The Society for Healthcare Epidemiologists of America (SHEA) and the Infectious Disease Society of America (IDSA) have recommended against using positive displacement needleless connectors with mechanical valves without a thorough assessment of risks and benefits; the document can be accessed HERE.
Additionally, there have been multiple clinical reports since 2006 showing an association between the introduction of positive displacement needleless connectors into a hospital or unit and an increased rate of BSI, followed by a reduction in BSI after changing to another type of needleless connector. However, the FDA says that limitations in study design make it difficult to gauge the true risk of BSI associated with positive displacement connectors. For example, the studies focused on BSI in the hospital or unit rather than detection of BSI associated with a specific device; lacked information about all positive displacement connectors; and lacked adjustment for patient case mix, demographics, season of the year, cleaning practices, and other potential influencing factors.
Because there is presently insufficient information to determine if positive displacement connectors increase the risk of BSI compared with other needleless connectors, the FDA is requiring the companies to conduct post-market surveillance studies to provide an assessment of the risk associated with positive displacement needleless connectors. Manufacturers must answer the following two public health questions about positive displacement needleless connectors with their postmarket surveillance studies:
1. What is the rate of bloodstream infections for subjects receiving your positive displacement connector for central line access and is it statistically non-inferior to the rates seen in subjects receiving other needleless connectors (e.g. negative, neutral, or split-septum connectors) for central line access, given comparable patient populations?
2. Are there patient demographics, comorbidities/severity of illness, or device cleaning practices for which placement of your positive displacement connector for central line access increases subjects risk of bloodstream infections compared with other needleless connectors?
These studies may take up to three years to complete. At the end of the study period, the FDA says it will assess whether regulatory or other actions need to be taken.
At this time, the FDA is not recommending changes in use of positive displacement needleless connectors. For practice recommendations to prevent healthcare-acquired infections in acute-care hospitals refer to the SHEA/IDSA HAI Prevention Compendium, which can be accessed HERE.
The FDA emphasizes that prompt reporting of adverse events can help the agency identify and better understand the risks associated with medical devices. If you suspect a problem with a positive displacement needleless connector, or any device, the FDA encourages you to file a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program. Healthcare personnel employed by facilities that are subject to FDA's user facility reporting requirements should follow the reporting procedures established by their facilities. Questions may be directed to Mary Beth Ritchey, RN, MSPH, PhD in the Division of Epidemiology at the Office of Surveillance and Biometrics, CDRH, 10903 New Hampshire Avenue, WO66, Silver Spring, Md., 20993, by email at [email protected], or by telephone message at (301) 796-6638.
The following companies have been ordered to conduct a post-market surveillance study on positive displacement needleless connectors:
Amsino International, Inc. -- Cortez Needle Free IV Connector
Baxter Healthcare Corporation -- IV/Catheter Extension Set with NAC Plus Needleless Access Connector and NAC Plus Needleless Access Connector
Becton Dickinson Infusion Therapy Systems Inc. -- BD posiflowTM Positive Displacement Valve
B. Braun Medical Inc. -- Ultrasite Valve
Cardinal Health -- IVAC Needle Free Administration Sets
CareFusion Corporation -- SmartSite Needle Free Valve Administration Sets
Critical Device Corporation-- NIMA Needleless Injectionsite Master Adapter with PosiFlow Positive Displacement Feature, and IV Sets
ICU Medical, Inc. -- CLC 2000; CLC2000 Catheter Patency Device; TEGO
Medegen Medical Manufacturing Services -- Maxplus Tru-Swab Positive Displacement Connector; MaxPlus Tru-Swab Positive Displacement Connector
Field K, McFarlane C, Cheng AC, Hughes AJ, Jacobs E, Styles K, Low J, Stow P, Campbell P, Athan E. Infect Control Hosp Epidemiol. 2007 May;28(5):610-3.
Jarvis WR, Murphy C, Hall KK, Fogle PJ, Karchmer TB, Harrington G, Salgado C, Giannetta ET, Cameron C, Sherertz RJ. Clin Infect Dis. 2009 Dec 15;49(12):1821-7.
Maragakis LL, Bradley KL, Song X, Beers C, Miller MR, Cosgrove SE, Perl TM. InfectControl Hosp Epidemiol. 2006 Jan;27(1):67-70.
Rupp ME, Sholtz LA, Jourdan DR, Marion ND, Tyner LK, Fey PD, Iwen PC, Anderson JR. Clin Infect Dis. 2007 Jun 1;44(11):1408-14.
Salgado CD, Chinnes L, Paczesny TH, Cantey JR. Infect Control Hosp Epidemiol. 2007 Jun;28(6):684-8.