You've no doubt seen fewer needlestick injuries since you began using needlefree devices to access IV lines. But what about your infection rates? Reports of increases in catheter-related bloodstream infection rates call into question the safety of needleless systems and make you wonder whether we're reducing the risk of needlestick injury but at the same time increasing infection risks.

Here's a scary thought: Compliance with disinfection of needlefree IV access devices is thought to be less than hand-hygiene compliance. These connectors are at the end of peripheral IVs, right next to the patient's skin. Like anything else in the perioperative environment, they're an infection risk. You must disinfect these devices before you access them. Other-wise, you'll inject into the bloodstream whatever bacteria is sitting on top of the devices.

There are 2 often-overlooked risk factors for catheter-related bloodstream infections associated with needleless connectors: how the device is designed and how you disinfect the device before you use it. Here's what my research tells us about how each of these factors influences bacterial transfer.

Connector device design
My research has shown that some devices will transfer bacteria more readily than others. For example, a device with a split septum delivers a high rate of bacteria if you don't properly disinfect it. My findings run somewhat counter to the current CDC recommendation (Category II) that states that a split septum valve may be preferred over some mechanical valves due to increased infection risk with the mechanical valves. This CDC recommendation is based on a particular design feature, but can this feature be used to predict infection risk with vascular access devices?

In one of my studies, I evaluated device design by comparing bacterial transfer from the surface of the connector to injected fluids for multiple commercially available needlefree connectors (about a dozen needlefree devices are on the market). All of the products in the split septum category let the mating luer or cannula actually pass through the septum for fluid to flow. None of the products in the mechanical valve category has this feature; all of their swabbing surfaces or seals "become" part of the fluid path.

Bottom line: The complexity of designs among the available devices makes the common classification of split septum and mechanical valve an over-simplification and an unreliable approach for making clinical decisions. My mantra: Select the device that has the minimal potential for the transfer of bacteria in the absence of effective disinfection (in other words, assume your nurses won't always comply with proper disinfection practices).

One of the prime value propositions when considering a neutral pressure connector is that it doesn't require a specific clamping sequence for connection and reconnection that a positive pressure device does. This enhances patient safety. In addition, using a neutral pressure technology may help you address recent concerns that the FDA raised regarding the safety of 9 positive displacement needless connectors on the market. You may read the FDA's alert at www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm220459.htm.

Aseptic device management
Constant exposure of the external surfaces of access sites to the patients' skin and environmental contamination requires scrubbing of the needleless connector septum with a disinfectant before access. Equally important is the disinfection of the internal lumen and external threads of the catheter hub. Until recently, effective technology designed specifically for this purpose was lacking. In addition, compliance with disinfection protocols by clinicians has been poor.

Both luer-activated needleless connectors and split septum devices can transfer bacteria if not disinfected. Experiments I conducted consistently showed that bacteria contaminating the surface of a connector will appear in the fluid flushed through the connector.

Alcohol prep pads aren't indicated for the disinfection of needlefree connectors. Several devices are commercially available for this purpose, including one product where you peel off a foil cap, swab it on the connector and throw it away. It takes 10 seconds. Others that contain a foam pad saturated with alcohol that you screw on and leave on the connector aren't appropriate for ambulatory surgery settings because they take 5 to 15 minutes to get the complete kill and they're very expensive.

In the absence of effective disinfection, there are significant differences in bacterial transfer rate among the various needleless connector designs. The connector and catheter assembly provides a continuous internal flow path with direct access to the blood- stream. Microorganisms entering this system are either flushed through the catheter or attach to the intraluminal components during infusion or locking.