Letter to the editor - prevention of arterial catheter-related bloodstream infections: current evidence and future directions

To the Editor

We read with great interest the contemporary review by Donner and colleagues on prevention of arterial catheter-related bloodstream infection (AC-CRBSI) [1]. Its central message is timely and important: arterial catheters are not benign monitoring accessories and deserve the same deliberate insertion and infection-prevention strategies as other intravascular devices. The review also identifies a practical implementation gap. Although it recommends procedural training, standardized insertion packs, 2% chlorhexidine in alcohol, and a bundled approach, arterial catheter insertion remains variably performed and ultrasound is still used inconsistently [1]. From a practical application of these recommendations, there is need for a standardized insertion protocol for arterial devices - and this protocol already exists.

We propose that healthcare organizations worldwide adopt standardized, evidence-informed pathways for arterial catheter insertion, exemplified by the Safe Insertion of Arterial Catheters (SIA) protocol. Developed through international collaboration and endorsed by leading vascular access organizations, including the Global Vascular Access Network/World Congress on Vascular Access (GloVANet/WoCoVA), GAVeCeLT (Gli Accessi Venosi Centrali a Lungo Termine), and IVAS (Italian Vascular Access Society), the SIA protocol is being progressively implemented across diverse healthcare systems. Its adoption provides a globally applicable framework to reduce practice variation, strengthen patient safety, and promote consistent, high-quality arterial catheter insertion regardless of geographic location or resource setting [2]. A standardized insertion pathway converts multiple high-consequence actions from variable individual habits into an evidence-based, reproducible sequence. This is especially important in the ICU, where urgency, poor perfusion, edema, coagulopathy, and frequent staff transitions can erode quality aseptic performance. The SIA protocol provides an appropriate, contemporaneous framework because it integrates pre-procedure ultrasound assessment, deliberate vessel and device selection, proper skin antisepsis, real-time ultrasound-guided puncture, and protection of the insertion site and catheter [2].

Ultrasound should be viewed as an integral component of a comprehensive arterial catheter insertion bundle rather than an independent infection-prevention strategy. Real-time imaging improves first-pass success, reduces cannulation time and mechanical complications, and decreases repeated skin punctures, bleeding, dressing disruption, and catheter reinsertion, thereby limiting opportunities for contamination [3]. However, these benefits depend on strict adherence to infection prevention measures, including probe disinfection, sterile covers, sterile gel, and strict maintenance of the sterile field. When incorporated within the Safe Insertion of Arterials (SIA) protocol, ultrasound enhances both procedural reliability and aseptic practice, supporting safer catheter insertion, which may reduce infectious and non-infectious complications.

The available infection-specific evidence supports caution rather than therapeutic overstatement. In a post-hoc analysis of two large, randomized trials involving 3,950 arterial catheters, ultrasound guidance was not associated with a higher risk of major catheter-related infection, bloodstream infection, or colonization after adjustment [4]. Donner et al. likewise conclude that ultrasound’s direct effect on AC-CRBSI remains uncertain [1]. Thus, it would be inaccurate to claim that ultrasound alone has already been proven to lower AC-CRBSI. The stronger and defensible conclusion is that standardized, aseptic, ultrasound-guided insertion plausibly reduces infection risk by preventing the avoidable procedural failures that create contamination opportunities, while ultrasound demonstrably improves the mechanical safety and efficiency of cannulation.

This distinction should drive implementation, not delay it. The World Health Organization recommends standardized insertion, supplies and sterile technique for peripheral intravascular catheters, and contemporary vascular-access guidance recommends real-time ultrasound for arterial access [3, 5]. An ICU SIA policy should therefore include competency-based training and simulation; a checklist or insertion pack containing 2% chlorhexidine-alcohol, sterile barriers, sterile ultrasound cover and gel, and an appropriate securement/dressing system; audit and feedback of first-pass success, compliance, and AC-CRBSI; and daily review of ongoing indication. Such a policy links procedural safety to infection prevention across the device lifecycle rather than treating them as separate quality projects.

Reducing infection risk is only one component of safe arterial catheter insertion; the broader clinical objective is to optimize the entire procedure to maximize insertion success, catheter longevity, and overall patient outcomes while minimizing infectious and non-infectious complications, including insertion failure, dislodgement, thrombosis, malfunction, and the need for reinsertion. This holistic approach underpins the rationale for a comprehensive insertion bundle such as the SIA protocol, which combines ultrasound guidance, standardized procedural steps, and strict aseptic technique to reduce practice variation and improve procedural reliability.

Future prospective multicenter studies should evaluate SIA-bundle adherence against current practice using outcomes such as AC-CRBSI per 1,000 catheter-days, first-pass success, catheter longevity, reinsertion rates, dressing integrity, and mechanical complications. Until these data are available, adopting a standardized, ultrasound-guided, sterile insertion bundle represents a pragmatic, evidence-informed patient safety strategy that aligns arterial catheter insertion with the high standards expected for all high-risk vascular access procedure.

Abbreviations

AC

CRBSI–Arterial Catheter–related Bloodstream Infection

SIA

Safe Insertion of Arterials

GloVANet

Global Vascular Access Network

WoCoVA

World Congress on Vascular Access

GAVeCeLT

Gli Accessi Venosi Centrali a Lungo Termine

IVAS

Italian Vascular Access Society

ICU

Intensive Care Unit

Author contributions

TRS, MP and FP wrote the main manuscript and TRS prepared all subsequent revisions. All authors reviewed and approved the manuscript for submission.

Funding

No internal or external funding, commercial or private, was used or secured to publish this work.

Data availability

No datasets were generated or analysed during the current study.

Declarations

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All authors consent to the submission and publication of this work.

Competing interests

The authors declare no competing interests.

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