The document is the eighth recommendation in a series produced by the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Paediatric Research, working together with NEVAT, a European network of vascular access specialists. The series is designed to cover the entire process of neonatal vascular access, and this installment focuses squarely on infection prevention. Its central message is that safe catheter care is not a single intervention but a chain of practices that must remain unbroken across insertion, maintenance and discontinuation, and that standardized protocols for assessment, insertion and evaluation are essential if units are to protect their most vulnerable patients.

The stakes could hardly be higher. Central-line-associated bloodstream infections, often abbreviated as CLABSI, remain a significant burden in neonatal intensive care, and Dutch surveillance data cited by the authors show that these infections continue to occur even in well-resourced units. For a premature infant, a bloodstream infection is not merely a temporary setback. Research summarized in the recommendation links neonatal sepsis to impaired neurocognitive outcomes, and studies of extremely preterm children show that late-onset meningitis and Candida infections are associated with worse neurodevelopmental trajectories. In other words, an infection that enters through a catheter can alter the course of a child’s entire life, which is why the authors argue that infection prevention strategies are key to safe neonatal vascular access.

Technically, the recommendation weaves together international guidance with adaptations specific to the neonatal intensive care unit. The authors draw on the ninth edition of the Infusion Therapy Standards of Practice, widely regarded as the reference framework for infusion care, as well as infection control strategies for acute-care hospitals updated in 2022 and a dedicated white paper series offering practical approaches to preventing central-line-associated bloodstream infections in neonatal units. The goal, the team explains, is to reduce the microbial burden around vascular devices by combining evidence-based measures with the practical realities of caring for infants who may weigh less than a kilogram and whose skin, immune system and veins are all uniquely vulnerable.

One of the technical pillars of the recommendation is aseptic technique, and in particular the Aseptic Non Touch Technique, known as ANTT. This practice framework, illustrated in one of the article’s figures, is built on the principle that the key parts of a vascular system, such as catheter hubs, connectors and injection ports, must never come into contact with non-sterile surfaces or hands. Studies from London hospitals and quality improvement projects in other settings have shown that improving compliance with ANTT during intravenous line maintenance can reduce healthcare-associated infections. By embedding this framework in neonatal practice, the European team aims to make the standard of asepsis uniform rather than dependent on the habits of individual clinicians or units.

Skin disinfection is another area where the recommendation engages with rapidly evolving evidence. The choice of antiseptic for central catheter insertion in neonates has long been contested, because chlorhexidine, the workhorse antiseptic in adult care, carries concerns about skin injury in premature infants. The authors reference a Cochrane review of antiseptic solutions for neonatal central catheter insertion and recent clinical trials comparing 2 percent chlorhexidine gluconate in 70 percent isopropyl alcohol with aqueous preparations, including the Arctic randomized feasibility trial. These studies reflect a genuine effort to determine which agent best balances antimicrobial efficacy against the delicate skin of a preterm infant, and the recommendation situates itself within this ongoing debate rather than pretending it is settled.

The recommendation also emphasizes that infection prevention begins before any catheter is inserted, with careful assessment of the infant’s veins and a deliberate choice of the most appropriate device. The authors cite the Assessment Better before Access project, a retrospective cohort study of neonatal intravascular device outcomes, and a pre-procedural systematic evaluation of superficial veins designed to optimize venous catheterization. The logic is straightforward: every failed peripheral attempt creates additional entry points for microorganisms and additional skin trauma, so choosing the right device the first time is itself an infection prevention measure. Consensus algorithms for selecting venous access in newborns, including work from Italian neonatal groups on umbilical venous catheters and epicutaneo-caval catheters, inform this assessment-first philosophy.

Once a line is in place, securement and dressing choices become critical to keeping microbes out. The recommendation discusses cyanoacrylate glue, a medical adhesive that seals the catheter entry site and has been tested in randomized trials for umbilical venous catheters and in observational studies for peripheral and central catheters in neonates, with evidence suggesting it can reduce complications as part of a broader bundle. It also considers subcutaneously anchored securement devices and modern dressing technologies, including dialkylcarbamoylchloride-coated dressings for catheter exit sites and the material properties of transparent semipermeable films. Each of these technologies aims to prevent the micro-movements of the catheter within the tract that allow skin flora to migrate inward, while also protecting the fragile skin from medical adhesive-related injuries, a recognized problem in neonatal units.

Perhaps the most distinctive feature of the recommendation is its attention to the social dimension of neonatal care. The authors highlight evidence that parent-infant skin-to-skin contact can be maintained even during peripheral catheter insertion, and they situate infection prevention within the broader movement toward family integrated care, in which parents are trained partners rather than visitors. Recent clinical trial data on close collaboration with parents in neonatal units and studies of family management skills suggest that involving families does not compromise safety and may enhance it. Hand hygiene, the subject of a Cochrane review on preventing infections in neonates, remains the simplest and most powerful tool available to staff and parents alike, and the recommendation frames it as a shared responsibility across the entire care environment.

Finally, the recommendation addresses the end of the catheter’s life. Timely discontinuation, careful removal technique and ongoing surveillance for bloodstream infection all form part of the lifecycle approach. The authors point to Dutch work on sustainable CLABSI surveillance and consensus toward new criteria, reflecting a European effort to measure these infections consistently so that units can compare performance and improve. Taken together, the document represents a rare attempt to consolidate scattered evidence into a single, practical standard for neonatal vascular access across the continent. For the clinicians who care for the smallest patients, and for the families who trust them, the message is clear: every catheter is a lifeline and a liability at once, and only disciplined, standardized, evidence-based practice from insertion to removal can keep the lifeline from becoming the pathway for harm.

Subject of Research: Infection prevention strategies for neonatal vascular access catheters

Article Title: Infection prevention: neonatal European vascular access team – ESPR recommendation 8

Article References: Infection prevention: neonatal European vascular access team – ESPR recommendation 8. (n.d.). https://doi.org/10.1038/s41390-026-05464-9

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05464-9

Keywords: neonatal intensive care, vascular access, CLABSI, infection prevention, catheter insertion, aseptic non touch technique, chlorhexidine, cyanoacrylate glue, preterm infants, hand hygiene, family integrated care, ESPR