Abstract

Purpose:

This study aimed to systematically search, evaluate, and synthesize the latest evidence on the prevention and management of nosocomial infections in patients supported by extracorporeal membrane oxygenation.

Methods:

The study included clinical practice guidelines, expert consensus statements, systematic reviews, and other relevant publications. The quality of the included literature was rigorously assessed using appropriate tools such as AGREE II and AMSTAR. Data extraction and evidence synthesis were performed independently by two researchers. A comprehensive search was conducted across multiple databases and sources, including PubMed, Embase, the Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Data, VIP, SinoMed, the National Guideline Clearinghouse, the Scottish Intercollegiate Guidelines Network, the Extracorporeal Life Support Organization website, and UpToDate. The search covered the period from the inception of each database up to October 31, 2025.

Results:

Fourteen studies met the inclusion criteria, comprising 2 clinical decisions, 4 guidelines, 4 expert consensus documents, 2 systematic reviews, and 2 cohort studies. All 14 studies were included following quality assessment. A total of 27 evidence items were synthesized and categorized into three domains: (1) infection prevention during extracorporeal membrane oxygenation initiation, (2) infection prevention during extracorporeal membrane oxygenation run, and (3) monitoring and treatment of extracorporeal membrane oxygenation-related infections.

Conclusion:

The prevention and control of nosocomial infections in patients receiving extracorporeal membrane oxygenation requires a comprehensive, bundle-based management strategy grounded in the best available evidence. The evidence synthesized in this study is both robust and practical. We recommend that clinical institutions adapt these evidence-based recommendations into specific clinical protocols and checklists tailored to their local context, with the ultimate goal of effectively reducing infection rates and improving clinical outcomes in patients receiving extracorporeal membrane oxygenation.

1 Introduction

The World Health Organization defines nosocomial infection (NI) as an infection that occurs during the process of care in a hospital or other healthcare facility, which was not present or incubating at the time of admission (1). NI is a common complication in patients receiving extracorporeal membrane oxygenation (ECMO) therapy, with a reported prevalence ranging from 8.8 to 64.0% and an incidence density of 1.7 to 85.4 per 1,000 ECMO-days (2). ECMO is a mode of extracorporeal life support that augments oxygenation, ventilation and/or cardiac output via cannulae connected to a circuit that pumps blood through an oxygenator and back into the patient (3). A recent systematic review indicated an observed NI incidence of 1,249 episodes per 1,000 ECMO-days, with ventilator-associated pneumonia and bloodstream infections being the most common types (4). Compared to non-infected patients, infected patients showed significantly lower ECMO survival and overall survival rates, with risk ratios of 0.84 (95% CI 0.74–0.96) and 0.80 (95% CI 0.71–0.90), respectively (4). Multiple meta-analyses (4, 5) have identified risk factors for NI in ECMO patients, including duration of mechanical ventilation, length of hospital stay, ECMO mode, immunosuppression, and heart transplantation. In addition, several ECMO-specific infection risks have not yet been fully elucidated. These include circuit biofilm formation, the complex interaction between anticoagulation and infection, and the adsorption of drugs by the circuit and oxygenator (6–8). It is the combination of these conventional and unique risk factors that poses substantial challenges to the prevention and control of NI in ECMO patients.

Current infection prevention measures for ECMO patients are often fragmented and inconsistently implemented across institutions, with significant variations in practice. Most existing protocols focus narrowly on care bundles for ventilator-associated pneumonia or catheter-related bloodstream infections, lacking a comprehensive, standardized, and systematic approach that covers the entire patient care pathway. Multiple studies have recommended five core measures for preventing NI in this population (9, 10): strict aseptic cannulation techniques, daily multidisciplinary assessment of circuit necessity, standardized oral care, goal-directed antibiotic stewardship, and bundled catheter care. A recent study evaluated a standardized prevention strategy incorporating chlorhexidine gluconate bathing and nasal decolonization (11). This multifaceted decontamination approach was associated with a significant reduction in NI risk (RR = 0.42 [95% CI, 0.23–0.60]) and multidrug-resistant organism acquisition (RR = 0.13 [0.03–0.56]), though no mortality difference was observed. For bloodstream infections, urinary tract infections, ventilator-associated pneumonia, and skin/soft tissue infections, Marcus et al. (12) emphasized the need for tailored, site-specific infection prevention and control protocols. However, it remains uncertain whether these conventional infection prevention bundles are sufficient for the ECMO population. A single-center study including 3,396 hospitalized patients and 288 ECMO patients revealed a higher incidence of NI in the ECMO group, despite receiving the same care and standardized protocols as non-ECMO patients (13). This suggests that routine infection control measures may be inadequate for this critically ill cohort, underscoring the need for specifically designed interventions tailored to the unique risks of ECMO support.

To address these challenges systematically, this study aims to synthesize the latest evidence related to the prevention and management of NI in ECMO patients, with the goal of providing a robust foundation for developing precise and effective prevention and control strategies in clinical practice.

2 Materials and methods2.1 Study design and inclusion/exclusion criteria

To systematically identify, evaluate, and synthesize existing evidence for deriving clear and critical conclusions regarding infection management in ECMO patients, this study was registered with the Fudan University Center for Evidence-Based Nursing on October 9, 2025 (Registration No: ES20259062). The evidence-based question was clarified using the PIPOST framework from the Joanna Briggs Institute (JBI) Fudan University Center. The PIPOST elements were defined as follows: Population (P): adult ECMO patients; Intervention (I): measures related to ECMO infection prevention and management; Professionals (P): clinical healthcare providers; Outcomes (O): patient infection incidence; Setting (S): intensive care units; Type of evidence (T): clinical decisions, guidelines, systematic reviews, expert consensus documents, and relevant original studies.

Based on this framework, the inclusion criteria were established as follows: (1) target population: adult ECMO patients; (2) interventions: measures related to ECMO infection prevention and management; (3) professionals applying the evidence: clinical healthcare providers; (4) outcomes: patient infection incidence; (5) setting for evidence application: intensive care units; (6) types of evidence: clinical decisions, guidelines, systematic reviews, expert consensus documents, and relevant original studies. Exclusion criteria comprised: (1) documents with incomplete data, and (2) duplicate publications.

2.2 Search strategy

Guided by the 6S evidence model (14), a comprehensive literature search was conducted across multiple databases and official websites. These included the National Guideline Clearinghouse (USA), the Scottish Intercollegiate Guidelines Network, the Extracorporeal Life Support Organization (ELSO) website, UpToDate, PubMed, Embase, the Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data, VIP, and SinoMed. The search period covered records from the inception of each database up to October 2025. Search terms encompassed the following key concepts: “extracorporeal membrane oxygenation,” “extracorporeal life support,” “cross infection,” “healthcare- associated infection,” “urinary tract infection,” “bloodstream infection,” “catheter-associated infection” and “ventilator-associated pneumonia.” Both controlled vocabulary (e.g., MeSH terms) and free-text keywords were utilized as appropriate for each database, with no language restrictions applied initially. The specific search strategy is provided in Appendix 1.

2.3 Quality assessment

Two reviewers systematically trained in evidence-based methods independently assessed the quality of the included literature. Any disagreements were resolved by a third expert reviewer. The methodological quality of clinical guidelines was evaluated using the AGREE II instrument (15), while expert consensus documents were appraised according to the criteria developed by the JBI Center for Evidence-Based Healthcare (2017 edition) (16). Clinical decision resources were assessed using a standardized tool for clinical applicability, and systematic reviews were evaluated with the AMSTAR tool (17). Cohort studies were appraised using the Newcastle-Ottawa Scale (18). Data were extracted by two independent reviewers, and the methodological quality of each included study was graded according to the 2011 Oxford Centre for Evidence-Based Medicine levels of evidence (19).

2.4 Data extraction

To ensure the accuracy and consistency of the data extraction process, two reviewers independently extracted data from the included studies. Any discrepancies or disagreements between the reviewers were resolved through consultation with a third reviewer for a final judgment. In cases where conflicting evidence was identified, priority was given to evidence from higher-quality and more recently published sources.

3 Results3.1 Literature search results

The study selection process followed the PRISMA guidelines and is summarized in Figure 1. Initially, 2,449 records were identified through database searching, with an additional 5 records retrieved from guideline websites. After removing 1,229 duplicate records using EndNote software, 1,225 publications underwent title and abstract screening. Following this screening, 1,196 records were excluded for not meeting the inclusion criteria. The remaining 29 full-text articles were further assessed for eligibility, of which 15 were excluded. Ultimately, 14 studies met the inclusion criteria, comprising 2 clinical decision resources (20, 21), 4 clinical guidelines (22–25), 4 expert consensus documents (26–29), 2 systematic reviews (4, 30), and 2 cohort studies (31). The characteristics of the included studies are summarized in Table 1.

Flow diagram of studies included and excluded at each stage of review.

AuthorYear of publicationTitleStudy typeSourceDarryl Abrams (20)2025Extracorporeal life support in adults: Management of venovenous extracorporeal membrane oxygenation (V-V ECMO)Clinical decisionUptoDateZhang (26)2025Consensus on nursing care for adult extracorporeal membrane oxygenation circulatory assistanceConsensusCNKITaylor M (11)2025Use of standardized nasal and skin decolonization to reduce rates of bacteremia in patients undergoing extracorporeal membrane oxygenationCohort StudyPubmedKlompas M (21)2024Treatment of hospital- acquired and ventilator- associated pneumonia in adultsClinical decisionUptoDateExtracorporeal Life Support Branch of Chinese Society of Cardiothoracic Vascular Anesthesia (27)2024Expert consensus on the prevention and management of infection during extracorporeal membrane oxygenation in adult patientsConsensusCNKINational Health Commission of the People’s Republic of China Medical Administration (23)2024Technical Operation Standards for Adult Extracorporeal Membrane Oxygenation (2024 Edition)GuidelineNational Health Commission of the People’s Republic of China Medical AdministrationAli Ait Hssain (4)2024Incidence, risk factors and outcomes of nosocomial infection in adult patients supported by extracorporeal membrane oxygenation: a systematic review and meta-analysisSystematic reviewPubmedOrso D (30)2024Do patients receiving extracorporeal membrane-oxygenation need antibiotic prophylaxis? A systematic review and meta-analysis on 7,996 patientsSystematic reviewPubmedChinese emergency ECMO research collaboration group (28)2023Chinese consensus of emergency experts on percutaneous cannulation for adult extracorporeal cardiopulmonary resuscitationConsensusCNKIMassart N (31)2023Multiple-site decontamination to prevent acquired infection in patients with veno-venous ECMO supportCohort StudyPubmedGraeme MacLaren (24)2022Extracorporeal Life Support: The ELSO Red Book 6th EditionGuidelineELSOAssmann A (22)2022Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure –A clinical practice Guideline Level 3GuidelinePubmedChinese Medical Doctor Association Committee of Extracorporeal Life Support (29)2018Consensus on extracorporeal membrane oxygenation for circulatory support in adultsConsensusCNKIExtracorporeal Life Support Organization (25)2017Extracorporeal Life Support Organization (ELSO) General Guidelines for all ECLS CasesGuidelineELSO

Characteristics of included studies (N = 14).

CNKI, China National Knowledge Infrastructure; ECLS, Extracorporeal Life Support; ELSO, Extracorporeal Life Support Organization.

3.2 Quality assessment of included studies

The methodological quality of the 4 included guidelines (22–25) was appraised, with detailed results presented in Table 2. The 4 expert consensus documents (26–29) were also quality assessed, and the results are shown in Table 3. Both systematic reviews (4, 30) met all quality criteria across assessment domains and were therefore included. The two included cohort studies (11, 31) received a quality score of 8 points. Both clinical decision resources (20, 21) were deemed suitable for inclusion.

Inclusion in the literatureStandardized score for each field (%)Number of fields with ≥60% (one)≥30% of the number of areas (one)Recommendation levelScope purposeParticipantsRigourClarityApplicabilityIndependenceNational Health Commission of the People’s Republic of China Medical Administration (23)97.22%38.89%53.13%94.44%43.75%100%36BGraeme MacLaren (24)97.22%72.22%71.88%100%62.5%100%66AAssmann, A. (22)88.89%72.22%90.63%100%60.42%100%66AExtracorporeal Life Support Organization (25)83.33%55.56%67.71%91.67%35.42%89.29%46B

Quality assessment results of guidelines (N = 4).

Included consensus①②③④⑤⑥IncludedZhang (26)YYYYYYYExtracorporeal Life Support Branch of Chinese Society of Cardiothoracic Vascular Anesthesia (27)YYYYYYYChinese emergency ECMO research collaboration group (28)YYYYYYYChinese Medical Doctor Association Committee of Extracorporeal Life Support (29)YYYYYYY

Quality assessment results of included consensus (N = 4).

① Are the sources of the ideas clearly marked? (YES/NO). ② Does the opinion come from an influential expert in the field? (YES/NO). ③ Whether the point of view presented is centered on the relevant population interests of the study? (YES/NO). ④ Are the stated conclusions based on the analysis? Are ideas expressed logically? (YES/NO). ⑤ Was there any reference to other literature? (YES/NO). ⑥ Are there any inconsistencies between the ideas presented and the previous literature? (YES/NO). Letter Y, indicates whether criteria ①–⑥ are met and decides whether to include evidence.

3.3 Evidence summary

Following literature screening and quality assessment, evidence related to infection prevention and management in ECMO patients was extracted from the 14 included studies. The extracted evidence was initially categorized into three phases: (1) infection prevention during ECMO initiation, (2) infection prevention during ECMO run, and (3) monitoring and treatment of ECMO-related infections. Two reviewers independently performed evidence extraction and categorization. Disagreements were resolved through discussion; if consensus could not be reached, a third reviewer was consulted. Subsequently, the research team conducted iterative discussions to synthesize the evidence by merging similar statements, removing duplicates, and reconciling conflicting recommendations. Through this consensus-building process, the evidence was consolidated into 27 distinct evidence statements. Any persistent disagreements during the synthesis and grading process were resolved by team discussion or consultation with an external expert when necessary. The final 27 evidence statements are presented in Table 4.

CategorySubcategoryEvidence itemsEvidence levelGrade of recommendationInfection prevention during ECMO initiationRisk factor identification

Multiple risk factors for nosocomial infections in ECMO patients have been identified. These include patient-related factors (advanced age, body mass index, underlying comorbidities, higher SOFA and SAPS scores); ECMO-related factors (VV vs. VA mode, duration of ECMO support, ECMO catheter colonization, duration of arterial catheterization); treatment-related factors (duration of mechanical ventilation, hospital length of stay, CPR duration <5 min, hemodialysis); organ dysfunction (acute renal failure, acute hepatic failure); and mechanical complications (4).

3AProcedural preparation and cannulation

A comprehensive sterile barrier should be strictly adhered to during ECMO cannulation, following a thorough assessment of the procedural environment (24, 27).

1A

Ultrasound-guided percutaneous cannulation is recommended as the preferred approach for ECMO initiation (24, 27, 28).

1A5B

The use of razors for preoperative hair removal is not recommended. Electric clippers should be used for surgical site hair management if necessary (24, 27).

5BEnvironmental and staffing management

Implementing single-room isolation and assigning dedicated nursing staff for ECMO patients is recommended whenever possible (22, 26, 27).

5BInfection prevention during ECMO runSkin and mucosal decontamination

For oral care in ECMO patients, gentle and thorough non-pharmacological cleaning is preferred over the routine use of chlorhexidine to protect the oral mucosa (24, 27).

3B

Chlorhexidine should be used for disinfecting the ECMO circuit and cannula insertion sites in patients receiving ECMO support (24, 27).

4B

ECMO patients should receive daily bathing with chlorhexidine wipes combined with once-daily nasal application of mupirocin (21, 24, 31).

4BRespiratory management4BCannula site management and skin protection

Use transparent dressings on ECMO cannulation sites for visual monitoring. Daily assess catheter and dressing/suture integrity. All changes/reinforcements must be aseptic per protocol (20, 24, 27).

5A

Hydrocolloid or foam dressings should be placed beneath ECMO cannulas to prevent medical device-related pressure injuries (23, 28).

5ACircuit integrity and invasive device management5A

Non-essential central venous catheters and other invasive devices should be removed as early as possible during ECMO support (24, 27).

5APatient positioning and early rehabilitation5A5B

Enteral nutrition should be established early, preferably via gastric or post-pyloric route within 48 h of ECMO initiation (27).

4BSedation and general infection prevention bundles

A light sedation strategy should be implemented as soon as the patient’s condition is stabilized during ECMO support (25, 27).

4A

Adhere to locally adapted care bundles for infection prevention in critically ill patients, including CLABSI, CAUTI, VAP, and SSI (24, 26, 27).

3AMonitoring and treatment of ECMO-related infectionsInfection surveillance and monitoring

Closely monitor ECMO patients for signs of sepsis and conduct prompt evaluation when indicated (24, 27).

2A

Maintain vigilant infection surveillance during ECMO. When infection is suspected, obtain repeat broad-spectrum cultures. Blood cultures should be indication-based, not routine daily; other site cultures (e.g., respiratory, urinary, catheter) may be increased as clinically indicated (24, 27).

3B

ECMO temperature >37.5 °C suggests infection. Monitor biomarkers (PCT, CRP, IL-6, IL-10) for early warning (23).

5AAntimicrobial prophylaxis and empirical therapy

Routine prophylactic antibiotics are not recommended during ECMO initiation. For postoperative patients, administer surgical prophylaxis per procedure type and institutional guidelines (24, 27, 29, 30).

3B

Initiate empirical broad-spectrum antibiotics immediately after obtaining cultures from suspected infection sites. Tailor the regimen to local epidemiology and antibiogram data; consider adjunctive antifungal therapy when indicated (24).

4BManagement of cannula-related infections5BAntibiotic pharmacokinetics and therapeutic drug monitoring