Purpose
Previously published guidelines provide comprehensive recommendations for detecting
and preventing healthcare-associated infections (HAIs). The intent of this document
is to highlight practical recommendations in a concise format designed to assist acute-care
hospitals in implementing and prioritizing their central line-associated bloodstream
infection (CLABSI) prevention efforts. This document updates the Strategies to Prevent
Central Line-Associated Bloodstream Infections in Acute-Care Hospitals published in
2014.
1
This expert guidance document is sponsored by the Society for Healthcare Epidemiology
of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious
Diseases Society of America (IDSA), the Association for Professionals in Infection
Control and Epidemiology (APIC), the American Hospital Association (AHA), and The
Joint Commission, with major contributions from representatives of a number of organizations
and societies with content expertise.
Summary of major changes
This section lists major changes from the Strategies to Prevent Central Line-Associated
Bloodstream Infections in Acute-Care Hospitals: 2014 Update,
1
including recommendations that have been added, removed, or altered. Recommendations
are categorized as essential practices that should be adopted by all acute-care hospitals
(in 2014 these were “basic practices,” renamed to highlight their importance as foundational
for hospitals’ HAI prevention programs) or additional approaches that can be considered
for use in locations and/or populations within hospitals when CLABSIs are not controlled
after implementation of essential practices (in 2014 these were “special approaches”).
See Table 1 for a complete summary of the recommendations contained in this document.
Table 1.
Summary of Recommendations to Prevent CLABSI
Essential Practices
Before insertion
1. Provide easy access to an evidence-based list of indications for CVC use to minimize
unnecessary CVC placement (Quality of Evidence: LOW)2. Require education and competency
assessment of HCP involved in insertion, care, and maintenance of CVCs about CLABSI
prevention (Quality of Evidence: MODERATE)
74–78
3. Bathe ICU patients aged >2 months with a chlorhexidine preparation on a daily basis
(Quality of Evidence: HIGH)
86–90
At insertion
1. In ICU and non-ICU settings, a facility should have a process in place, such as
a checklist, to ensure adherence to infection prevention practices at the time of
CVC insertion (Quality of Evidence: MODERATE)
101
2. Perform hand hygiene prior to catheter insertion or manipulation (Quality of Evidence:
MODERATE)
102–107
3. The subclavian site is preferred to reduce infectious complications when the catheter
is placed in the ICU setting (Quality of Evidence: HIGH)
33,37,108–110
4. Use an all-inclusive catheter cart or kit (Quality of Evidence: MODERATE)
118
5. Use ultrasound guidance for catheter insertion (Quality of Evidence: HIGH)
119,120
6. Use maximum sterile barrier precautions during CVC insertion (Quality of Evidence:
MODERATE)
123–128
7. Use an alcoholic chlorhexidine antiseptic for skin preparation (Quality of Evidence:
HIGH)
42,129–134
After insertion
1. Ensure appropriate nurse-to-patient ratio and limit use of float nurses in ICUs
(Quality of Evidence: HIGH)
34,35
2. Use chlorhexidine-containing dressings for CVCs in patients over 2 months of age
(Quality of Evidence: HIGH)
45,135–142
3. For non-tunneled CVCs in adults and children, change transparent dressings and
perform site care with a chlorhexidine-based antiseptic at least every 7 days or immediately
if the dressing is soiled, loose, or damp. Change gauze dressings every 2 days or
earlier if the dressing is soiled, loose, or damp (Quality of Evidence: MODERATE)
145–148
4. Disinfect catheter hubs, needleless connectors, and injection ports before accessing
the catheter (Quality of Evidence: MODERATE)
150–154
5. Remove nonessential catheters (Quality of Evidence: MODERATE)6. Routine replacement
of administration sets not used for blood, blood products, or lipid formulations can
be performed at intervals up to 7 days (Quality of Evidence: HIGH)
164
7. Perform surveillance for CLABSI in ICU and non-ICU settings (Quality of Evidence:
HIGH)
13,165,166
Additional Approaches
1. Use antiseptic- or antimicrobial-impregnated CVCs (Quality of Evidence: HIGH in
adult patients
38,39,169–171
and Quality of Evidence: MODERATE in pediatric patients)
172,173
2. Use antimicrobial lock therapy for long-term CVCs (Quality of Evidence: HIGH)
177–184
3. Use recombinant tissue plasminogen activating factor (rt-PA) once weekly after
hemodialysis in patients undergoing hemodialysis through a CVC (Quality of Evidence:
HIGH)
192
4. Utilize infusion or vascular access teams for reducing CLABSI rates (Quality of
Evidence: LOW)
193,194
5. Use antimicrobial ointments for hemodialysis catheter insertion sites (Quality
of Evidence: HIGH)
197–201
6. Use an antiseptic-containing hub/connector cap/port protector to cover connectors
(Quality of Evidence: MODERATE)
202–208
Approaches that Should Not Be Considered a Routine Part of CLABSI Prevention
1. Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion
or while catheters are in situ (Quality of Evidence: HIGH)
209–213
2. Do not routinely replace CVCs or arterial catheters (Quality of Evidence: HIGH)
214
Unresolved Issues
1. Routine use of needleless connectors as a CLABSI prevention strategy before an
assessment of risks, benefits, and education regarding proper use
215–219
2. Surveillance of other types of catheters (eg, peripheral arterial or peripheral venous
catheters)
11,21,22
3. Standard, nonantimicrobial transparent dressings and CLABSI risk.4. The impact
of using chlorhexidine-based products on bacterial resistance to chlorhexidine5. Sutureless
securement6. Impact of silver zeolite-impregnated umbilical catheters in preterm infants
(applicable in countries where it is approved for use in children)
227
7. Necessity of mechanical disinfection of a catheter hub, needleless connector, and
injection port before accessing the catheter when antiseptic-containing caps are being
used
Note. CLABSI, central line-associated bloodstream infection; CVC, central venous catheter;
HCP, healthcare personnel; ICU, intensive care unit.
Essential practices
The subclavian vein is considered the preferable site for central venous catheter
(CVC) insertion in the intensive care setting to reduce infectious complications.
Previously, the primary recommendation was to avoid the femoral vein for access. Although
this remains valid, it has been replaced by a positively formulated recommendation
regarding the subclavian site.
The recommendation to use ultrasound guidance for catheter insertion is backed by
better evidence than was available previously; however, the procedure itself may jeopardize
the strict observation of sterile technique.
The use of chlorhexidine-containing dressings is now considered an “essential practice”;
in the past, it was listed under special approaches that should only be employed if
CLABSI rates remain high despite the implementation of basic practices.
Routine replacement of administration sets not used for blood, blood products, or
lipid formulations can be performed at intervals of up to 7 days. Previously, this
interval was no longer than 4 days.
Additional approaches
Antimicrobial ointment for the catheter site, which is geared toward the population
of hemodialysis patients, has been moved to “additional practices” given the focus
on a specific population.
Despite currently being supported by high-level evidence, antiseptic-containing caps
remain an “additional practice” because they are not considered superior to the manual
disinfection, an essential practice.
The importance of infusion teams has been highlighted by listing it under “additional
practices” (previously considered unresolved).
Sutureless securement of catheters was not discussed in the previous version of this
section.
Intended use
This document was developed following the process outlined in the Handbook for SHEA-Sponsored
Guidelines and Expert Guidance Documents.
2
No guideline or expert guidance document can anticipate all clinical situations, and
this document is not meant to be a substitute for individual clinical judgment by
qualified professionals.
This document is based on a synthesis of evidence, theoretical rationale, current
practices, practical considerations, writing-group consensus, and consideration of
potential harm, where applicable. A summary list of recommendations is provided along
with their relevant rationales (see Table 1).
Methods
SHEA recruited 3 subject-matter experts in the prevention of CLABSI to lead the panel
of members representing the Compendium partnering organizations: SHEA, the Infectious
Diseases Society of America (IDSA), the Association for Professionals in Infection
Control and Epidemiology (APIC), the American Hospital Association (AHA), and The
Joint Commission, as well as representation by the Centers for Disease Control and
Prevention (CDC).
SHEA utilized a consultant medical librarian, who worked with each panel to develop
a comprehensive search strategy for PubMed and Embase (January 2012–July 2019; updated
to August 2021). Articles’ abstracts were reviewed by panel members in a double-blind
fashion using the abstract management software, Covidence (Melbourne, Australia),
and subsequently reviewed as full text. The Compendium Lead Authors group voted to
update the literature findings, and the librarian reran the search to update it to
August 2021. Panel members reviewed the abstracts of these articles via Covidence
and incorporated relevant references.
Recommendations resulting from this literature review process were classified based
on the quality of evidence and the balance between desirable and potential for undesirable
effects of various interventions (see Table 2). Panel members met via video conference
to discuss literature findings; recommendations; quality of evidence for these recommendations;
and classification as essential practices, additional approaches, or unresolved issues.
Panel members reviewed and approved the document and its recommendations.
Table 2.
Quality of Evidence
a
Category
Definition
HIGH
Highly confident that the true effect lies close to that of the estimated size and
direction of the effect. Evidence is rated as high quality when there are a wide range
of studies with no major limitations, there is little variation between studies, and
the summary estimate has a narrow confidence interval.
MODERATE
The true effect is likely to be close to the estimated size and direction of the effect,
but there is a possibility that it is substantially different. Evidence is rated as
moderate quality when there are only a few studies and some have limitations but not
major flaws, there is some variation between studies, and/or the confidence interval
of the summary estimate is wide.
LOW
The true effect may be substantially different from the estimated size and direction
of the effect. Evidence is rated as low quality when supporting studies have major
flaws, there is important variation between studies, the confidence interval of the
summary estimate is very wide, and/or there are no rigorous studies.
a
Based on the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC)
“Update to the Centers for Disease Control and Prevention and the Healthcare Infection
Control Practices Advisory Committee Recommendations Categorization Scheme for Infection
Control and Prevention Guideline Recommendations” (October 2019), the Grades of Recommendation,
Assessment, Development, and Evaluation (GRADE),
265
and the Canadian Task Force on Preventive Health Care.
266
The Compendium Expert Panel, made up of members with broad healthcare epidemiology
and infection prevention expertise, reviewed the draft manuscript after consensus
had been reached by writing panel members.
Following review and approval by the Expert Panel, the 5 partnering organizations,
stakeholder organizations, and the CDC reviewed the document. Prior to dissemination,
the guidance document was reviewed and approved by the SHEA Guidelines Committee,
the IDSA Standards and Practice Guidelines Committee, and the Boards of SHEA, IDSA,
APIC, AHA, and The Joint Commission.
All panel members complied with SHEA and IDSA policies on conflict-of-interest disclosure.
Section 1: Rationale and statements of concern
Burden of outcomes associated with hospital-acquired CLABSI
Increased length of hospital stay
3–6
Increased cost. The adjusted variable costs for patients with CLABSI were $32,000
(2010 US dollars) higher on average than for patients without CLABSI
7
Increased morbidity and mortality
8
Risk factors for CLABSI
Patients at risk for CLABSI in acute-care facilities are those with a CVC in place:
Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high.
Reasons for this include the frequent insertion of multiple catheters
9,10
; the use of specific types of catheters that are almost exclusively inserted in ICU
patients and associated with substantial risk (eg, pulmonary artery catheters with
catheter introducers); and the fact that catheters are frequently placed in emergency
circumstances, repeatedly accessed each day, and often needed for extended periods.
11,12
Non-ICU population: Although the primary focus of attention over the last 20 years
has been the ICU setting, most CLABSIs occur in hospital units outside the ICU or
in outpatients.
13–17
Infection prevention and control efforts should include other vulnerable populations
such as patients receiving hemodialysis through catheters,
18
intraoperative patients,
19
and oncology patients.
20
In addition to CVCs, short-term peripheral catheters,
21
peripherally inserted central venous catheters (PICCs), midline catheters, and peripheral
arterial catheters also carry a risk of infection.
22
Independent risk factors for CLABSI (in at least 2 published studies)
23–45
Prolonged hospitalization before catheterization
Prolonged duration of catheterization
Heavy microbial colonization at insertion site
Heavy microbial colonization of the catheter hub
Multilumen catheters
Concurrent catheters
Neutropenia
Body mass index (BMI) >40
Prematurity (ie, early gestational age)
Reduced nurse-to-patient ratio in the ICU
Parenteral nutrition
Substandard catheter care (eg, excessive manipulation of the catheter)
Transfusion of blood products (in children)
Section 2: Background on detection of CLABSI
Surveillance methods and definitions for CLABSI
Use consistent surveillance methods and definitions to allow comparison to benchmark
data.
Refer to the National Healthcare Safety Network (NHSN) Patient Safety Component Manual
for information on the appropriate surveillance methodology, including information
about blood specimen collection and surveillance definitions of CLABSIs. The relevant
chapter of the manual is “Chapter 4: Bloodstream Infection Event (Central Line-Associated
Bloodstream Infection and Non-Central Line-Associated Bloodstream Infection).”
46
Recent data suggest that interrater reliability using NHSN definitions is lower than
expected.
47–50
This may also affect the reliability of public reporting.
The NHSN surveillance definition for CLABSI is different than the clinical definition
for catheter-related bloodstream infection (CRBSI). The latter is subject to various
factors (eg, laboratory capabilities, catheter removal, and submitting the catheter
tip for culture).
51
The evidence presented here includes studies that used either CLABSI or CRBSI as an
outcome measure and the lesser accuracy of CLABSI may impact the validity of the evidence.
Section 3: Background on prevention of CLABSI
Summary of existing guidelines and recommendations
Several governmental, public health, and professional organizations have published
evidence-based guidelines and/or implementation aids regarding the prevention of CLABSI
including the following:
Healthcare Infection Control Practices Advisory Committee (HICPAC), Centers for Disease
Control and Prevention (CDC)
52,53
Institute for Healthcare Improvement (IHI)
54
Agency for Healthcare Research and Quality, Making Health Care Safer
55
American Pediatric Surgical Association, Outcomes and Clinical Trials Committee
56
The Joint Commission
57
APIC, Implementation Guide to Preventing Central Line-Associated Bloodstream Infections
58
Infusion Nurses Society, Infusion Nursing Standards of Practice
59
The recommendations in this document focus on CVCs unless noted otherwise. These recommendations:
Are not stratified based on the type of catheter (eg, tunneled, implanted, cuffed,
non-cuffed catheter, dialysis catheter).
May not be applicable in their entirety for prevention of bloodstream infections with
other intravascular devices.
Infrastructure requirements
Facilities undertaking CLABSI interventions should have the following elements in
place:
An adequately staffed infection prevention and control program responsible for identifying
patients who meet the surveillance definition for CLABSI.
Infection prevention staff and, preferably, information technology support to collect
and calculate catheter days as a denominator when computing rates of CLABSI and patient
days to allow calculation of CVC utilization. Catheter days from information systems
should be validated against a manual method, with a margin of error no greater than
±5%.
60–62
Resources to provide appropriate education and training.
Adequate laboratory support for timely processing of specimens and reporting of results,
as specified by the supervisor of the surveillance program.
Section 4: Recommended strategies to prevent CLABSI
Recommendations are categorized as either (1) essential practices that should be adopted
by all acute-care hospitals or (2) additional approaches that can be considered in
locations and/or populations within hospitals when CLABSIs are not controlled by use
of essential practices. Essential practices include recommendations in which the potential
to affect CLABSI risk clearly outweighs the potential for undesirable effects. Additional
approaches include recommendations in which the intervention is likely to reduce CLABSI
risk but there is concern about the risks for undesirable outcomes, recommendations
for which the quality of evidence is low, recommendations in which cost-to-benefit
ratio may be high, or recommendations in which evidence supports the impact of the
intervention in select settings (eg, during outbreaks) or for select patient populations.
Hospitals can prioritize their efforts by initially focusing on implementation of
the prevention strategies listed as essential practices. If CLABSI surveillance or
other risk assessments suggest ongoing opportunities for improvement, hospitals should
consider adopting some or all of the prevention approaches listed as additional approaches.
These can be implemented in specific locations or patient populations or can be implemented
hospital-wide, depending on outcome data, risk assessment, and/or local requirements.
Each infection prevention recommendation is given a quality of evidence grade (see
Table 2).
Essential practices for preventing CLABSI recommended for all acute-care hospitals
Some of the following measures have been combined into a “prevention bundle” that
focuses on catheter insertion.
63,64
Numerous studies have documented that use of such bundles is effective, sustainable,
and cost-effective in both adults and children.
63,65–68
Bundles are most likely to be successful if implemented in a previously established
patient safety culture and their success depends on adherence to individual measures.
69
However, data suggests that not all components of bundles may be necessary to achieve
an effect on CLABSI rates.
70
After catheter insertion, maintenance bundles have been proposed to ensure optimal
catheter care.
71
More data are needed to determine which components of the maintenance bundle are essential
in reducing risk.
72,73
Before insertion
Provide easy access to an evidence-based list of indications for CVC use to minimize
unnecessary CVC placement (Quality of Evidence: LOW)
Require education and competency assessment of healthcare personnel (HCP) involved
in insertion, care, and maintenance of CVCs about CLABSI prevention (Quality of Evidence:
MODERATE)
74–78
Include the indications for catheter use, appropriate insertion and maintenance, the
risk of CLABSI, and general infection prevention strategies.
Ensure that all HCP involved in catheter insertion and maintenance complete an educational
program on essential practices to prevent CLABSI before performing these duties.
79,80
Periodic retraining with a competency assessment may be of benefit.
81
Periodically assess HCP knowledge of and adherence to preventive measures.
Require all HCP who insert a CVC to undergo a credentialing process (as established
by the individual healthcare institution) to ensure their competency before independently
inserting a CVC and aseptic technique for accessing and maintaining the CVC thereafter.
Re-educate when an institution changes components of the infusion system that requires
a change in practice (eg, when an institution’s change of the needleless connector
requires a change in nursing practice).
Use simulation training for proper catheter insertion and maintenance if available.
82–85
Bathe ICU patients >2 months of age with a chlorhexidine preparation on a daily basis
(Quality of Evidence: HIGH)
86–90
In long-term acute-care hospitals (LTACHs), daily chlorhexidine bathing may also be
considered as a preventive measure.
91
The role of chlorhexidine bathing in non-ICU patients remains unclear.
92,93
One cluster-randomized study found a significant reduction in device-associated bacteremia
with CHG bathing in this patient population
93
; however, some of these patients also received methicillin-resistant Staphylococcus
aureus (MRSA) decolonization, making it difficult to draw firm conclusions regarding
CHG bathing alone. Several studies have suggested benefit among adult hematology-oncology
patients; however, a similar reduction was not observed for pediatric patients with
similar conditions.
94,95
Accordingly, potential benefits and risks, such as increases in resistance and cost,
need to be carefully considered.
The safety and efficacy of routine use of chlorhexidine bathing in infants <2 months
of postnatal age remains unclear.
96
Although life-threatening skin injuries from CHG have been reported in very young
or very preterm infants, they typically occur in infants with a birthweight <1,000
g who are <7 days postnatal age, and they appear rare in older infants.
97–99
Widespread use of chlorhexidine may be associated with decreased chlorhexidine susceptibility,
although the clinical relevance of this finding is not well defined.
100
At insertion
In ICU and non-ICU settings, a facility should have a process in place, such as a
checklist, to ensure adherence to infection prevention practices at the time of CVC
insertion (Quality of Evidence: MODERATE)
101
Ensure and document adherence to aseptic technique
Checklists have been suggested to ensure optimal insertion practices. If used, the
documentation should be done by someone other than the inserter.
Observation of CVC insertion should be done by a nurse, physician, or other HCP who
has received appropriate education (see above) to ensure that aseptic technique is
maintained.
HCP should be empowered to stop the procedure if breaches in aseptic technique are
observed.
Perform hand hygiene prior to catheter insertion or manipulation (Quality of Evidence:
MODERATE)
102–107
Use an alcohol-based waterless product or soap and water.
Use of gloves does not obviate hand hygiene.
The subclavian site is preferred to reduce infectious complications when the catheter
is placed in the ICU setting (Quality of Evidence: HIGH)
33,37,108–110
In the non-ICU setting, the risk of infection between the different sites remains
unclear. Importantly, in emergent settings, ensuring life-saving vascular access in
the fastest possible way may determine the choice of access site.
In children and infants, femoral vein catheterization may be considered if upper body
sites are contraindicated.
111
Tunneled femoral vein catheters, with an exit site outside the diaper area in the
mid-thigh, may be safer and provide additional risk reduction.
112,113
Controversy exists regarding infectious and noninfectious complications associated
with different short-term CVC access sites.
33
The risk and benefit of different insertion sites must be considered on an individual
basis with regard to infectious and noninfectious complications.
33
Among others, this applies to patients currently receiving or likely to require hemodialysis
in whom the subclavian site is avoided due to risk of stenosis.
Do not use peripherally inserted central venous catheters (PICCs) as a strategy to
reduce the risk of CLABSI. Risk of infection with PICCs in hospitalized patients approaches
that of other CVCs.
114
However, the majority of CLABSIs due to PICCs occur in non-ICU settings.
115
Midline catheters are increasingly being used as an alternative to CVCs for short-term
vascular access, with some observational studies suggesting lower bloodstream infection
risk associated with midline catheters versus PICCs
116
and versus CVCs,
117
respectively. Randomized controlled trials comparing the risk of bloodstream infections
and other complications associated with these devices are needed.
Use an all-inclusive catheter cart or kit (Quality of Evidence: MODERATE)
118
A catheter cart or kit that contains all necessary components for aseptic catheter
insertion should be available and easily accessible in all units where CVCs are inserted.
Use ultrasound guidance for catheter insertion (Quality of Evidence: HIGH)
119,120
Ultrasound-guided internal jugular and femoral vein catheterization reduces the risk
of noninfectious complications associated with CVC placement
121
but the use of ultrasound may lead to a breach in aseptic technique.
122
It is unclear whether ultrasound-guided subclavian vein insertion reduces risk of
infectious complications.
Use maximum sterile barrier precautions during CVC insertion (Quality of Evidence:
MODERATE)
123–128
Use maximum sterile barrier precautions:
A mask, cap, sterile gown, and sterile gloves are to be worn by all HCP involved in
the catheter insertion procedure.
The patient is to be covered with a large (“full-body”) sterile drape during catheter
insertion.
These measures should also be followed when exchanging a catheter over a guidewire.
A prospective, randomized study in surgical patients showed no additional benefit
for maximum sterile barrier precautions
126
; nevertheless, most available evidence suggests risk reduction with this intervention.
Use an alcoholic chlorhexidine antiseptic for skin preparation (Quality of Evidence:
HIGH)
42,129–134
Before catheter insertion, apply an alcoholic chlorhexidine solution containing at
least 2% chlorhexidine gluconate to the insertion site.
The antiseptic solution must be allowed to dry before making the skin puncture.
Alcoholic chlorhexidine for skin antisepsis to prevent CLABSI in NICU patients should
be used when the benefits are judged to outweigh potential risk.
After insertion
Ensure appropriate nurse-to-patient ratio and limit use of float nurses in ICUs (Quality
of Evidence: HIGH)
34,35
Observational studies suggest that an adequate nurse-to-patient ratio must be maintained
in ICUs where nurses are managing patients with CVCs and that the number of float
nurses working in the ICU environment should be minimized.
Use chlorhexidine-containing dressings for CVCs in patients over 2 months of age (Quality
of Evidence: HIGH)
45,135–142
It is unclear whether there is additional benefit with use of a chlorhexidine-containing
dressing if daily chlorhexidine bathing is already established and vice-versa.
For long-term catheters (eg, hemodialysis catheters) in well-healed access sites,
it is unclear whether use of a chlorhexidine dressing reduces risk of infectious complications.
140,143,144
For children under 2 months of age, use of chlorhexidine dressings remains unclear,
particularly in very preterm or low birthweight infants.
98
For nontunneled CVCs in adults and children, change transparent dressings and perform
site care with a chlorhexidine-based antiseptic at least every 7 days or immediately
if the dressing is soiled, loose, or damp. Change gauze dressings every 2 days or
earlier if the dressing is soiled, loose, or damp. (Quality of Evidence: MODERATE)
145–148
Less frequent, clinically indicated dressing changes may be used for NICU patients
or others at high risk of serious complications from catheter dislodgement.
149
If there is excessive bleeding or drainage from the catheter exit site, use gauze
dressings instead of transparent dressings until drainage resolves.
Disinfect catheter hubs, needleless connectors, and injection ports before accessing
the catheter (Quality of Evidence: MODERATE)
150–154
Before accessing catheter hubs, needleless connectors, or injection ports, vigorously
apply mechanical friction with an alcoholic chlorhexidine preparation, or 70% alcohol.
Alcoholic chlorhexidine may have additional residual activity compared to alcohol
for this purpose and is therefore preferred.
155
Apply mechanical friction for a minimum of 5 seconds to reduce contamination.
156,157
It is unclear whether this duration of disinfection can be generalized to needleless
connectors not tested in these studies.
Monitor compliance with hub-connector-port disinfection because approximately half
of such catheter components are colonized under conditions of standard practice.
152,156,158
Remove nonessential catheters (Quality of Evidence: MODERATE)
Assess the need for continued intravascular access on a daily basis during multidisciplinary
rounds. Remove catheters not required for patient care. Decreasing CVC utilization
reduces CRBSI risk.
159
However, reducing CVC utilization may result in increased use of other intravascular
catheters with corresponding infection risk.
Audits to determine whether CVCs are routinely removed after their intended use may
be helpful.
160,161
Both simple and multifaceted interventions are effective at reducing unnecessary CVC
use.
162,163
Routine replacement of administration sets not used for blood, blood products, or
lipid formulations can be performed at intervals up to 7 days (Quality of Evidence:
HIGH)
164
The optimal replacement of intermittently used administration sets is unresolved.
Perform surveillance for CLABSI in ICU and non-ICU settings (Quality of Evidence:
HIGH)
13,165,166
Measure unit-specific incidence of CLABSI (eg, CLABSI per 1,000 catheter days) and
report the data on a regular basis to the units, physician and nursing leadership,
and hospital administrators overseeing the units.
Compare CLABSI incidence to historical data for individual units and to national rates
(ie, NHSN).
167
Audit surveillance as necessary to minimize variation in interobserver reliability.
48,168
Additional approaches for preventing CLABSI
Several additional approaches are currently available for use. Perform a CLABSI risk
assessment before considering implementation of any of these approaches, taking potential
adverse events and costs into consideration. Although it is reasonable to evaluate
the utility of technology-based interventions when CLABSI rates are above the institutional-
or unit-based threshold, this is also an opportunity to review practices and consider
behavioral changes that may be instituted to reduce CLABSI risk. These additional
approaches are recommended for use in locations and/or populations within the hospital
with unacceptably high CLABSI rates despite implementation of the essential CLABSI
prevention strategies listed above. These measures may not be indicated if institutional
goals have been consistently achieved.
Use antiseptic- or antimicrobial-impregnated CVCs (Quality of Evidence: HIGH in adult
patients
38,39,169–171
and MODERATE in pediatric patients
172,173
)
The risk of CLABSI is reduced with some currently marketed antiseptic-impregnated
(eg, chlorhexidine-silver sulfadiazine) catheters and antimicrobial-impregnated (eg,
minocycline-rifampin) catheters. Use such catheters under the following conditions:
Hospital units or patient populations have a CLABSI rate above institutional goals
despite compliance with essential CLABSI prevention practices. Some evidence suggests
that use of antimicrobial CVCs, along with other preventive technologies, may have
no additional benefit in patient care units that have already established a low incidence
of catheter infections.
174,175
Patients have limited venous access and a history of recurrent CLABSI.
Patients are at heightened risk of severe sequelae from a CLABSI (eg, patients with
recently implanted intravascular devices such as a prosthetic heart valve or aortic
graft).
Monitor patients for adverse effects such as anaphylaxis.
176
Many studies investigating antimicrobial-impregnated catheters were performed before
infection preventive bundles were routine. Whether such catheters have an impact on
CLABSI in such settings remains unknown.
Use antimicrobial lock therapy for long-term CVCs (Quality of Evidence: HIGH)177–184
Antibiotic and antiseptic locks are created by filling the lumen of the catheter with
a supratherapeutic concentration of an antibiotic solution and leaving the solution
in place until the catheter hub is re-accessed. Such an approach can reduce the risk
of CLABSI. The optimal antimicrobial agent or combination of agents, their concentration,
and duration of lock therapy are matters of ongoing research. Due to concerns regarding
the potential for the emergence of resistance in exposed organisms, use antimicrobial
locks as a preventative strategy for the following:
Patients with long-term hemodialysis catheters who have a history of recurrent CLABSI.
185
Prophylaxis for patients with limited venous access and a history of recurrent CLABSI.
Patients who are at heightened risk of severe sequelae from a CLABSI (eg, patients
with recently implanted intravascular devices such as a prosthetic heart valve or
aortic graft).
To minimize systemic toxicity, aspirate rather than flush the antimicrobial lock solution
after the dwell time has elapsed.
186–189
The potential of adverse effects associated with ethanol locks should be carefully
considered before use.
190,191
Use recombinant tissue plasminogen activating factor (rt-PA) once weekly after hemodialysis
in patients undergoing hemodialysis through a CVC (Quality of Evidence: HIGH)
192
Utilize infusion or vascular access teams for reducing CLABSI rates (Quality of Evidence:
LOW)
193,194
Studies have shown that an infusion/vascular access team responsible for insertion
and maintenance of peripheral intravenous catheters reduces the risk of bloodstream
infections
195
; however, few studies have been performed regarding the impact of intravenous therapy
teams on CLABSI rates.
196
Use antimicrobial ointments for hemodialysis catheter insertion sites (Quality of
Evidence: HIGH)
197–201
Apply polysporin “triple” (where available) or povidone-iodine ointment to hemodialysis
catheter insertion if compatible with the catheter material.
Ingredients in ointments may interact with the chemical composition of some catheters.
Thus, ensure the selected ointment will not interact with the catheter material before
any such product is applied to the catheter insertion/exit site. For example, ointments
containing glycol should not be applied to insertion/exit sites of polyurethane catheters.
Mupirocin ointment should not be applied to the catheter insertion site due to the
risks of facilitating mupirocin resistance and the potential damage to polyurethane
catheters.
Use an antiseptic-containing hub/connector cap/port protector to cover connectors
(Quality of Evidence: MODERATE)
202–208
The utility of routinely disinfecting hub connectors and ports when using antiseptic-containing
hub/connector cap/port protectors is unknown.
Approaches that should not be considered a routine part of CLABSI prevention
Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion
or while catheters are in situ (Quality of Evidence: HIGH)
209–213
Systemic antimicrobial prophylaxis is not recommended.
Do not routinely replace CVCs or arterial catheters (Quality of Evidence: HIGH)
214
Routine catheter replacement is not recommended.
Unresolved issues
Routine use of needleless connectors as a CLABSI prevention strategy before an assessment
of risks, benefits, and education regarding proper use
215–219
Multiple devices are currently available but the optimal design for preventing infections
is unresolved. The original purpose of needleless connectors was to prevent needlestick
injuries during intermittent use. No data are available regarding their use with continuous
infusions. Needle-free connectors with 3-way stopcocks may increase the risk of catheter
infections.
220
Use of silver-coated catheter connectors may be associated with reduced intraluminal
contamination in ex vivo catheters and CLABSI.
221,222
Clinical evidence is limited regarding the risk reduction with their routine use or
use of other antimicrobial catheter connectors.
Surveillance of other types of catheters (eg, peripheral arterial or venous catheters)
11,21,22
Peripheral arterial catheters, short-term peripheral venous catheters and midline
catheters are not included in most surveillance systems although they are associated
with risk of bloodstream infection. Future surveillance systems should consider including bloodstream
infections associated with these types of catheters.
If considering further infection prevention interventions due to concern for an increase
in infections, hospitals may want to consider extending their surveillance programs
to include all types of catheters used to gauge the size of the problem.
Standard, nonantimicrobial transparent dressings and CLABSI risk
A meta-analysis reported an association between CLABSI and transparent dressing use;
however, the source studies for the meta-analysis reporting this association were
of low quality.
223
The impact of using chlorhexidine-based products on bacterial resistance to chlorhexidine
Widespread use of chlorhexidine-based products (eg, use of chlorhexidine bathing,
antisepsis, and dressings) may promote reduced chlorhexidine susceptibility.
224
However, testing for chlorhexidine susceptibility is not standardized. The clinical
impact of reduced chlorhexidine susceptibility is unknown.
Sutureless securement
The impact of sutureless securement devices in reducing CLABSI is unknown.
225,226
Impact of silver zeolite-impregnated umbilical catheters in preterm infants (applicable
in countries where it is approved for use in children)
227
One randomized study suggests that antimicrobial-impregnated umbilical catheters appear
to be safe and effective in NICU patients.
228
Necessity of mechanical disinfection of a catheter hub, needleless connector, and
injection port before accessing the catheter when antiseptic-containing caps are being
used.
It is unknown whether the application and removal of an antiseptic-containing cap
provides the same benefit to reducing risk of CLABSI as manual disinfection. Future
research is needed to determine if using such a cap will obviate the need for manual
disinfection before accessing a catheter.
Section 5: Performance measures
Internal reporting
These performance measures are intended to support internal hospital quality improvement
efforts
229,230
and do not necessarily address external reporting needs.
The process and outcome measures suggested here are derived from published guidelines,
other relevant literature, and the opinion of the authors. Report process and outcome
measures to senior hospital leadership, nursing leadership, and clinicians who care
for patients at risk for CLABSI.
Process measures (Table 3)
Compliance with CVC insertion guidelines as documented on an insertion checklist
Assess compliance with the checklist in all hospital settings where CVCs are inserted
(eg, ICUs, ED, OR, radiology, general patient care units) and assign HCP familiar
with CVCs to this task.
Documenting compliance using the insertion checklist upholds accountability and compliance
with the proper procedure steps and identifies gaps to be mitigated. The Institute
for Healthcare Improvement (IHI) provides an example of a central catheter checklist.
231
Documentation of CVC insertion procedures in compliance with appropriate hand hygiene,
use of maximal sterile barrier precautions, and use of chlorhexidine-based cutaneous
antisepsis of the insertion site:
Numerator: Number of CVC insertions that have documented the use of all 3 interventions
(hand hygiene, maximal barrier precautions, and chlorhexidine-based cutaneous antiseptic
use) performed at the time of CVC insertion.
Denominator: Number of all CVC insertions.
Multiply by 100 so that the measure is expressed as a percentage.
Compliance with documentation of daily assessment regarding the need for continuing
CVC access.
Measure the percentage of patients with a CVC where there is documentation of daily
assessment:
Numerator: Number of patients with a CVC who have documentation of daily assessment.
Denominator: Number of patients with a CVC.
Multiply by 100 so that the measure is expressed as a percentage.
Simulation of catheter maintenance as an alternative to address HCP competency
232,233
Numerator: Number of HCP properly simulating the aseptic infusion of medications.
Denominator: Number of HCP simulating the aseptic infusion of medications.
Multiply by 100 so that the measure is expressed as a percentage.
Device utilization can be evaluated over time to assess any changes. Utilization may
be compared at the hospital and unit level. It provides a surrogate for patient exposure
risk.
234
The standardized utilization ratio (SUR) is an NHSN measure that accounts for facility-
and location-level factors that may affect device use.
SUR: Observed device days divided by predicted device days.
Table 3.
CLABSI Prevention Process Measures
Assessing Compliance According to Practice
Use of proper CVC insertion interventions:1. Hand hygiene2. Use of maximal sterile
barrier precautions3. Use of chlorhexidine-based cutaneous antisepsis
(Number of CVC insertions that have documented the use of all 3 interventions performed
at the time of CVC insertion divided by number of all CVC insertions) ×100 = % properly
performed procedures
Documentation of daily assessment regarding patient’s need for continuing CVC access
(Number of CVC insertions with documentation of daily assessment divided by number
of patients with CVC) ×100 = % of patients who received daily assessment for continuing
need for CVC access
Assessing Compliance by Simulation
Simulation of catheter maintenance to assess HCP competency
(Number of HCP properly simulating aseptic infusion of medications divided by number
of HCP simulating the aseptic infusion of medications) ×100 = % of HCP competent in
catheter maintenance
Assessing Device Utilization as a Surrogate for Patient Exposure Risk
Standard utilization ratio (SUR)
Number of observed device days divided by number of predicted device days
Outcome measures (See Table 4)
CLABSI rate: Use NHSN definitions.
Numerator: Number of CLABSIs in each unit assessed (using NHSN definitions).
Denominator: Total number of catheter days in each unit assessed (using NHSN definitions).
Multiply by 1,000 so that the measure is expressed as number of CLABSIs per 1,000
catheter days.
Risk adjustment: Stratify CLABSI rates by type of patient-care unit.
235–237
Report comparisons based on historic data and NHSN data, if available.
167
Use the NHSN device standardized infection ratio (dSIR) to evaluate hospital and unit
CLABSI rates.
dSIR: Observed CLABSI events divided by predicted CLABSI events based on actual device
days.
Consider measures that address device risk at the patient population level. A population
SIR (pSIR)
238
accounts for both device SIR and SUR, reflecting both the care of the device, and
interventions to reduce utilization.
pSIR: Observed CLABSI events divided by predicted CLABSI events based on predicted
device days.
Table 4.
CLABSI Prevention Outcome Measures
Assessing CLABSI Rate
Using NHSN definitions
(Number of CLABSIs in each unit assessed with NHSN definitions divided bytotal number
of catheter days in each unit assessed using NHSN definitions) ×1,000 = Number of
CLABSIs per 1,000 catheter days
Risk Adjustment
Report comparisons based on historic data and NHSN data, if available.
By type of patient-care unit
Device standardized infection ratio (dSIR) = Observed CLABSI events divided bypredicted
CLABSI events based on actual device days
By the patient population level to reflect the care of the device, and interventions
to reduce utilization
Population standardized infection ratio (pSIR) = Observed CLABSI events divided bypredicted
CLABSI events based on predicted device days
External reporting
Many challenges exist in providing useful information to consumers and other stakeholders
and in preventing unintended consequences of public reporting of HAIs.
239,240
Recommendations for public reporting of HAIs have been provided by the Healthcare
Infection Control Practices Advisory Committee (HICPAC),
241
the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee,
242
and the National Quality Forum.
243
State and federal requirements
Hospitals in states that have mandatory reporting requirements for CLABSI must collect
and report the data required by the state.
For information on state and federal requirements, contact your state or local health
department.
External quality initiatives
Hospitals that participate in external quality initiatives or state programs must
collect and report the data required by the initiative or the program.
Problems with interrater reliability may affect comparisons between different institutions.
Section 6: Implementation of CLABSI prevention strategies
Prevention of CLABSI depends on integrating best practices to reduce the risk of infection
and incorporating a culture to support implementation. Hospitals should address technical
and socioadaptive components
244
to CLABSI prevention, including formal training of HCP on indications, placement,
and maintenance of devices, in addition to regular assessment of competencies.
245
One example of a widely used model in the United States, known as the Four Es (ie,
engage, educate, execute, and evaluate
246
), involves summarizing evidence, identifying local barriers to implementation, measuring
performance, and ensuring that patients receive the infection prevention intervention
247
by addressing knowledge, critical thinking, behavior and psychomotor skills, as well
as attitudes and beliefs of all members of the healthcare team involved with the insertion
and care of CVCs.
248,249
Facilities may consider utilizing tools to promote high-reliability processes (eg,
Lean Six Sigma) and to enhance teamwork (eg, Team STEPPS).
Engage
Historically, efforts have been centered around having a champion to support CLABSI
reduction initiatives. Champions are often very effective in initial phases of adoption,
but their efforts may not be enough for integration of processes and sustainability.
250
It is important to engage both frontline and senior leadership champions in the process
and outcome improvement plan,
251
but institutionalizing the work and garnering the support of stakeholder groups facilitates
successful, long-lasting results.
252
Educate
HCP, patients, and caregivers involved in care of a CVC should be trained in and competent,
relative to their role, with the following:
Appropriate indications prior to insertion.
Use of full barrier precautions at the time of insertion.
Daily evaluation of necessity of the device.
Execute
A standardized competency assessment checklist should be used to assess and document
competency of each individual performing CVC insertion and procedures related to care
and maintenance (eg, dressing changes).
253–255
In addition, education of the patient and/or family, as appropriate, is required for
all CVC care procedures especially when transfer to an alternative setting (eg, home
care, ambulatory setting) is planned.
256,257
Evaluate
Evaluation involves both process and outcome measurement.
258
Multidisciplinary teams should set clear goals and identify the key factors to be
measured. It is important for members of the healthcare team to receive feedback on
their performance. Feedback should include periodic (eg, monthly, quarterly) communication
(eg, e-mail messages, written reports) of process measurement data via posters, reports,
or other forms of communication with graphs showing cumulative compliance with process
measures.
259–262
Differences between age groups should also be considered (eg, neonates, pediatrics,
and adults).
260,263,264
Central line data can be used to capture trends over time. The standardized utilization
ratio (SUR) provides a method for the hospital’s units to compare themselves to others
with similar characteristics. CLABSI events are important to discuss with the different
members of the team caring for the patient to have a clear understanding of gaps and
ways to mitigate them in the future.