What are the prevention and management strategies for Central Line-Associated Bloodstream Infections (CLABSI)?

Prevention and Management Strategies for Central Line-Associated Bloodstream Infections (CLABSI)

A multidimensional approach with care bundles, education, surveillance, compliance monitoring, and performance feedback is essential for effective CLABSI prevention and management. 1

Prevention Strategies

Before Insertion

1. Education and Competency Assessment

   • Mandate education and competency assessments for all healthcare professionals involved in central line insertion and maintenance 1
   • Include information on indications for central line use, proper insertion techniques, maintenance practices, and infection prevention strategies 1
   • Implement periodic assessments of knowledge and adherence to preventive measures 1

2. Hand Hygiene

   • Perform hand hygiene with alcohol-based products or antiseptic soap before catheter insertion or manipulation 1
   • Remember that wearing gloves does not eliminate the need for hand hygiene 1

3. Site Selection

   • Avoid femoral sites in ICU settings to minimize infectious complications 1
   • Consider PICCs which exhibit lower risk of CLABSI compared to other central line types 1
   • For pediatric patients, upper or lower extremities (or scalp in neonates) can be used 1

During Insertion

1. Maximum Sterile Barrier Precautions

   • Ensure all healthcare professionals wear mask, cap, sterile gown, and sterile gloves 1
   • Cover patient with large sterile drape 1

2. Skin Preparation

   • Use alcoholic chlorhexidine solution (minimum 2% CHG) for patients over 2 months of age 1
   • For neonates less than 2 months: use povidone-iodine with 2-minute dry time 1
   • Allow antiseptic to completely dry before skin puncture 1

3. Ultrasound Guidance

   • Use ultrasound guidance for catheter insertion to decrease risk of non-infectious complications 1

After Insertion

1. Staffing Considerations

   • Maintain appropriate nurse-to-patient ratios in ICUs 1
   • Restrict the use of float nurses in ICUs 1

2. Dressings and Site Care

   • Apply chlorhexidine-containing dressings for central lines in patients over two months of age 1, 2
   • Replace transparent dressings and perform site care with CHG-based antiseptic at least every seven days 1
   • Replace gauze dressings every 2 days 1
   • Replace dressings immediately if soiled, loose, or damp 1
   • Use gauze dressings for sites with significant bleeding or drainage until resolved 1

3. Hub and Port Disinfection

   • Disinfect catheter hubs, needleless connectors, and injection ports before accessing 1, 2
   • Consider passive disinfection with caps containing disinfectant agents (70% isopropyl alcohol, iodinated alcohol, or CHG) 1, 2
   • If using active disinfection, apply mechanical friction with alcoholic CHG or 70% alcohol for 5-15 seconds 1

4. Daily Assessment

   • Conduct daily assessments to evaluate the ongoing necessity of the central line 1
   • Consider daily chlorhexidine bathing for ICU patients over two months of age 1

Surveillance and Monitoring

1. CLABSI Surveillance

   • Use standardized CDC/NHSN surveillance methods and definitions 1
   • Calculate CLABSI rate: (Number of CLABSIs ÷ Total central line-days) × 1,000 1
   • Stratify rates by patient-care unit type 1
   • Monitor central line device utilization (DU) ratio: observed central line days ÷ observed patient days 1

2. Compliance Monitoring

   • Track bundle compliance rates using objective measures (yes/no, completed/not completed) 1
   • Perform root cause analysis for all CLABSI events 1
   • Provide regular performance feedback to staff 1

Special Considerations

1. Neonatal Patients

   • CHG bathing and dressings are not recommended for infants under two months due to risk of severe skin reactions 1, 2
   • Consider less frequent dressing changes for NICU patients at high risk of complications from catheter dislodgement 1
   • Life-threatening skin injuries have been reported in infants with birth weight below 1,000 grams who are less than 7 days postnatal age 1

2. Resource-Limited Settings

   • Use collapsible closed-system intravenous fluid containers 1
   • Prefer needleless connectors over three-way stopcocks 1
   • Use positive displacement needleless connectors instead of negative or neutral displacement 1

Interventions to Avoid

1. Do not use antimicrobial prophylaxis during short-term tunneled catheter insertion or while catheters are in place 1

2. Do not routinely replace central lines or arterial catheters 1

Common Pitfalls and Caveats

1. Femoral Site Selection

   • While generally avoided in adults, femoral vein catheterization may be considered for infants if upper body sites are contraindicated 1
   • For infants requiring femoral access, tunneled femoral vein catheters with exit sites outside the diaper area may provide enhanced safety 1

2. Chlorhexidine Use in Neonates

   • Contact dermatitis is a significant adverse event with CHG dressings, particularly in neonates and pediatric populations 1, 2
   • Use alternative antiseptics for patients under 2 months of age 1

3. Maintenance vs. Insertion Focus

   • Many CLABSI events are attributed to breaches in catheter maintenance rather than insertion 1
   • Focus CLABSI prevention efforts on both insertion and maintenance practices 3, 4