Which site for central line (Central Venous Catheter) placement has the lowest risk of infection?

Central Line Insertion Site Selection to Minimize Infection Risk

The subclavian vein is the preferred insertion site for central venous catheters as it has the lowest risk of catheter-related bloodstream infections compared to internal jugular or femoral sites. 1

Evidence-Based Site Selection Hierarchy

1. Subclavian vein (first choice)

   • Lowest infection risk: 0.97-1.57 infections per 1,000 catheter days 1, 2
   • CDC 2011 recommendation supports subclavian placement for non-tunneled CVCs 1
   • Lower risk of both bloodstream infection and symptomatic thrombosis 1

2. Internal jugular vein (second choice)

   • Moderate infection risk: 2.99-7.65 infections per 1,000 catheter days 2
   • Higher risk of colonization compared to subclavian 3
   • Specific approaches matter: low lateral "Jernigan" approach (exit site in supraclavicular fossa) has lower infection risk than high posterior approach (exit site at midneck) 1

3. Femoral vein (avoid when possible)

   • Highest infection risk: 8.34-15.83 infections per 1,000 catheter days 2
   • Associated with higher risk of deep vein thrombosis 1
   • Not recommended in adult patients receiving parenteral nutrition 1

Important Considerations

• Placement technique matters: Real-time ultrasound guidance is associated with lower infection rates due to less tissue trauma and shorter procedure time 1

• Exit site location affects infection risk: Sites in the groin, neck, or antecubital fossa carry higher contamination risk compared to sites in the supraclavicular fossa, infraclavicular fossa, or midarm 1

• Mechanical complications trade-off: While subclavian placement has the lowest infection risk, it has a higher rate of pneumothorax compared to other sites 1

• Catheter type considerations:

  • Totally implantable devices have lowest infection rates (0.1 per 1,000 catheter days)
  • Tunneled catheters have intermediate rates (1.6 per 1,000 catheter days)
  • Non-tunneled CVCs have highest rates (2.7 per 1,000 catheter days) 1, 4

Infection Prevention Best Practices

• Use maximal sterile barrier precautions during insertion 1
• Apply 2% chlorhexidine gluconate in 70% isopropyl alcohol for skin preparation 1
• Place catheters as far away as possible from open wounds 1
• Use sutureless securement devices when possible 1
• Consider antimicrobial-impregnated catheters in high-risk patients 4
• Remove central lines when no longer clinically necessary 4

Evolving Evidence

Recent meta-analyses suggest the infection risk difference between sites may be decreasing over time 5, likely due to improved insertion techniques and care protocols. However, the most current guidelines still recommend the subclavian approach when feasible, as it consistently demonstrates the lowest infection risk in high-quality studies.