What are the best practices for preventing central line infections?

Prevention of Central Line Infections

The most effective approach to prevent central line-associated bloodstream infections (CLABSI) is implementing a comprehensive bundle management strategy based on evidence-based guidelines, with dedicated healthcare teams using standardized checklists to ensure compliance. 1

Core Prevention Bundle Components

Before Insertion

• Proper Education and Training

  • Mandate education for all healthcare professionals involved in central line insertion and maintenance 2
  • Conduct periodic competency assessments and implement credentialing processes 2
  • Designate only trained personnel for central line procedures 1

• Patient and Site Selection

  • Avoid femoral sites in adults (highest infection risk) 1
  • Prefer subclavian sites (lowest infection risk) 1
  • Consider PICCs which have lower CLABSI risk 1
  • Select catheters with minimum number of lumens necessary 1

During Insertion

• Maximal Sterile Barrier Precautions

  • Hand hygiene before all procedures 1
  • Use of cap, mask, sterile gown, and sterile gloves 1, 2
  • Full-body sterile drape covering the patient 1, 2

• Skin Antisepsis

  • Use alcoholic chlorhexidine solution (>2% CHG) for patients over 2 months 2
  • Allow antiseptic to completely dry before skin puncture 2
  • Use povidone-iodine with 2-minute dry time for neonates under 2 months 2

• Insertion Technique

  • Implement ultrasound guidance to reduce placement attempts 1
  • Use sutureless securement devices 1

After Insertion

• Dressing Management

  • Apply chlorhexidine-containing dressings for patients over 2 months 2
  • Replace transparent dressings at least every 7 days 1
  • Replace gauze dressings every 2 days 2
  • Replace immediately if soiled, loose, or damp 1, 2

• Hub and Port Care

  • Disinfect catheter hubs, connectors, and ports before accessing 2
  • Use passive disinfection caps or active mechanical friction 2
  • Replace administration sets and needleless connectors at least every 7 days 1
  • Replace within 24 hours after blood product or lipid infusions 1

• Daily Assessment

  • Evaluate ongoing necessity of central line daily 2
  • Remove catheters as soon as they are no longer needed 1, 2
  • Consider daily chlorhexidine bathing for ICU patients over 2 months 2

Surveillance and Quality Improvement

• Monitoring

  • Track CLABSI rates using standardized CDC/NHSN definitions 2
  • Calculate CLABSI rate: (Number of CLABSIs ÷ Total central line-days) × 1,000 2
  • Monitor bundle compliance using objective measures 2
  • Perform root cause analysis for all CLABSI events 2

• Performance Feedback

  • Provide regular feedback to staff on CLABSI rates and compliance 1, 2
  • Implement collaborative performance improvement initiatives 1

Common Pitfalls and How to Avoid Them

1. Inadequate Staff Training

   • Ensure all staff receive proper education and competency assessment 2
   • Designate specialized teams for central line care when possible 1

2. Poor Compliance Monitoring

   • Use checklists to ensure adherence to all bundle elements 1
   • Empower staff to stop procedures if protocols aren't followed 1

3. Delayed Catheter Removal

   • Implement daily review protocols for central line necessity 2
   • Remove central lines as soon as they are no longer needed 1

4. Inappropriate Antimicrobial Use

   • Avoid routine systemic antimicrobial prophylaxis 1
   • Do not use topical antimicrobial ointments at insertion sites 1

5. Inadequate Staffing

   • Maintain appropriate nurse-to-patient ratios in ICUs 2
   • Restrict use of float nurses in ICUs 2

Special Considerations

• Pediatric Patients

  • Upper or lower extremities (or scalp in neonates) can be used 2
  • Avoid chlorhexidine in infants under 2 months due to skin reaction risk 2
  • Consider less frequent dressing changes for NICU patients at high risk of catheter dislodgement 2

• Oncology Patients

  • Higher risk due to chemotherapy, neutropenia, and long-term catheter use 1
  • Femorally inserted central catheters have highest infection risk, followed by centrally inserted catheters, PICCs, and totally implantable venous access devices 1

When properly implemented, these bundle approaches have demonstrated significant reductions in CLABSI rates by up to 66-80% 1, with some studies reporting reductions from 15.34 to 2.23 per 1,000 catheter-days 1.