How can Central Line-Associated Bloodstream Infections (CLABSIs) be prevented and treated?

Prevention and Treatment of Central Line-Associated Bloodstream Infections (CLABSIs)

Implementing a multidimensional approach with evidence-based care bundles is the most effective strategy to prevent Central Line-Associated Bloodstream Infections (CLABSIs), significantly reducing morbidity and mortality in both high-resource and limited-resource settings. 1

Prevention Strategies

Insertion Bundle Components

• Site Selection: Avoid femoral vein placement when possible (except for hemodialysis and some pediatric patients); peripherally inserted central catheters (PICCs) show the lowest risk of CLABSI compared to other central line types 1

• Hand Hygiene: Perform hand hygiene before catheter insertion or manipulation using either alcohol-based hand rub or soap and water; wearing gloves does not eliminate the need for hand hygiene 1

• Skin Preparation: Use 2% alcoholic chlorhexidine solution for skin antisepsis before insertion; allow the solution to completely dry before catheter insertion 1, 2

• Maximum Sterile Barrier Precautions: Ensure all healthcare providers involved in insertion wear mask, cap, sterile gown, and sterile gloves; cover patient with large sterile drape 1

• Ultrasound Guidance: Use ultrasound guidance for catheter insertion to reduce non-infectious complications, particularly for internal jugular and femoral vein catheterization 1

Maintenance Bundle Components

• Daily Assessment: Review necessity of the central line daily; remove promptly when no longer needed 1, 3

• Dressing Management:

  • Use transparent semipermeable dressings and replace every 7 days 1
  • Use chlorhexidine-impregnated dressings for patients over two months of age (High quality evidence) 1, 2
  • Replace dressings immediately if soiled, loose, or damp 1
  • Use gauze dressings if bleeding or drainage is present and change every 2 days 1

• Hub/Connector Disinfection: Disinfect catheter hubs, needleless connectors, and injection ports before accessing using alcoholic chlorhexidine or 70% alcohol with mechanical friction 1, 2

  • Consider using antiseptic-containing caps or port protectors to cover needleless connectors 1, 2

• Daily Chlorhexidine Bathing: Provide daily chlorhexidine bathing for ICU patients over two months of age (High quality evidence) 1, 2

  • Not recommended for infants under two months due to risk of skin injuries 1, 2

System-Level Interventions

• Education and Competency Assessment: Mandate education and competency assessments for all healthcare professionals involved in central line insertion and maintenance 1

  • Include simulation training for catheter insertion and maintenance procedures 1
  • Conduct periodic assessments of knowledge and adherence to preventive measures 1

• Surveillance:

  • Monitor CLABSI rates using standardized definitions (e.g., CDC/NHSN) 1
  • Calculate rates as number of CLABSIs per 1,000 central line-days 1
  • Stratify rates by unit type and provide comparative data 1

• Staffing: Maintain appropriate nurse-to-patient ratios and limit use of float nurses in ICUs 1

Additional Recommendations for Resource-Limited Settings

• Closed System Components: Use collapsible closed-system intravenous fluid containers instead of open-system rigid containers 1

• Needleless Connectors: Use needleless connectors instead of three-way stopcocks; positive displacement connectors are preferred over negative or neutral displacement types 1

• Implementation Strategy: Follow the INICC Multidimensional Approach which has demonstrated significant CLABSI reductions (33-76%) in limited-resource settings 1

Practices to Avoid

• Routine Catheter Replacement: Do not routinely replace central lines or arterial catheters 1

• Antimicrobial Prophylaxis: Avoid using systemic antimicrobial prophylaxis during short-term tunneled catheter insertion or while catheters are in place 1

Common Pitfalls and How to Avoid Them

• Inadequate Skin Preparation: Failure to allow chlorhexidine to completely dry before catheter insertion reduces its effectiveness 1, 2

• Improper Hub Disinfection: Insufficient mechanical friction during hub disinfection or inadequate contact time reduces effectiveness; apply for 5-15 seconds 1

• Artificial Compliance Reporting: Measuring CLABSI bundle compliance only per submitted forms rather than per actual CVC placement can artificially inflate compliance rates 4

• Knowledge Gaps: Healthcare workers often have incomplete knowledge about evidence-based practices; formal training significantly improves knowledge and adherence 5

• Inconsistent Bundle Implementation: Partial implementation of bundles reduces effectiveness; all components should be implemented together for maximum benefit 6