What are the guidelines for preventing Central Line-Associated Bloodstream Infections (CLABSI)?

Guidelines for Preventing Central Line-Associated Bloodstream Infections (CLABSI)

To effectively prevent Central Line-Associated Bloodstream Infections (CLABSI), healthcare facilities must implement a multidimensional approach with evidence-based care bundles that include proper insertion techniques, maintenance practices, and system-level interventions. 1, 2

Necessary Prerequisites for CLABSI Prevention

• Establish an infection prevention team to identify patients meeting CLABSI definitions and monitor compliance 1
• Implement information technology support for tracking central line days and patient days to calculate device utilization ratios 1
• Ensure adequate laboratory support for timely processing of specimens and reporting results 1
• Validate central line days data with manual methods (acceptable error margin ≤5%) 1

Insertion Bundle Components

• Perform proper hand hygiene before catheter insertion using alcohol-based hand rub or soap and water (wearing gloves does not eliminate this need) 2
• Use 2% alcoholic chlorhexidine solution for skin antisepsis before insertion and allow complete drying 2, 3
• Ensure maximum barrier precautions including mask, cap, sterile gown, sterile gloves, and large sterile drape covering the patient 2
• Select optimal catheter insertion site to minimize infection risk, avoiding femoral vein when possible (except for hemodialysis and some pediatric patients) 2
• Use ultrasound guidance for catheter insertion, particularly for internal jugular and femoral vein catheterization 2
• Document insertion procedure using standardized forms to ensure compliance with best practices 4

Maintenance Bundle Components

• Review necessity of central line daily and remove promptly when no longer needed 2
• Replace transparent semipermeable dressings every 7 days and gauze dressings every 2 days 1
• Replace any dressing immediately if soiled, loose, or damp 1
• Use chlorhexidine-impregnated dressings for patients over two months of age 1, 3
• Use gauze dressings instead of transparent dressings if there is significant bleeding or drainage until resolved 1
• Disinfect catheter hubs, needleless connectors, and injection ports before accessing using either:
  • Passive disinfection with antiseptic-containing caps (containing 70% isopropyl alcohol, iodinated alcohol, or chlorhexidine) 1
  • Active mechanical disinfection with 2% chlorhexidine in 70% alcohol 3
• Provide daily chlorhexidine bathing for ICU patients over two months of age 2, 3

System-Level Interventions

• Mandate education and competency assessments for all healthcare professionals involved in central line insertion and maintenance 1, 2
• Conduct periodic assessments of healthcare professionals' knowledge and adherence to preventive measures 1
• Implement a credentialing process to verify competence in central line insertion and maintenance 1
• Monitor CLABSI rates using standardized CDC/NHSN definitions and calculate as number of CLABSIs per 1,000 central line-days 1, 2
• Stratify CLABSI rates by unit type and compare with historical data and benchmarks 1
• Maintain appropriate nurse-to-patient ratios and limit use of float nurses in ICUs 1, 2

Additional Recommendations for Resource-Limited Settings

• Use collapsible closed-system intravenous fluid containers instead of open-system rigid containers 1, 2
• Use needleless connectors instead of three-way stopcocks, with positive displacement connectors preferred over negative or neutral displacement types 1, 2

Practices to Avoid

• Do not routinely replace central lines or arterial catheters 1, 2
• Avoid using systemic antimicrobial prophylaxis during short-term tunneled catheter insertion or while catheters are in place 1, 2
• Do not use chlorhexidine in infants younger than two months due to risk of skin injuries 2, 3

Implementation Strategies

• Use quality improvement methodologies like Plan-Do-Study-Act cycles 5
• Conduct direct observation audits rather than documentation audits for more accurate compliance assessment 6
• Provide regular feedback on CLABSI rates and bundle compliance to all stakeholders 7, 6
• Extend CLABSI prevention efforts beyond ICUs to include all units where central lines are used 7, 4

Common Pitfalls to Avoid

• Failing to allow antiseptic solutions to completely dry before inserting catheters or applying dressings 3
• Neglecting to disinfect catheter hubs and injection ports before accessing 1
• Inconsistent documentation of central line insertion practices 4
• Delayed removal of unnecessary central lines 2
• Inadequate training of healthcare workers on evidence-based practices 8