What are the best practices for preventing healthcare-associated infections in a preterm newborn with an umbilical catheter?

Best Practices for Preventing Healthcare-Associated Infections in Preterm Newborns with Umbilical Catheters

Remove umbilical catheters as soon as clinically feasible—umbilical artery catheters should optimally not remain beyond 5 days, and umbilical venous catheters can stay up to 14 days if managed aseptically, but emerging evidence suggests removal or replacement by day 7 may further reduce infection risk. 1, 2, 3

Catheter Duration and Removal Strategy

Umbilical Artery Catheters (UAC)

• Remove UACs within 5 days maximum or immediately when no longer needed 1, 2
• Immediate removal is mandatory if any signs of catheter-related bloodstream infection (CRBSI), vascular insufficiency to lower extremities, or thrombosis appear 1, 2
• Do not replace UACs once removed in the setting of infection or complications 1, 2

Umbilical Venous Catheters (UVC)

• UVCs can remain up to 14 days if managed aseptically, but recent evidence suggests removal or replacement with a peripherally inserted central catheter (PICC) by day 4-7 may reduce CLABSI rates 1, 2, 3
• Remove immediately if signs of CRBSI or thrombosis develop 1, 2
• Replace UVCs only if the catheter malfunctions, not routinely 1, 2

Clinical nuance: While CDC guidelines from 2002 allow UVCs up to 14 days, more recent 2022 evidence and updated Infusion Therapy Standards suggest limiting dwell time to 7-10 days, with consideration for PICC placement after day 4 if prolonged access is needed 1, 3. This represents evolving practice based on newer infection data.

Insertion Site Preparation

Antiseptic Selection by Age

• For neonates <2 months old: Use povidone-iodine with 2 minutes dry time before insertion 1
• Avoid tincture of iodine due to potential neonatal thyroid effects 1, 2
• For infants >2 months: Use 2% chlorhexidine gluconate/70% isopropyl alcohol scrub 1

Critical pitfall: Do not use chlorhexidine sponge dressings in neonates <7 days old or gestational age <26 weeks 1

Site Care and Maintenance

What TO DO:

• Perform hand hygiene with alcohol-based product or antiseptic soap before and after accessing the catheter 1
• Maintain strict aseptic technique during insertion, tubing changes, and catheter access ("scrub the hub") 1
• Add low-dose heparin (0.25-1.0 U/ml) to fluid infused through umbilical arterial catheters to prevent thrombosis 1, 2
• Keep all pressure monitoring components sterile and minimize manipulations 1

What NOT TO DO:

• Never use topical antibiotic ointments or creams on umbilical catheter insertion sites—this is a Category IA recommendation against use due to promotion of fungal infections and antimicrobial resistance 1, 2
• Do not administer dextrose-containing solutions or parenteral nutrition through pressure monitoring circuits 1

Administrative and System-Level Interventions

Essential Infrastructure

• Provide dedicated central line insertion and maintenance kits at the bedside 1
• Increase staff-to-patient ratios in the NICU to allow adequate time for proper catheter care 1
• Implement daily line necessity checklists to prompt early removal when no longer needed 1
• Establish continuous CLABSI monitoring with periodic feedback to staff 1

Staff Training Requirements

• Train and monitor staff competency in infection control practices and line insertion/maintenance skills 1
• Consider a dedicated central line team for catheter insertion 1
• Conduct root cause analysis for all CLABSI events 1

Special Considerations for Preterm Infants

Preterm newborns face uniquely elevated infection risk due to poor skin integrity, immature immune systems, prolonged hospitalization, and multiple invasive procedures 1, 4. The mortality from bloodstream infections in neonates reaches 21%, with increased length of stay by 23 days 1.

High-Risk Factors Requiring Enhanced Vigilance:

• Very low birth weight (<1500g) 1, 4
• Gestational age <26 weeks 1
• Prolonged catheter placement 4
• Intra-abdominal pathology or mucosal barrier injury 1

Monitoring and Early Detection

Daily Assessment Must Include:

• Inspection for periumbilical erythema, tenderness, or purulent discharge 2, 5
• Monitoring for systemic signs: fever, chills, hypotension without other apparent source 2
• Assessment for vascular insufficiency in lower extremities (for UACs) 1, 2
• Evaluation for catheter malfunction requiring replacement 1, 2

Common pitfall: Catheter malposition occurs frequently (up to 20% in some series) and requires ongoing vigilance during follow-up care, not just at insertion 6. Imaging confirmation of position is essential.

Bundle Approach Effectiveness

Implementation of care bundles in NICUs has shown a 60% reduction in CLABSI rates (rate ratio 0.40, CI 0.31-0.51, p<0.00001), though specific effective elements vary by setting 1. Unlike adult ICUs, pediatric and neonatal bundle outcomes have been more inconsistent, emphasizing the need for unit-specific protocols 1.