What are the recommended strategies for preventing and treating central line‑associated bloodstream infections (CLABSI) in patients with a central venous catheter?

CLABSI Prevention and Treatment

Primary Prevention Strategy

Implement a comprehensive insertion and maintenance bundle combining maximal sterile barrier precautions, >0.5% chlorhexidine-alcohol skin antisepsis, optimal catheter site selection (subclavian preferred over jugular or femoral in adults), and daily assessment of catheter necessity—this bundled approach has demonstrated sustained reductions in CLABSI rates and represents the cornerstone of prevention. 1

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Catheter Insertion Bundle (Critical Prevention Phase)

Site Selection Algorithm

• First choice: Subclavian vein in adults for non-tunneled CVCs 1
• Avoid: Femoral vein in adults (highest infection risk) 1
• Exception: Avoid subclavian in hemodialysis patients and advanced kidney disease (risk of stenosis) 1
• Use ultrasound guidance when available to reduce mechanical complications and cannulation attempts 1

Maximal Sterile Barrier Precautions (Non-Negotiable)

• Sterile gloves, sterile gown, mask, cap, and full-body sterile drape 1, 2
• Pitfall: Omitting any single component of maximal barrier precautions significantly increases CLABSI risk 1, 3

Skin Antisepsis Protocol

• Primary: >0.5% chlorhexidine preparation with alcohol 1
• Allow antiseptic to dry completely per manufacturer recommendations before catheter insertion 1
• Alternative (if chlorhexidine contraindicated): Povidone-iodine with alcohol 4
• Chlorhexidine adoption has increased from 69% to 91% in high-performing hospitals 5

Catheter Selection

• Use minimum number of lumens necessary for patient management 1
• Consider antimicrobial-impregnated catheters (chlorhexidine/silver sulfadiazine or minocycline/rifampin) if CLABSI rates remain elevated despite full bundle implementation and catheter expected to remain >5 days 1

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Catheter Maintenance Bundle (Ongoing Prevention)

Hand Hygiene (Most Critical Single Intervention)

• Perform hand hygiene immediately before and after every catheter manipulation 1, 4, 6
• Use alcohol-based hand rubs (superior to soap and water) 4
• This is the single most crucial nursing intervention to prevent CLABSI 6

Hub Disinfection Protocol

• Scrub catheter hubs, connectors, and injection ports with alcoholic chlorhexidine or 70% alcohol using mechanical friction for at least 15 seconds before each access 1, 4
• Repeat disinfection at disconnection 4
• Replace needleless connectors when administration sets are changed (no more frequently than every 72 hours) 1

Dressing Management

• Transparent semi-permeable dressing: Change every 7 days for short-term CVCs 1
• Gauze dressing: Change every 2 days 1
• Use gauze if patient is diaphoretic or site is bleeding/oozing 1
• Replace dressing immediately if damp, loosened, or visibly soiled 1

Chlorhexidine-Impregnated Sponge Dressings

• Use for temporary short-term catheters in patients >2 months of age if CLABSI rates remain elevated despite basic prevention measures 1
• Do not use topical antibiotic ointments on insertion sites (except dialysis catheters) due to risk of fungal infections and antimicrobial resistance 1

Daily Assessment Protocol

• Review catheter necessity daily—remove promptly when no longer essential 1
• Monitor insertion site visually during dressing changes or by palpation through intact dressing 1
• Instruct patients to report any catheter site changes or new discomfort immediately 1

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Additional High-Risk Interventions

Daily Chlorhexidine Bathing

• Use 2% chlorhexidine wash for daily skin cleansing in ICU patients 1
• Demonstrated reductions in CLABSI rates in adult and pediatric ICU populations 1

Catheter Securement

• Use sutureless securement devices to reduce infection risk 1

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Hemodialysis Catheter-Specific Care

Exit Site Care Protocol

• Examine exit site after hand hygiene 4
• Disinfect with alcohol-based chlorhexidine (>0.5%) for at least 60 seconds 4
• Alternatives: 10% povidone-iodine for 2-3 minutes or 70% alcohol 4

Topical Antimicrobial Application

• Apply povidone-iodine ointment or bacitracin/gramicidin/polymyxin B ointment at exit site after insertion and after each dialysis session 1, 4
• Critical caveat: Only use if ointment does not interact with catheter material per manufacturer 1, 4
• Alternative: Chlorhexidine disk (Biopatch) with Tegaderm dressing changed weekly 4

Connection/Disconnection Procedure

• Wear gloves and mask during all catheter handling 4
• Clamp catheter before removing cap 4
• Scrub hub with chlorhexidine or 70% alcohol for ≥15 seconds before connecting to dialysis machine 4

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Prophylactic Antimicrobial Lock Therapy

Indications (Highly Selective)

• Use only in patients with long-term catheters who have history of multiple CRBSI despite optimal aseptic technique 1, 7, 8
• Not for routine prophylaxis in general populations 1

Recommended Lock Solutions

• Vancomycin 5 mg/mL with heparin 2500-5000 IU/mL (for methicillin-resistant staphylococci) 8
• Gentamicin 1.0 mg/mL with heparin 2500 IU/mL (for gram-negative organisms) 8
• Taurolidine-heparin (DEFENCATH): FDA-approved for hemodialysis patients to reduce CLABSI incidence 9
  • Instill at conclusion of each HD session 9
  • Aspirate and discard before next HD session 9
  • Contraindicated in heparin-induced thrombocytopenia and heparin hypersensitivity 9

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Treatment of Active CLABSI

Catheter Removal Decisions

• Do not remove catheter based on fever alone 1, 4
• Mandatory removal for: S. aureus, Candida species, Pseudomonas species, exit site/tunnel infection, persistent symptoms >72 hours, or metastatic infection 7, 8
• Do not routinely replace CVCs to prevent infection 1
• Do not replace over guidewire if CLABSI suspected—remove and insert new catheter at different site 1

Antibiotic Lock Therapy for Catheter Salvage

• Use only with concurrent systemic antibiotics for 10-14 days 7, 8
• Indicated when: no exit site/tunnel infection, symptoms resolve within 2-3 days, no metastatic infection 7, 8
• Renew lock solution after every dialysis session 7
• Success rates vary: 87-100% for gram-negatives, 75-84% for coagulase-negative staphylococci, only 40-55% for S. aureus 7, 8

Systemic Antibiotic Dosing (Hemodialysis Patients)

• Vancomycin: 20 mg/kg loading dose during last hour of dialysis, then 500 mg during last 30 minutes of subsequent sessions 8
• Gentamicin: 1 mg/kg (max 100 mg) after each dialysis session 8
• Cefazolin: 20 mg/kg after dialysis (for MSSA after switching from vancomycin) 8

Post-Treatment Surveillance

• Obtain surveillance blood cultures 1 week after completing antibiotic course if catheter retained 7, 8

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Critical Pitfalls to Avoid

• Incomplete bundle implementation: Using only some components of maximal sterile barriers significantly increases infection risk 1, 3
• Femoral site selection in adults (highest infection risk) 1, 4
• Routine catheter replacement does not reduce infection and increases complications 1
• Systemic antibiotic prophylaxis at insertion is not recommended 1
• Antibiotic lock monotherapy for active CLABSI (must combine with systemic antibiotics) 7, 8
• Attempting catheter salvage with S. aureus or Candida CLABSI (remove catheter) 7, 8
• Emergency catheter placement: Replace within 48 hours when aseptic technique cannot be ensured 1

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Quality Monitoring

• Monitor CLABSI rates with regular auditing of hand hygiene compliance, vascular access care, exit site disinfection technique, and hub disinfection practices 4
• Only 21% of centers currently monitor CLABSI rates despite high-risk populations 3
• Implementation of comprehensive bundles has achieved 68% reduction in CLABSI cases and 42% reduction in CLABSI per 1000 catheter days 10