Appendix 2. Central Line-Associated Bloodstream Infections Fact Sheet
Tools for Reducing Central Line-Associated Blood Stream Infections
Central line-associated bloodstream infections (CLABSIs) result annually in:
- 84,551 to 203,916 preventable infections.
- 10,426 to 25,145 preventable deaths.
- $1.7 to $21.4 billion avoidable costs.
The following interventions decrease the risk for CLABSIs
- Use appropriate hand hygiene.
- Use chlorhexidine for skin preparation.
- Use full-barrier precautions during central venous catheter (CVC) insertion.
- Avoid using the femoral vein for CVCs in adult patients.
- Remove unnecessary CVCs.
Umscheid CA, Mitchell MD et al. Estimating the proportion of reasonably preventable hospital-acquired infections and associated mortality and costs. Infect Control Hosp Epidemiol. 2011 Feb;32(2):101-114.
Our current performance
Based on our current performance, our opportunity to improve the care that we provide to patients if we eliminated CLABSIs in our unit:*
Current CLABSI rate:
Excess intensive care unit days/year:
* This data may be calculated using the CLABSI Opportunity Estimator at http://www.hopkinsmedicine.org/quality_safety_research_group/our_projects/stop_bsi/toolkits_resources/
clabsi_estimator.html. The opportunity estimator uses current evidence from multiple studies, and the list of references can be found on the opportunity estimator Web site.
The following information is from the 2008 Society for Healthcare Epidemiology of America and Infectious Disease Society of America Practice Recommendation: Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals. (Infect Control Hosp Epidemiol 2008;29:S22-S30.)
Each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact. Category A-I recommendations are strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
Use appropriate hand hygiene
Bottom line: Proper hand hygiene is required before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. In addition, the use of gloves does not obviate the need for hand hygiene. Category B-II
Since 1977, at least seven prospective studies have shown that improvement in hand hygiene significantly decreases a variety of infectious complications. Proper hand hygiene procedures can be achieved through the use of either a waterless, alcohol-based product or antibacterial soap and water with adequate rinsing. Compared with peripheral venous catheters, CVCs carry a substantially greater risk for infection; therefore, the level of barrier precautions needed to prevent infection during insertion of CVCs should be more stringent than proper hand hygiene alone.
Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet. 2000 Oct 14;356(9238):1307-1312.
Larson EL. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995 Aug;23(4):251-269.
Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. Am J Infect Control. 2005 Sep;33(7):392-397.
Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002 Oct 25;51(RR-16):1-45, quiz CE1-4.
Yilmaz G, Koksal I, Aydin K, et al. Risk factors of catheter-related bloodstream infections in parenteral nutrition catheterization. J Parnter Enteral Nutr. 2007 Jul-Aug;31(4):284-287.
Use chlorhexidine for skin preparation
Bottom line: Disinfect clean skin with an appropriate antiseptic before catheter insertion and during dressing changes. An alcoholic chlorhexidine solution containing a concentration greater than 0.5 percent is preferred. Category A-I
In a study from 1991, preparation of central venous and arterial sites with a 2 percent aqueous chlorhexidine gluconate lowered blood stream infection rates compared with site preparation with 10 percent povidone-iodine or 70 percent alcohol. Since that time, there has been growing evidence that chlorhexidine-containing skin preparation is superior to other options. A meta-analysis from 2002 that pooled results of these studies demonstrated use of a chlorhexidine-containing preparation decreased central catheter-related infections by 49 percent relative to povidone-iodine preparations. Because a smaller effect of chlorhexidine was seen in studies using a 0.5 percent concentration of chlorhexidine, preparations with greater concentrations are recommended.
Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters. Lancet. 1991 Aug 10;338(8763):339-343.
Chaiyakunapruk N, Veenstra DL, Lipsky BA, et al. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002 Jun 4;136(11):792-801.
Humar A, Ostromecki A, Direnfeld J, et al. Prospective randomized trial of 10% povidone-iodine versus 0.5% tincture of chlorhexidine as cutaneous antisepsis for prevention of central venous catheter infection. Clin Infect Dis. 2000 Oct;31(4):1001-1007. Epub 2000 Oct 25.
Use full-barrier precautions during CVC insertion
Bottom line: Maintain aseptic technique for the insertion of intravascular catheters. Category A-I
Maximal sterile barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape) during the insertion of CVCs substantially reduces the incidence of CLABSI compared with standard precautions (e.g., sterile gloves and small drapes).
Mermel LA, McCormick RD, Springman SR, et al. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med. 1991 Sep 16;91(3B):197S-205S.
Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994 Apr;15(4 Pt 1):231-238.
Hu KK, Lipsky BA, Veenstra DL, et al. Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review. Am J Infect Control. 2004 May;32(3):142-146.
Young EM, Commiskey ML, Wilson SJ. Translating evidence into practice to prevent central venous catheter-associated bloodstream infections: a systems-based intervention. Am J Infect Control. 2006 Oct;34(8):503-506.
Avoid using the femoral vein for CVCs in adult patients
Bottom line: Use of the femoral site is associated with greater risk of infection and deep venous thrombosis in adults. Category A-I
The site at which a catheter is placed influences the subsequent risk for catheter-related infection and noninfectious complications. For adults, lower extremity insertion sites are associated with a higher risk for infection than are upper extremity sites. As a result, authorities recommend that the femoral vein be avoided. Place CVCs in an alternative site to reduce the risk for infection. The risk of noninfectious complications should be assessed on an individual basis when determining which site to place the CVC.
Lorente L, Henry C, Martín MM, et al. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005;9(6):R631-635. Epub 2005 Sep 28.
Merrer J, De Jonghe B, Golliot F, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001 Aug 8;286(6):700-707.
Goetz AM, Wagener MM, Miller JM, et al. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998 Nov;19(11):842-845.
Remove unnecessary CVCs
Bottom line: Promptly remove any intravascular catheter that is no longer essential. Category A-II
One of the most effective strategies for preventing CLABSIs is to eliminate or at least reduce exposure to CVCs. The decision regarding the need for a catheter is complex, however, and difficult to standardize into a practice guideline. Nonetheless, to reduce exposure to CVCs, the multidisciplinary team should adopt a strategy to systematically evaluate daily whether any catheters or tubes can be removed.
Lederle FA, Parenti CM, Berskow LC, et al. The idle intravenous catheter. Ann Intern Med. 1992 May 1;116(9):737-738.
Parenti CM, Lederle FA, Impola CL, et al. Reduction of unnecessary intravenous catheter use. Internal medicine house staff participate in a successful quality improvement project. Arch Intern Med. 1994 Aug 22;154(16):1829-1832.