1. Definition.

The definition of central line-associated blood-stream infections (CLABSI) are systemic infections with the central venous catheter (CVC) is its source and when other sites of infection have been excluded (i.e. the isolation of the same microorganism from blood cultures and the CVC in significant numbers) [1]. CVCs are colonized by microorganisms on either the endoluminal or the external catheter surface beneath the skin and originate from microorganisms colonizing the patient’s skin at the insertion site or the hands of the staff during insertion or contaminating the hub during care interventions. Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are the microorganisms most frequently implicated in CR-BSI. Other microorganisms commonly involved include Staphylococcus aureus, Candida spp and enterococci.

2. Burden of disease.

CLABSI represents 10% of all healthcare associated infections (HAIs) and are the fourth most common HAIs in acute care hospitals in Europe according to the ECDCs annual report from 2008. The prevalence of CLABSI in intensive care is higher and represents 30% of HAIs, being the second most common type of infection after respiratory infections in intensive care settings. The incidence of CLABSI is estimated to 2.7/1000 catheter days and the literature suggests that up to 70% of CLABSI could be prevented if adequate measures are undertaken [2]. In the most recent national prevalence survey in the UK, the Health Protection Agency reported that the prevalence of CLABSI was 0.5%, accounting for 7.3% of the HAIs detected. Mortality and morbidity from CLABSI are substantial and is costly for the health care system since CLABSI increase antibiotic use and length of stay in intensive care and the hospital. It is estimated that each year in the United States, central venous catheters may cause 80,000 catheter-related bloodstream infections and, as a result, up to 28,000 deaths among patients in intensive care units (ICUs) [3]. In a study from Spain the attributable mortality from CLABSI in intensive care was 10% and the medium length of stay was 13 days longer for patients with CLABSI compared to controls [4].

3. How to prevent - specific requirements.

General conditions must be met to prevent HAIs described elsewhere regarding education of staff, surveillance and infrastructure. The following recommendations are based on three recent guidelines [5-7].

A. Before insertion:

  • indication: avoid unnecessary CVC insertion by providing access to an evidence-based list of indications;
  • selection of site: select the most appropriate site for every patient. Choose subclavian veins before jugular and femoral veins when the catheter is placed under planned and controlled conditions. Use ultrasound guidance for jugular vein. Avoid femoral veins;
  • type of catheter material: polytetrafluoroethylene (Teflon) and polyurethane catheters have been associated with fewer infections than catheters made of polyvinyl chloride or polyethylene. The choice of multi-lumen or single lumen catheter is still debatable. Use all-inclusive kits;
  • skin asepsis before insertion: use alcoholic solution (70% isopropanol) containing chlorhexidine (0.5%) for skin preparation before insertion.

B. Principles for insertion:

  • ensure maximum aseptic technique during insertion: the person inserting the catheter should wear a head cap, face mask, sterile body gown and sterile gloves, and use a full-size sterile drape. Use a checklist to ensure that aseptic technique is maintained. Another healthcare personnel person than the inserter should observe and document the insertion procedure. These healthcare personnel should be empowered to stop the procedure if breaches in aseptic technique are observed;
  • choose the right dressing for the insertion site.

c. Principles for maintenance:

  • catheter care and catheter site care: daily inspection of CVC site;
  • hand hygiene and aseptic technique during care and maintenance and accessing the system;
  • disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter;
  • remove nonessential catheters: assess the need for continued intravascular access on a daily basis during multidisciplinary rounds;
  • replacement strategies: routinely change of intravascular devises does not prevent CLABSI.

References.

  1. O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recommendations and reports: Morbidity and mortality weekly report Recommendations and reports/Centers for Disease Control. 2002;51(Rr-10):1-29.
  2. Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infection control and hospital epidemiology. 2011;32(2):101-14.
  3. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. The New England journal of medicine. 2006;355(26):2725-32.
  4. Olaechea PM, Palomar M, Alvarez-Lerma F, Otal JJ, Insausti J, Lopez-Pueyo MJ. Morbidity and mortality associated with primary and catheter-related bloodstream infections in critically ill patients. Revista espanola de quimioterapia : publicacion oficial de la Sociedad Espanola de Quimioterapia. 2013;26(1):21-9.
  5. O'Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Summary of recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2011;52(9):1087-99.
  6. Elliott T, Timsit JF. epic3: guidelines for preventing infections associated with the use of intravascular access devices. The Journal of hospital infection. 2014;87(3):182.
  7. 7.Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infection control and hospital epidemiology. 2014;35(7):753-71.