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Guidelines to Prevent Central Line
Associated Blood Stream Infections
© 2009
Why do I Need to
Complete this Orientation?
• Problem
Vascular access device (VAD) associated infections
increase morbidity, mortality, hospital length of stay (LOS)
and costs
Education of health care workers decreases health care
associated infections
• Intervention
Mandatory course to achieve standardization of infection
control practices during central vascular access device
(C-VAD) insertion
© 2009
Why do I Need to
Complete this Orientation? (Cont.)
• Outcome
– Education in another center1 achieved a 26% relative
reduction in central line infections & saved 1.3 million dollars
– Since implementation of this orientation, JHH central line
related bloodstream infection (CLABSI) rates have
decreased below the national average
1 Sheretz et al. Ann Intern Med. 2000;64:1-8
© 2009
• 90% of all blood stream infections are associated with C-VADs
• 400,000 CLABSIs occur per year in U.S.
• CLABSIs are
– 1) Associated with increased morbidity
– 2) Associated with mortality rates of 10% to 20%
– 3) Associated with prolonged hospitalization (mean of 7 days)
and increase in medical costs > $28,000
© 2009
National Nosocomial Infection
Surveillance (NNIS) Rates
• In 2003, NNIS (from the Centers for Disease Control &
Prevention {CDC}) reported the number of CLABSIs per
1000 catheter days based on nationwide intensive care
unit (ICU) surveillance
• Table 1 compares ICUs from one academic medical
center to the national benchmark CLABSI rates
© 2009
Table 1: CLABSI Rate
per 1000 Catheter Days
NHSN 90th
NHSN 50th
© 2009
Risk Factors for CLABSIs
• Site of insertion; subclavian vein poses less risk than
internal jugular or femoral vein2
• Multiple lumen catheters– increased tissue trauma predisposes to CLABSI
– more manipulation and contamination of multiple ports/hubs
• TPN and/or lipids
• Low nurse to patient ratio
© 2009
Merrer et al. JAMA. 2001;286:700-7
Risk Factors for CLABSIs (Cont.)
• Infection elsewhere (remote, ie UTI or wound) –
secondary source
• Colonization of catheter with organisms
• IV catheterization longer than 72 hours
• Inexperience of personnel inserting the C-VAD
• Use of stopcocks
© 2009
Process of
Catheter Related Infections
© 2009
Evidence Based JHH 5 Steps to
Preventing CLABSI
• Clean hands (waterless alcohol based hand
sanitizer or wash hands with soap and water)
• Select best insertion site
• Use proper skin preparation (chlorhexidine)
• Use maximal barrier precautions
• Remove catheter as soon as possible
© 2009
Hand Hygiene:
When and Where?
Wash hands with soap & water
or use a waterless hand sanitizer
Before and after invasive procedures
Between patients
After removing gloves
Before eating
After using the bathroom
If contamination is suspected
© 2009
Hand Hygiene Does Work!
↓Nosocomial Infection
↓Nosocomial Infection
↓Nosocomial Infection
↓MRSA Rates
© 2009
Infection Prevention
Waterless Hand Hygiene Steps:
• Coat all surfaces of your hands thoroughly
with waterless hand sanitizer, including
your palms, in between fingers and under
fingernails, backs of hands and around
• Rub your hands briskly until they feel
comfortably dry.
• It takes about 15 seconds, and no water or
towels are needed.
© 2009
Infection Prevention
Handwashing Steps:
1. Wet hands
2. Obtain soap
3. Lather for 10-15 seconds
4. Rinse hands
5. Turn off faucet handles
with paper towel
© 2009
C-VAD Site Selection
• Use the SUBCLAVIAN site unless medically
contraindicated (e.g. patient has an anatomic deformity,
coagulopathy, or has renal disease that may require dialysis)
© 2009
C-VAD Site Selection:
Special Considerations
• For patients on hemodialysis, National Kidney
Foundation 2000 Guidelines recommended against
the use of the subclavian vein for any VAD unless
use of the IJ vein is absolutely contraindicated. This
is due to the risk of subclavian vein stenosis
• If the IJ vein is chosen, use the right side to reduce
risk of non-infectious complications
© 2009
C-VAD Line Selection
• Use a single lumen C-VAD, unless multiple lumens are
absolutely necessary
• Consider a tunneled or implanted C-VAD for patients
requiring long-term access (> 30 days), or a PICC or
cuffed C-VAD for patients requiring therapy for >1 week
• Evaluate daily the need for C-VAD and remove when
not needed or change to a single lumen C-VAD when
© 2009
Aseptic Technique: Goals
• Remove transient organisms and soil from the skin
• Reduce number of resident microbial flora and inhibit
their rebound growth
• Create a sterile working surface that acts as a barrier
between the insertion site and any possible source of
© 2009
Aseptic Technique
• Prepare skin with antiseptic/detergent
Chlorhexidine 2% in 70% isopropyl alcohol
• Pinch wings on the “Chloraprep” applicator to pop
the ampule. Hold the applicator down to allow the
solution to saturate the pad. Press sponge against
skin, apply chlorhexidine solution using a back and
forth friction scrub for at least 30 seconds. Do not
wipe or blot
• Allow antiseptic solution time to dry completely
before puncturing the site (may take 2 minutes).
© 2009
Evidence supporting use of
Chlorhexidine: Skin Prep−Meta Analysis
Pooled RR
for BSI
Ann Intern Med. 2002;136:792-801
© 2009
Maximal Barriers Required
for C-VAD Insertion
• Use face mask, cap and sterile gloves
• Wear a sterile gown with neck snaps and wrap-around
ties properly secured
• Instruct anyone assisting you to wear the same barriers
• Drape the patient with a LARGE sterile drape that covers
the entire patient
© 2009
Maximal Barrier Precautions (MBR)
Decrease CLABSI Infections
Mermel / 1990
Raad / 1994
Catheter Type
OR for Infection without MBR
OR=odds ratio MBR= inserter washes hands and wears mask,
sterile gown, sterile gloves and patient’s head & body are
covered with a large, sterile drape
© 2009
Caveats: Catheter Insertion
• IV antimicrobial prophylaxis does not reduce CLABSI1
• Insertion of C-VADs through open
techniques/cutdown increases the risk of CLABSI
• Ensure adequate room to perform the procedure
without risk of contamination
1 Ranson.
© 2009
J Hosp Infect. 1990;15(1):95-102.
Post Insertion: C-VAD Care
• Antimicrobial ointments do not reduce the incidence of
• Apply a sterile dressing to the insertion site before the sterile
barriers are removed
• Transparent dressings are preferred to allow visualization of the
• If the insertion site is oozing, apply a gauze dressing instead of
a transparent dressing
• Replace C-VAD dressings when the dressing becomes damp,
loosened, soiled or after lifting the dressing to inspect the site
© 2009
Replacing CVADs
• Remove the line as soon as possible
• Routine C-VAD guidewire exchange or site rotation is not
• Guidewire exchange is acceptable for replacing a
malfunctioning catheter or downsizing a PA catheter to a CVC
• Patients who clearly have a CLABSI should not undergo
guidewire exchange
• Selected patients with suspected BSI and limited venous
access may have their catheter exchanged over a guidewire
and the catheter tip should be cultured
• Switch to a new set of sterile gloves before handling the new
© 2009
et al. Crit Care Med. 1990;18(10):1073-9 .
Suspected C-VAD Infections
Remove the C-VAD in a patient with proven CLABSI
(i.e., blood culture positive for a recognized pathogen
with no identified secondary source)
If a BSI is only suspected, or the C-VAD is not known to
be the source, or the C-VAD cannot be removed,
clinical judgment is necessary. Extensive, evidencebased guidelines exist for the diagnosis and treatment of
catheter-related infections1
1 Mermel
© 2009
et al. Clin Infect Dis. 2001;32(9):1249-72.
Suspected C-VAD Infections (Cont.)
• Draw two sets of blood cultures from a patient with new
episode of suspected C-VAD infection, preferably both sets
• It is not always necessary to remove the CVAD in a mildly ill
patient with unexplained fever
• If the catheter is the suspected source of the infection, it can
be changed over a wire and cultured. If the catheter culture
grows  15 colony forming units of organisms, remove it and
place at a different site
• Tailor antimicrobial therapy to the individual patient, based on
severity of illness, suspected pathogen, and presence of
complicating factors
© 2009
C-VAD Line Cultures: Indications
The utility of catheter cultures is controversial
Nonetheless, proper technique is imperative to evaluate
the data. The catheter tip may be submitted for semiquantitative culture if there is clinical suspicion of CLABSI
Routinely removed catheters should NOT be sent for
© 2009
C-VAD Line Cultures: Method
• Remove all dressings and cap off all hubs/ports, then
paint the site with antiseptic solution, and include within
the sterile field
• Remove C-VAD en-bloc. Under no circumstance should
catheters be cut prior to removal
• Remove the catheter aseptically, avoiding contact with
the patient’s skin and catheter tray
• Use sterile scissors (not the scalpel used to cut the CVAD
sutures) to cut a 5cm segment, including the tip and
place it into a culture container
© 2009
C-VAD Line Cultures:
• A catheter culture yield of 15 CFU, accompanied
by signs and/or symptoms of infection is consistent
with a catheter-related infection
• Do not give antibiotics based on a positive catheter
culture only, evaluate the clinical picture
© 2009
Blood Cultures
• Patients with a new episode of suspected catheterrelated infection should have two sets of peripheral
blood samples drawn for culture. In rare instances
where access for peripheral blood draws is limited, one
set may be drawn from the line and one percutaneously
© 2009
Peripheral Blood Cultures:
• Don sterile gloves and observe Standard Precautions
• Apply chlorhexidine 2% in 70% isopropyl alcohol (Chloraprep
Frepp) using a back and forth friction rub for at least 30 seconds
over a 5 cm area
• Allow solution time to dry completely before puncturing the skin
• Do not touch the venipuncture site after skin prep except with
sterile gloves
• Insert needle into vein and withdraw 20cc of blood (adults)
• Distribute the blood evenly between 2 culture bottles (10 cc per
bottle), taking care not to inject air into the anaerobic bottle
• Always send a second set of blood cultures from a separate
venipuncture site
© 2009
Arterial Line: Site Selection
• Radial artery is the preferred site
• Dorsalis pedis is an alternative
• Femoral sites have higher infection rates and risk of
• Brachial/maxillary sites are a last resort, due to lack of
collateral circulation
© 2009
Arterial Lines: Aseptic Technique
• As with C-VADs, always:
– Clean your hands with soap & water or waterless
hand cleaner
– Maintain Standard Precautions
– Perform a thorough skin preparation
– Use barrier protection
© 2009
Arterial Lines: Barriers
• For radial or dorsalis pedis sites, create a generous sterile
working surface using sterile drapes; wear sterile gloves
and a mask with face shield
• Femoral or axillary arterial catheters may increase the risk
of infection and require maximum barriers as with CVADs, including mask, sterile gloves, sterile gown and
large sterile drape
© 2009
With Special Thanks to All the
Contributors to this Effort:
Sean Berenholtz, M.D.
Roy Brower, M.D.
Raphe Consunji, M.D.
Sara Cosgrove, M.D.
Pamela Lipsett, M.D.
Trish Perl, M.D.
Peter Pronovost, M.D.
Lisa Cooper, R.N.
© 2009