Central Line–Associated Bloodstream Infections: Prevention and Management
Section snippets
Definitions
To understand the literature one must understand the terminology used to describe different types of catheters. A catheter can be defined by the type of vessel cannulated (eg, peripheral vein, central vein, artery); its planned duration (eg, short-term vs permanent); its site of insertion (eg, for central venous catheters: subclavian, femoral, internal jugular, or peripherally inserted central catheter [PICC]); the catheter’s pathway from skin to vessel (eg, tunneled vs nontunneled); and
Prevalence, incidence, and impact of CLA-BSIs
In a 1-day point prevalence study during 1992 of 10,038 patients in 1417 European intensive care units (ICUs), Vincent and colleagues7 reported that 12% had a bloodstream infection. A follow-up 1-day point prevalence study during 2007 of 13,796 adult patients in 1265 ICUs from 75 countries revealed that 15.1% had a bloodstream infection.8 The prevalence of CLA-BSIs has not been determined but in the United States, it has been estimated that there are approximately 80,000 CLA-BSIs per year in
Pathogens
The pathogens causing nosocomial bloodstream infections and their associated mortality have been described in an analysis of 49 United States hospitals in the SCOPE surveillance system (Fig. 3).16 The top 3 pathogens were all gram-positive cocci (ie, coagulase-negative Staphylococcus, Staphylococcus aureus, and Enterococcus spp). The SENTRY system monitored both health care- and community-acquired bloodstream infections from a sample of hospitals worldwide. Their data revealed that S aureus was
Pathogenesis
Colonization of a central venous catheter is a prerequisite for infection.21 Colonization most commonly occurs via migration of bacteria along the skin-catheter interface (extraluminal route) or via contamination of a hub (endoluminal route). For short-term use central venous catheters (ie, duration less than 7–10 days), the skin around the catheter insertion site is the most common source of organisms.21, 22 For long-term use central venous catheters, the most common source of organisms are
Risk factors for CLA-BSI
Independent risk factors for CLA-BSI reported in 2 or more published studies have included the following: (1) prolonged hospitalization before catheterization, (2) prolonged duration of catheterization, (3) heavy microbial colonization at the insertion site, (4) heavy microbial colonization of the catheter hub, (5) internal jugular catheterization, (6) neutropenia, (7) premature birth, (8) total parenteral nutrition through the catheter, and (9) substandard care of the catheter (eg, excessive
Basic Recommendations
Several guidelines and reviews have provided recommendations for the prevention of CLA-BSIs.31, 32, 33, 34, 35, 36 These recommendations are based on studies demonstrating a risk with failure to follow the recommendations as well as studies demonstrating effectiveness of the recommended procedures to reduce the risk of CLA-BSI. Recommendations of the most current guidelines from the Society of Healthcare Epidemiologists of America (SHEA) and the Infectious Disease Society of America (IDSA) are
Bloodstream Infections
In evaluating a new fever in an ICU patient, blood cultures should be obtained when clinical evaluation does not strongly suggest a noninfectious source.104 Blood cultures should also be obtained when bacteremia/fungemia is suspected in non-ICU patients with a fever or other signs of sepsis. Cultures should always be obtained before the initiation of antibiotics.105 Before obtaining a blood culture from a peripheral vein, skin disinfection should preferentially be performed with 2%
Surveillance of CLA-BSI
A consensus guideline recommends that all hospitals measure their CLA-BSI rate using the definitions developed by the NHSN.35 The numerator consists of the number of CLA-BSIs in each unit assessed. The denominator consists of total number of catheter days in each unit assessed. This ratio (ie, CLA-BSI/number of catheter days) is multiplied by 1000 so that the measure is expressed as number of CLA-BSIs per 1000 catheter days. The CDC recommends that surveillance should be undertaken in the
General Recommendations
The management of CLA-BSI has been recently reviewed (Box 2).105, 113, 135, 136 If the patient has severe sepsis or septic shock, additional therapy is warranted.137 The following recommendations for management are largely based on the most current IDSA guideline.105 Empiric therapy is often initiated for suspected CLA-BSI. The initial choice of antibiotics depends on the patient’s risk factors for infection, underlying diseases, and likely pathogens associated with the specific intravascular
Summary
Central venous access is an important treatment modality in the current management of critically ill patients or those requiring long-term venous access (eg, hemodialysis, chemotherapy). Recent studies suggest that by strict adherence to current guidelines for insertion and maintenance, the incidence of CLA-BSI can be dramatically reduced. Proper diagnosis and treatment of CLA-BSI can in some cases allow potential catheter retention, as well as reduce the morbidity and mortality associated with
References (138)
- et al.
Systematic review of economic analyses of health care-associated infections
Am J Infect Control
(2005) Prevention of central venous catheter-related infections: what works other than impregnated or coated catheters?
J Hosp Infect
(2007)- et al.
CDC definitions for nosocomial infections, 1988
Am J Infect Control
(1988) - et al.
National Healthcare Safety Network (NHSN) report, data summary for 2006 through 2007, issued November 2008
Am J Infect Control
(2008) - et al.
Occurrence and antimicrobial resistance pattern comparisons among bloodstream isolates from the SENTRY antimicrobial surveillance program (1997–2202)
Diagn Microbiol Infect Dis
(2004) - et al.
Age-related changes in pathogen frequency and antimicrobial susceptibility of bloodstream isolates in North America SENTRY Antimicrobial Surveillance Program, 1997–2000
Int J Antimicrob Agents
(2002) - et al.
An attachable silver-impregnated cuff for prevention of infection with central venous catheters: a prospective randomized multicenter trial
Am J Med
(1988) - et al.
Relevance of the catheter hub as a portal for microorganisms causing catheter-related infections
Nutrition
(1997) - et al.
Contamination of intravenous fluids: a continuing cause of hospital bacteremia
Am J Infect Control
(2010) - et al.
Rate, risk factors and outcomes of catheter-related bloodstream infection in a paediatric intensive care unit in Saudi Arabia
J Hosp Infect
(2006)
The risk of bloodstream infection in adults with different intravascular devices; a systematic review of 200 published prospective studies
Mayo Clin Proc
Catheter-related bloodstream infection
Surg Clin North Am
Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina
Am J Infect Control
Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review
Am J Infect Control
Translating evidence into practice to prevent central-venous catheter-associated bloodstream infections: a systems-based intervention
Am J Infect Control
Prospective randomized trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial catheters
Lancet
Comparison of the microbial barrier properties of a needleless and a conventional needle-based intravenous access system
Am J Infect Control
A randomized, prospective clinical trial to access the potential infection risk associated with the PosiFlow needleless connector
J Hosp Infect
Mupirocin resistance in coagulase-negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters
J Hosp Infect
Anti-infective-treated central venous catheters for total parental nutrition or chemotherapy: a systematic review
J Hosp Infect
In vitro exposure of bacteria to antimicrobial impregnated-central venous catheters does not directly lead to the emergence of antimicrobial resistance
Chest
Antibiotic-coated hemodialysis catheters for the prevention of vascular catheter-related infections: a prospective, randomized study
Am J Med
A meta-analysis of hemodialysis catheter lock solutions in the prevention of catheter-related infection
Am J Kidney Dis
Estimating health care-associated infections and deaths in U.S. hospitals, 2002
Public Health Rep
The impact of hospital-acquired bloodstream infections
Emerg Infect Dis
Selected aspects of the socioeconomic impact of nosocomial infections: morbidity, mortality, costs, and prevention
Infect Control Hosp Epidemiol
Underresourced hospital infection control and prevention programs: penny wise, pound foolish?
Infect Control Hosp Epidemiol
Nosocomial infection rates in adult and pediatric intensive care units in the United States
Am J Med
The prevalence of nosocomial infection in intensive care units in Europe
JAMA
International study of the prevalence and outcomes of infection in intensive care units
JAMA
Surveillance of nosocomial infections
National Nosocomial Infection Surveillance (NNIS) system report, data summary from January 1992 through June 2004, issued October 2004
Am J Infect Control
Comparison of hospitalwide surveillance and targeted intensive care unit surveillance of healthcare-associated infections
Infect Control Hosp Epidemiol
The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention
Nosocomial bloodstream infections in United States hospitals: a three-year analysis
Clin Infect Dis
Antimicrobial-resistant pathogens associated with healthcare-associated infections: annual summary of data reported to the National Healthcare Safety Network at the Centers for Disease Control and Prevention, 2006–2007
Infect Control Hosp Epidemiol
Increasing prevalence of antimicrobial resistance in intensive care units
Crit Care Med
Skin versus hub cultures to predict colonization and infections of central venous catheter in intensive care patients
Infection
A prospective study of the catheter hub as the portal of entry for microorganisms causing catheter-related sepsis in neonates
J Infect Dis
Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units
Infect Control Hosp Epidemiol
Central venous catheter-related infection in a prospective and observational study of 2,595 catheters
Crit Care
Central venous access sites for the prevention of venous thrombosis, stenosis and infection in patients requiring long-term intravenous therapy
Cochrane Database Syst Rev
A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters
Medicine
Guideline for the prevention of intravascular catheter-related infections
Clin Infect Dis
Guidelines on the insertion and management of central venous access devices in adults
Int J Lab Hematol
Catheter-related bloodstream infections in intensive care units: a systematic review with meta-analysis
J Adv Nurs
Strategies to prevent central line-associated bloodstream infections in acute care hospitals
Infect Control Hosp Epidemiol
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
MMWR Recomm Rep
Risk factors of catheter-related bloodstream infections in parenteral nutrition catheterization
JPEN J Parenter Enteral Nutr
Eliminating catheter-related bloodstream infections in the intensive care unit
Crit Care Med
Cited by (52)
Preventing Central Line Blood Stream Infections in Critical Care Patients
2021, Critical Care Nursing Clinics of North AmericaOncologic Emergencies: The Fever With Too Few Neutrophils
2019, Journal of Emergency MedicineInfectious Disease Emergencies in Oncology Patients
2018, Emergency Medicine Clinics of North AmericaCitation Excerpt :Risk factors that increase the risk of developing a CRBSI include prolonged hospitalization before catheter placement, duration of catheterization, neutropenia, total parenteral nutrition, and heavy microbial colonization of the catheter insertion site or hub.35 Subcutaneous ports are associated with a lower risk of infection.35 Despite the presence of a CVC, the catheter should remain the last consideration on the list of likely sources of systemic infection.
Back to Basics: Sterile Technique
2017, AORN JournalCitation Excerpt :Perioperative team members should place sterile drapes not only on the patient but on equipment and furniture used in the sterile field and should handle the drapes in a manner that prevents them from becoming contaminated. Perioperative team members should also use sterile drapes when placing central venous catheters and peripherally inserted central catheters and when performing guidewire exchanges.14,15 The top, bottom, and sides of any unsterile equipment (eg, a Mayo stand) must be covered with sterile drapes before a team member brings the equipment to the sterile field.
Staphylococcus aureus Vaccines
2017, Plotkin's Vaccines