Skip to main content Accessibility help
×
Home
Hostname: page-component-7f7b94f6bd-q7wkk Total loading time: 2.524 Render date: 2022-06-30T02:15:25.472Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true } hasContentIssue true

Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update

Published online by Cambridge University Press:  19 April 2022

Niccolò Buetti
Affiliation:
Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland University of Paris, Paris, France
Jonas Marschall
Affiliation:
Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States
Marci Drees
Affiliation:
ChristianaCare, Wilmington, Delaware, United States Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States
Mohamad G. Fakih
Affiliation:
Ascension Healthcare and Wayne State University School of Medicine, Detroit, Michigan, United States
Lynn Hadaway
Affiliation:
Lynn Hadaway Associates, Milner, Georgia, United States
Lisa L. Maragakis
Affiliation:
Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
Elizabeth Monsees
Affiliation:
Children’s Mercy Hospital, Kansas City, Missouri, United States University of Missouri–Kansas City School of Medicine, Kansas City, Missouri, United States,
Shannon Novosad
Affiliation:
Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
Naomi P. O’Grady
Affiliation:
National Institutes of Health, Bethesda, Maryland, United States
Mark E. Rupp
Affiliation:
University of Nebraska Medical Center, Omaha, Nebraska, United States
Joshua Wolf
Affiliation:
Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, United States
Deborah Yokoe
Affiliation:
University of California–San Francisco, San Francisco, California, United States
Leonard A. Mermel*
Affiliation:
Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States Rhode Island Hospital, Providence, Rhode Island, United States
*
Author for correspondence: Dr. Leonard A. Mermel, E-mail: lmermel@lifespan.org
Rights & Permissions[Opens in a new window]

Abstract

Type
SHEA/IDSA/APIC Practice Recommendation
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
Copyright
© The Author(s), 2022. Published by Cambridge University Press on behalf of The Society for Healthcare Epidemiology of America

Purpose

Previously published guidelines provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates the Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute-Care Hospitals published in 2014. Reference Marschall, Mermel and Fakih1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Summary of major changes

This section lists major changes from the Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute-Care Hospitals: 2014 Update, Reference Marschall, Mermel and Fakih1 including recommendations that have been added, removed, or altered. Recommendations are categorized as essential practices that should be adopted by all acute-care hospitals (in 2014 these were “basic practices,” renamed to highlight their importance as foundational for hospitals’ HAI prevention programs) or additional approaches that can be considered for use in locations and/or populations within hospitals when CLABSIs are not controlled after implementation of essential practices (in 2014 these were “special approaches”). See Table 1 for a complete summary of the recommendations contained in this document.

Table 1. Summary of Recommendations to Prevent CLABSI

Note. CLABSI, central line-associated bloodstream infection; CVC, central venous catheter; HCP, healthcare personnel; ICU, intensive care unit.

Essential practices

  • The subclavian vein is considered the preferable site for central venous catheter (CVC) insertion in the intensive care setting to reduce infectious complications. Previously, the primary recommendation was to avoid the femoral vein for access. Although this remains valid, it has been replaced by a positively formulated recommendation regarding the subclavian site.

  • The recommendation to use ultrasound guidance for catheter insertion is backed by better evidence than was available previously; however, the procedure itself may jeopardize the strict observation of sterile technique.

  • The use of chlorhexidine-containing dressings is now considered an “essential practice”; in the past, it was listed under special approaches that should only be employed if CLABSI rates remain high despite the implementation of basic practices.

  • Routine replacement of administration sets not used for blood, blood products, or lipid formulations can be performed at intervals of up to 7 days. Previously, this interval was no longer than 4 days.

Additional approaches

  • Antimicrobial ointment for the catheter site, which is geared toward the population of hemodialysis patients, has been moved to “additional practices” given the focus on a specific population.

  • Despite currently being supported by high-level evidence, antiseptic-containing caps remain an “additional practice” because they are not considered superior to the manual disinfection, an essential practice.

  • The importance of infusion teams has been highlighted by listing it under “additional practices” (previously considered unresolved).

  • Sutureless securement of catheters was not discussed in the previous version of this section.

Intended use

This document was developed following the process outlined in the Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents. 2 No guideline or expert guidance document can anticipate all clinical situations, and this document is not meant to be a substitute for individual clinical judgment by qualified professionals.

This document is based on a synthesis of evidence, theoretical rationale, current practices, practical considerations, writing-group consensus, and consideration of potential harm, where applicable. A summary list of recommendations is provided along with their relevant rationales (see Table 1).

Methods

SHEA recruited 3 subject-matter experts in the prevention of CLABSI to lead the panel of members representing the Compendium partnering organizations: SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, as well as representation by the Centers for Disease Control and Prevention (CDC).

SHEA utilized a consultant medical librarian, who worked with each panel to develop a comprehensive search strategy for PubMed and Embase (January 2012–July 2019; updated to August 2021). Articles’ abstracts were reviewed by panel members in a double-blind fashion using the abstract management software, Covidence (Melbourne, Australia), and subsequently reviewed as full text. The Compendium Lead Authors group voted to update the literature findings, and the librarian reran the search to update it to August 2021. Panel members reviewed the abstracts of these articles via Covidence and incorporated relevant references.

Recommendations resulting from this literature review process were classified based on the quality of evidence and the balance between desirable and potential for undesirable effects of various interventions (see Table 2). Panel members met via video conference to discuss literature findings; recommendations; quality of evidence for these recommendations; and classification as essential practices, additional approaches, or unresolved issues. Panel members reviewed and approved the document and its recommendations.

Table 2. Quality of Evidence a

a Based on the CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) “Update to the Centers for Disease Control and Prevention and the Healthcare Infection Control Practices Advisory Committee Recommendations Categorization Scheme for Infection Control and Prevention Guideline Recommendations” (October 2019), the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE), Reference Guyatt, Oxman and Vist265 and the Canadian Task Force on Preventive Health Care. 266

The Compendium Expert Panel, made up of members with broad healthcare epidemiology and infection prevention expertise, reviewed the draft manuscript after consensus had been reached by writing panel members.

Following review and approval by the Expert Panel, the 5 partnering organizations, stakeholder organizations, and the CDC reviewed the document. Prior to dissemination, the guidance document was reviewed and approved by the SHEA Guidelines Committee, the IDSA Standards and Practice Guidelines Committee, and the Boards of SHEA, IDSA, APIC, AHA, and The Joint Commission.

All panel members complied with SHEA and IDSA policies on conflict-of-interest disclosure.

Section 1: Rationale and statements of concern

Burden of outcomes associated with hospital-acquired CLABSI

  1. 1. Increased length of hospital stay Reference Digiovine, Chenoweth, Watts and Higgins3Reference Leistner, Hirsemann, Bloch, Gastmeier and Geffers6

  2. 2. Increased cost. The adjusted variable costs for patients with CLABSI were $32,000 (2010 US dollars) higher on average than for patients without CLABSI Reference Stevens, Geiger, Concannon, Nelson, Brown and Dumyati7

  3. 3. Increased morbidity and mortality Reference Ziegler, Pellegrini and Safdar8

Risk factors for CLABSI

  1. 1. Patients at risk for CLABSI in acute-care facilities are those with a CVC in place:

    1. a. Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters Reference Dube, Jacob and Zheng9,Reference Mermel10 ; the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with substantial risk (eg, pulmonary artery catheters with catheter introducers); and the fact that catheters are frequently placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods. Reference Maki, Kluger and Crnich11,12

    2. b. Non-ICU population: Although the primary focus of attention over the last 20 years has been the ICU setting, most CLABSIs occur in hospital units outside the ICU or in outpatients. Reference Marschall, Leone, Jones, Nihill, Fraser and Warren13Reference Rhee, Heung, Chen and Chenoweth17

  2. 2. Infection prevention and control efforts should include other vulnerable populations such as patients receiving hemodialysis through catheters, Reference Nguyen, Shugart and Lines18 intraoperative patients, Reference Loftus, Brown and Koff19 and oncology patients. Reference Zakhour, Chaftari and Raad20

  3. 3. In addition to CVCs, short-term peripheral catheters, Reference Mermel21 peripherally inserted central venous catheters (PICCs), midline catheters, and peripheral arterial catheters also carry a risk of infection. Reference O’Horo, Maki, Krupp and Safdar22

  4. 4. Independent risk factors for CLABSI (in at least 2 published studies) Reference Almuneef, Memish, Balkhy, Hijazi, Cunningham and Francis23Reference Timsit, Mimoz and Mourvillier45

    1. a. Prolonged hospitalization before catheterization

    2. b. Prolonged duration of catheterization

    3. c. Heavy microbial colonization at insertion site

    4. d. Heavy microbial colonization of the catheter hub

    5. e. Multilumen catheters

    6. f. Concurrent catheters

    7. g. Neutropenia

    8. h. Body mass index (BMI) >40

    9. i. Prematurity (ie, early gestational age)

    10. j. Reduced nurse-to-patient ratio in the ICU

    11. k. Parenteral nutrition

    12. l. Substandard catheter care (eg, excessive manipulation of the catheter)

    13. m. Transfusion of blood products (in children)

Section 2: Background on detection of CLABSI

Surveillance methods and definitions for CLABSI

  1. 1. Use consistent surveillance methods and definitions to allow comparison to benchmark data.

  2. 2. Refer to the National Healthcare Safety Network (NHSN) Patient Safety Component Manual for information on the appropriate surveillance methodology, including information about blood specimen collection and surveillance definitions of CLABSIs. The relevant chapter of the manual is “Chapter 4: Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-Central Line-Associated Bloodstream Infection).” 46

    1. a. Recent data suggest that interrater reliability using NHSN definitions is lower than expected. Reference Grooth, Timsit and Mermel47Reference Mayer, Greene, Howell, Ying, Rubin and Trick50 This may also affect the reliability of public reporting.

    2. b. The NHSN surveillance definition for CLABSI is different than the clinical definition for catheter-related bloodstream infection (CRBSI). The latter is subject to various factors (eg, laboratory capabilities, catheter removal, and submitting the catheter tip for culture). Reference Mermel, Allon and Bouza51 The evidence presented here includes studies that used either CLABSI or CRBSI as an outcome measure and the lesser accuracy of CLABSI may impact the validity of the evidence.

Section 3: Background on prevention of CLABSI

Summary of existing guidelines and recommendations

  1. 1. Several governmental, public health, and professional organizations have published evidence-based guidelines and/or implementation aids regarding the prevention of CLABSI including the following:

    1. a. Healthcare Infection Control Practices Advisory Committee (HICPAC), Centers for Disease Control and Prevention (CDC) Reference O’Grady, Alexander and Dellinger52,Reference O’Grady, Alexander and Burns53

    2. b. Institute for Healthcare Improvement (IHI) Reference Masse, Elkalioubie and Blazejewski54

    3. c. Agency for Healthcare Research and Quality, Making Health Care Safer Reference Saint55

    4. d. American Pediatric Surgical Association, Outcomes and Clinical Trials Committee Reference Huang, Chen and Abdullah56

    5. e. The Joint Commission 57

    6. f. APIC, Implementation Guide to Preventing Central Line-Associated Bloodstream Infections Reference Barnes, Olmsted and Monsees58

    7. g. Infusion Nurses Society, Infusion Nursing Standards of Practice Reference Gorski, Hadaway and Hagle59

  2. 2. The recommendations in this document focus on CVCs unless noted otherwise. These recommendations:

    1. a. Are not stratified based on the type of catheter (eg, tunneled, implanted, cuffed, non-cuffed catheter, dialysis catheter).

    2. b. May not be applicable in their entirety for prevention of bloodstream infections with other intravascular devices.

Infrastructure requirements

Facilities undertaking CLABSI interventions should have the following elements in place:

  1. 1. An adequately staffed infection prevention and control program responsible for identifying patients who meet the surveillance definition for CLABSI.

  2. 2. Infection prevention staff and, preferably, information technology support to collect and calculate catheter days as a denominator when computing rates of CLABSI and patient days to allow calculation of CVC utilization. Catheter days from information systems should be validated against a manual method, with a margin of error no greater than ±5%. 60Reference Woeltje, McMullen, Butler, Goris and Doherty62

  3. 3. Resources to provide appropriate education and training.

  4. 4. Adequate laboratory support for timely processing of specimens and reporting of results, as specified by the supervisor of the surveillance program.

Section 4: Recommended strategies to prevent CLABSI

Recommendations are categorized as either (1) essential practices that should be adopted by all acute-care hospitals or (2) additional approaches that can be considered in locations and/or populations within hospitals when CLABSIs are not controlled by use of essential practices. Essential practices include recommendations in which the potential to affect CLABSI risk clearly outweighs the potential for undesirable effects. Additional approaches include recommendations in which the intervention is likely to reduce CLABSI risk but there is concern about the risks for undesirable outcomes, recommendations for which the quality of evidence is low, recommendations in which cost-to-benefit ratio may be high, or recommendations in which evidence supports the impact of the intervention in select settings (eg, during outbreaks) or for select patient populations. Hospitals can prioritize their efforts by initially focusing on implementation of the prevention strategies listed as essential practices. If CLABSI surveillance or other risk assessments suggest ongoing opportunities for improvement, hospitals should consider adopting some or all of the prevention approaches listed as additional approaches. These can be implemented in specific locations or patient populations or can be implemented hospital-wide, depending on outcome data, risk assessment, and/or local requirements. Each infection prevention recommendation is given a quality of evidence grade (see Table 2).

Essential practices for preventing CLABSI recommended for all acute-care hospitals

Some of the following measures have been combined into a “prevention bundle” that focuses on catheter insertion. Reference Pronovost, Watson, Goeschel, Hyzy and Berenholtz63,64 Numerous studies have documented that use of such bundles is effective, sustainable, and cost-effective in both adults and children. Reference Pronovost, Watson, Goeschel, Hyzy and Berenholtz63,Reference Kim, Holtom and Vigen65Reference Ista, van der Hoven and Kornelisse68 Bundles are most likely to be successful if implemented in a previously established patient safety culture and their success depends on adherence to individual measures. Reference Richter and McAlearney69 However, data suggests that not all components of bundles may be necessary to achieve an effect on CLABSI rates. Reference Furuya, Dick, Perencevich, Pogorzelska, Goldmann and Stone70 After catheter insertion, maintenance bundles have been proposed to ensure optimal catheter care. Reference Guerin, Wagner, Rains and Bessesen71 More data are needed to determine which components of the maintenance bundle are essential in reducing risk. Reference Miller, Niedner and Huskins72,Reference O’Neil, Ball and Wood73

Before insertion

  1. 1. Provide easy access to an evidence-based list of indications for CVC use to minimize unnecessary CVC placement (Quality of Evidence: LOW)

  2. 2. Require education and competency assessment of healthcare personnel (HCP) involved in insertion, care, and maintenance of CVCs about CLABSI prevention (Quality of Evidence: MODERATE) Reference Sherertz, Ely and Westbrook74Reference Warren, Zack and Mayfield78

    1. a. Include the indications for catheter use, appropriate insertion and maintenance, the risk of CLABSI, and general infection prevention strategies.

    2. b. Ensure that all HCP involved in catheter insertion and maintenance complete an educational program on essential practices to prevent CLABSI before performing these duties. Reference Lobo, Levin and Oliveira79,Reference Cherry, Brown, Neal and Ben Shaw80 Periodic retraining with a competency assessment may be of benefit. 81

    3. c. Periodically assess HCP knowledge of and adherence to preventive measures.

    4. d. Require all HCP who insert a CVC to undergo a credentialing process (as established by the individual healthcare institution) to ensure their competency before independently inserting a CVC and aseptic technique for accessing and maintaining the CVC thereafter.

    5. e. Re-educate when an institution changes components of the infusion system that requires a change in practice (eg, when an institution’s change of the needleless connector requires a change in nursing practice).

    6. f. Use simulation training for proper catheter insertion and maintenance if available. Reference Barsuk, Cohen and Potts82Reference Ma, Brindle, Ronksley, Lorenzetti, Sauve and Ghali85

  3. 3. Bathe ICU patients >2 months of age with a chlorhexidine preparation on a daily basis (Quality of Evidence: HIGH) Reference Bleasdale, Trick, Gonzalez, Lyles, Hayden and Weinstein86Reference Afonso, Blot and Blot90

    1. a. In long-term acute-care hospitals (LTACHs), daily chlorhexidine bathing may also be considered as a preventive measure. Reference Munoz-Price, Hota, Stemer and Weinstein91

    2. b. The role of chlorhexidine bathing in non-ICU patients remains unclear. Reference Medina, Serratt, Pelter and Brancamp92,Reference Huang, Septimus and Kleinman93 One cluster-randomized study found a significant reduction in device-associated bacteremia with CHG bathing in this patient population Reference Huang, Septimus and Kleinman93 ; however, some of these patients also received methicillin-resistant Staphylococcus aureus (MRSA) decolonization, making it difficult to draw firm conclusions regarding CHG bathing alone. Several studies have suggested benefit among adult hematology-oncology patients; however, a similar reduction was not observed for pediatric patients with similar conditions. Reference Tien, Sheng and Shieh94,Reference Zerr, Milstone and Dvorak95 Accordingly, potential benefits and risks, such as increases in resistance and cost, need to be carefully considered.

    3. c. The safety and efficacy of routine use of chlorhexidine bathing in infants <2 months of postnatal age remains unclear. Reference Milstone, Bamford, Aucott, Tang, White and Bearer96 Although life-threatening skin injuries from CHG have been reported in very young or very preterm infants, they typically occur in infants with a birthweight <1,000 g who are <7 days postnatal age, and they appear rare in older infants. Reference Kieran, O’Sullivan, Miletin, Twomey, Knowles and O’Donnell97Reference Chandonnet, Toole and Young99

    4. d. Widespread use of chlorhexidine may be associated with decreased chlorhexidine susceptibility, although the clinical relevance of this finding is not well defined. Reference Kampf100

At insertion

  1. 1. In ICU and non-ICU settings, a facility should have a process in place, such as a checklist, to ensure adherence to infection prevention practices at the time of CVC insertion (Quality of Evidence: MODERATE) Reference Wichmann and Belmar Campos101

    1. a. Ensure and document adherence to aseptic technique

      1. i. Checklists have been suggested to ensure optimal insertion practices. If used, the documentation should be done by someone other than the inserter.

      2. ii. Observation of CVC insertion should be done by a nurse, physician, or other HCP who has received appropriate education (see above) to ensure that aseptic technique is maintained.

      3. iii. HCP should be empowered to stop the procedure if breaches in aseptic technique are observed.

  2. 2. Perform hand hygiene prior to catheter insertion or manipulation (Quality of Evidence: MODERATE) Reference Elgohari, Wilson, Saei, Sheridan and Lamagni102Reference van der Kooi, Sax and Pittet107

    1. a. Use an alcohol-based waterless product or soap and water.

      1. i. Use of gloves does not obviate hand hygiene.

  3. 3. The subclavian site is preferred to reduce infectious complications when the catheter is placed in the ICU setting (Quality of Evidence: HIGH) Reference Parienti, Mongardon and Megarbane33,Reference Merrer, De Jonghe and Golliot37,Reference Arvaniti, Lathyris, Blot, Apostolidou-Kiouti, Koulenti and Haidich108Reference Timsit, Bouadma and Mimoz110

    1. a. In the non-ICU setting, the risk of infection between the different sites remains unclear. Importantly, in emergent settings, ensuring life-saving vascular access in the fastest possible way may determine the choice of access site.

    2. b. In children and infants, femoral vein catheterization may be considered if upper body sites are contraindicated. Reference Ullman, Bernstein and Brown111 Tunneled femoral vein catheters, with an exit site outside the diaper area in the mid-thigh, may be safer and provide additional risk reduction. Reference Chau, Hernandez, Pimpalwar, Ashton and Kukreja112,Reference Gaballah, Krishnamurthy and Berman113

    3. c. Controversy exists regarding infectious and noninfectious complications associated with different short-term CVC access sites. Reference Parienti, Mongardon and Megarbane33 The risk and benefit of different insertion sites must be considered on an individual basis with regard to infectious and noninfectious complications. Reference Parienti, Mongardon and Megarbane33 Among others, this applies to patients currently receiving or likely to require hemodialysis in whom the subclavian site is avoided due to risk of stenosis.

    4. d. Do not use peripherally inserted central venous catheters (PICCs) as a strategy to reduce the risk of CLABSI. Risk of infection with PICCs in hospitalized patients approaches that of other CVCs. Reference Chopra, O’Horo, Rogers, Maki and Safdar114 However, the majority of CLABSIs due to PICCs occur in non-ICU settings. Reference Ajenjo, Morley and Russo115

    5. e. Midline catheters are increasingly being used as an alternative to CVCs for short-term vascular access, with some observational studies suggesting lower bloodstream infection risk associated with midline catheters versus PICCs Reference Swaminathan, Flanders, Horowitz, Zhang, O’Malley and Chopra116 and versus CVCs, Reference Mushtaq, Navalkele and Kaur117 respectively. Randomized controlled trials comparing the risk of bloodstream infections and other complications associated with these devices are needed.

  4. 4. Use an all-inclusive catheter cart or kit (Quality of Evidence: MODERATE) Reference Berenholtz, Pronovost and Lipsett118

    1. a. A catheter cart or kit that contains all necessary components for aseptic catheter insertion should be available and easily accessible in all units where CVCs are inserted.

  5. 5. Use ultrasound guidance for catheter insertion (Quality of Evidence: HIGH) Reference Karakitsos, Labropoulos and De Groot119,Reference Brass, Hellmich, Kolodziej, Schick and Smith120

    1. a. Ultrasound-guided internal jugular and femoral vein catheterization reduces the risk of noninfectious complications associated with CVC placement Reference Hind, Calvert and McWilliams121 but the use of ultrasound may lead to a breach in aseptic technique. Reference Buetti, Mimoz and Mermel122

    2. b. It is unclear whether ultrasound-guided subclavian vein insertion reduces risk of infectious complications.

  6. 6. Use maximum sterile barrier precautions during CVC insertion (Quality of Evidence: MODERATE) Reference Mermel, McCormick, Springman and Maki123Reference Lee, Jung and Choi128

    1. a. Use maximum sterile barrier precautions:

      1. i. A mask, cap, sterile gown, and sterile gloves are to be worn by all HCP involved in the catheter insertion procedure.

      2. ii. The patient is to be covered with a large (“full-body”) sterile drape during catheter insertion.

    2. b. These measures should also be followed when exchanging a catheter over a guidewire.

    3. c. A prospective, randomized study in surgical patients showed no additional benefit for maximum sterile barrier precautions Reference Ishikawa, Kiyama and Haga126 ; nevertheless, most available evidence suggests risk reduction with this intervention.

  7. 7. Use an alcoholic chlorhexidine antiseptic for skin preparation (Quality of Evidence: HIGH) Reference Mimoz, Lucet and Kerforne42,Reference Garland, Buck and Maloney129Reference Masuyama, Yasuda, Sanui and Lefor134

    1. a. Before catheter insertion, apply an alcoholic chlorhexidine solution containing at least 2% chlorhexidine gluconate to the insertion site.

      1. i. The antiseptic solution must be allowed to dry before making the skin puncture.

      2. ii. Alcoholic chlorhexidine for skin antisepsis to prevent CLABSI in NICU patients should be used when the benefits are judged to outweigh potential risk.

After insertion

  1. 1. Ensure appropriate nurse-to-patient ratio and limit use of float nurses in ICUs (Quality of Evidence: HIGH) Reference Fridkin, Pear, Williamson, Galgiani and Jarvis34,Reference Cimiotti, Haas, Saiman and Larson35

    1. a. Observational studies suggest that an adequate nurse-to-patient ratio must be maintained in ICUs where nurses are managing patients with CVCs and that the number of float nurses working in the ICU environment should be minimized.

  2. 2. Use chlorhexidine-containing dressings for CVCs in patients over 2 months of age (Quality of Evidence: HIGH) Reference Timsit, Mimoz and Mourvillier45,Reference Garland, Alex and Mueller135Reference Puig-Asensio, Marra, Childs, Kukla, Perencevich and Schweizer142

    1. a. It is unclear whether there is additional benefit with use of a chlorhexidine-containing dressing if daily chlorhexidine bathing is already established and vice-versa.

    2. b. For long-term catheters (eg, hemodialysis catheters) in well-healed access sites, it is unclear whether use of a chlorhexidine dressing reduces risk of infectious complications. Reference Camins, Richmond and Dyer140,Reference Righetti, Palmieri and Bracchi143,Reference Apata, Hanfelt, Bailey and Niyyar144

    3. c. For children under 2 months of age, use of chlorhexidine dressings remains unclear, particularly in very preterm or low birthweight infants. Reference Neri, Ravaioli, Faldella, Capretti, Arcuri and Patrizi98

  3. 3. For nontunneled CVCs in adults and children, change transparent dressings and perform site care with a chlorhexidine-based antiseptic at least every 7 days or immediately if the dressing is soiled, loose, or damp. Change gauze dressings every 2 days or earlier if the dressing is soiled, loose, or damp. (Quality of Evidence: MODERATE) Reference Maki, Stolz, Wheeler and Mermel145Reference Gavin, Webster, Chan and Rickard148

    1. a. Less frequent, clinically indicated dressing changes may be used for NICU patients or others at high risk of serious complications from catheter dislodgement. Reference Short149

    2. b. If there is excessive bleeding or drainage from the catheter exit site, use gauze dressings instead of transparent dressings until drainage resolves.

  4. 4. Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (Quality of Evidence: MODERATE) Reference Salzman, Isenberg and Rubin150Reference Soothill, Bravery, Ho, Macqueen, Collins and Lock154

    1. a. Before accessing catheter hubs, needleless connectors, or injection ports, vigorously apply mechanical friction with an alcoholic chlorhexidine preparation, or 70% alcohol. Alcoholic chlorhexidine may have additional residual activity compared to alcohol for this purpose and is therefore preferred. Reference Hong, Morrow, Sandora and Priebe155

    2. b. Apply mechanical friction for a minimum of 5 seconds to reduce contamination. Reference Rupp, Yu and Huerta156,Reference Simmons, Bryson and Porter157 It is unclear whether this duration of disinfection can be generalized to needleless connectors not tested in these studies.

    3. c. Monitor compliance with hub-connector-port disinfection because approximately half of such catheter components are colonized under conditions of standard practice. Reference Casey, Worthington, Lambert, Quinn, Faroqui and Elliott152,Reference Rupp, Yu and Huerta156,Reference Hankins, Majorant and Rupp158

  5. 5. Remove nonessential catheters (Quality of Evidence: MODERATE)

    1. a. Assess the need for continued intravascular access on a daily basis during multidisciplinary rounds. Remove catheters not required for patient care. Decreasing CVC utilization reduces CRBSI risk. Reference van der Kooi, Sax and Pittet159 However, reducing CVC utilization may result in increased use of other intravascular catheters with corresponding infection risk.

    2. b. Audits to determine whether CVCs are routinely removed after their intended use may be helpful. Reference Rotz and Sopirala160,Reference Cload, Day and Ilan161 Both simple and multifaceted interventions are effective at reducing unnecessary CVC use. Reference Seguin, Laviolle, Isslame, Coue and Malledant162,Reference Faruqi, Medefindt, Dutta, Philip, Tompkins and Carey163

  6. 6. Routine replacement of administration sets not used for blood, blood products, or lipid formulations can be performed at intervals up to 7 days (Quality of Evidence: HIGH) Reference Rickard, Marsh and Larsen164

    1. a. The optimal replacement of intermittently used administration sets is unresolved.

  7. 7. Perform surveillance for CLABSI in ICU and non-ICU settings (Quality of Evidence: HIGH) Reference Marschall, Leone, Jones, Nihill, Fraser and Warren13,Reference Gastmeier, Geffers and Brandt165,Reference Zingg, Sax and Inan166

    1. a. Measure unit-specific incidence of CLABSI (eg, CLABSI per 1,000 catheter days) and report the data on a regular basis to the units, physician and nursing leadership, and hospital administrators overseeing the units.

    2. b. Compare CLABSI incidence to historical data for individual units and to national rates (ie, NHSN). Reference Sunkesula, Kundrapu, Knighton, Cadnum and Donskey167

    3. c. Audit surveillance as necessary to minimize variation in interobserver reliability. Reference Niedner48,Reference Lin, Hota and Khan168

Additional approaches for preventing CLABSI

Several additional approaches are currently available for use. Perform a CLABSI risk assessment before considering implementation of any of these approaches, taking potential adverse events and costs into consideration. Although it is reasonable to evaluate the utility of technology-based interventions when CLABSI rates are above the institutional- or unit-based threshold, this is also an opportunity to review practices and consider behavioral changes that may be instituted to reduce CLABSI risk. These additional approaches are recommended for use in locations and/or populations within the hospital with unacceptably high CLABSI rates despite implementation of the essential CLABSI prevention strategies listed above. These measures may not be indicated if institutional goals have been consistently achieved.

  1. 1. Use antiseptic- or antimicrobial-impregnated CVCs (Quality of Evidence: HIGH in adult patients Reference Raad, Darouiche and Dupuis38,Reference Hanna, Benjamin and Chatzinikolaou39,Reference Wang, Tong and Liu169Reference Novikov, Lam, Mermel, Casey, Elliott and Nightingale171 and MODERATE in pediatric patients Reference Gilbert, Mok and Dwan172,Reference Lai and Yue173 )

    1. a. The risk of CLABSI is reduced with some currently marketed antiseptic-impregnated (eg, chlorhexidine-silver sulfadiazine) catheters and antimicrobial-impregnated (eg, minocycline-rifampin) catheters. Use such catheters under the following conditions:

      1. i. Hospital units or patient populations have a CLABSI rate above institutional goals despite compliance with essential CLABSI prevention practices. Some evidence suggests that use of antimicrobial CVCs, along with other preventive technologies, may have no additional benefit in patient care units that have already established a low incidence of catheter infections. Reference Cherry-Bukowiec, Denchev and Dickinson174,Reference Ullman, Paterson and Schults175

      2. ii. Patients have limited venous access and a history of recurrent CLABSI.

      3. iii. Patients are at heightened risk of severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices such as a prosthetic heart valve or aortic graft).

    2. b. Monitor patients for adverse effects such as anaphylaxis. Reference Guleri, Kumar, Morgan, Hartley and Roberts176

    3. c. Many studies investigating antimicrobial-impregnated catheters were performed before infection preventive bundles were routine. Whether such catheters have an impact on CLABSI in such settings remains unknown.

  2. 2. Use antimicrobial lock therapy for long-term CVCs (Quality of Evidence: HIGH)Reference Carratala, Niubo and Fernandez-Sevilla177Reference Sheng, Zhang and Li184

    1. a. Antibiotic and antiseptic locks are created by filling the lumen of the catheter with a supratherapeutic concentration of an antibiotic solution and leaving the solution in place until the catheter hub is re-accessed. Such an approach can reduce the risk of CLABSI. The optimal antimicrobial agent or combination of agents, their concentration, and duration of lock therapy are matters of ongoing research. Due to concerns regarding the potential for the emergence of resistance in exposed organisms, use antimicrobial locks as a preventative strategy for the following:

      1. i. Patients with long-term hemodialysis catheters who have a history of recurrent CLABSI. Reference Arechabala, Catoni and Claro185

      2. ii. Prophylaxis for patients with limited venous access and a history of recurrent CLABSI.

      3. iii. Patients who are at heightened risk of severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices such as a prosthetic heart valve or aortic graft).

    2. b. To minimize systemic toxicity, aspirate rather than flush the antimicrobial lock solution after the dwell time has elapsed. Reference Opilla, Kirby and Edmond186Reference Heng, Abdelkader and Diaconita189 The potential of adverse effects associated with ethanol locks should be carefully considered before use. Reference Mermel and Alang190,Reference Wolf, Connell and Allison191

  3. 3. Use recombinant tissue plasminogen activating factor (rt-PA) once weekly after hemodialysis in patients undergoing hemodialysis through a CVC (Quality of Evidence: HIGH) Reference Hemmelgarn, Moist and Lok192

  4. 4. Utilize infusion or vascular access teams for reducing CLABSI rates (Quality of Evidence: LOW) Reference Miller, Goetz, Squier and Muder193,Reference Taylor, Massaro and Williams194

    1. a. Studies have shown that an infusion/vascular access team responsible for insertion and maintenance of peripheral intravenous catheters reduces the risk of bloodstream infections Reference Soifer, Borzak, Edlin and Weinstein195 ; however, few studies have been performed regarding the impact of intravenous therapy teams on CLABSI rates. Reference Carr, Higgins, Cooke, Mihala and Rickard196

  5. 5. Use antimicrobial ointments for hemodialysis catheter insertion sites (Quality of Evidence: HIGH) Reference Levin, Mason, Jindal, Fong and Goldstein197Reference James, Conley, Tonelli, Manns, MacRae and Hemmelgarn201

    1. a. Apply polysporin “triple” (where available) or povidone-iodine ointment to hemodialysis catheter insertion if compatible with the catheter material.

    2. b. Ingredients in ointments may interact with the chemical composition of some catheters. Thus, ensure the selected ointment will not interact with the catheter material before any such product is applied to the catheter insertion/exit site. For example, ointments containing glycol should not be applied to insertion/exit sites of polyurethane catheters.

    3. c. Mupirocin ointment should not be applied to the catheter insertion site due to the risks of facilitating mupirocin resistance and the potential damage to polyurethane catheters.

  6. 6. Use an antiseptic-containing hub/connector cap/port protector to cover connectors (Quality of Evidence: MODERATE) Reference Oto, Imanaka, Konno, Nakataki and Nishimura202Reference Flynn, Larsen, Keogh, Ullman and Rickard208

    1. a. The utility of routinely disinfecting hub connectors and ports when using antiseptic-containing hub/connector cap/port protectors is unknown.

Approaches that should not be considered a routine part of CLABSI prevention

  1. 1. Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (Quality of Evidence: HIGH) Reference McKee, Dunsmuir, Whitby and Garden209Reference van de Wetering, van Woensel and Lawrie213

    1. a. Systemic antimicrobial prophylaxis is not recommended.

  2. 2. Do not routinely replace CVCs or arterial catheters (Quality of Evidence: HIGH) Reference Cook, Randolph and Kernerman214

    1. a. Routine catheter replacement is not recommended.

Unresolved issues

  1. 1. Routine use of needleless connectors as a CLABSI prevention strategy before an assessment of risks, benefits, and education regarding proper use Reference Maragakis, Bradley and Song215Reference Jarvis, Murphy and Hall219

    1. a. Multiple devices are currently available but the optimal design for preventing infections is unresolved. The original purpose of needleless connectors was to prevent needlestick injuries during intermittent use. No data are available regarding their use with continuous infusions. Needle-free connectors with 3-way stopcocks may increase the risk of catheter infections. Reference Rosenthal220

      1. i. Use of silver-coated catheter connectors may be associated with reduced intraluminal contamination in ex vivo catheters and CLABSI. Reference Casey, Karpanen, Nightingale, Cook and Elliott221,Reference Jacob, Chernetsky Tejedor and Dent Reyes222 Clinical evidence is limited regarding the risk reduction with their routine use or use of other antimicrobial catheter connectors.

  2. 2. Surveillance of other types of catheters (eg, peripheral arterial or venous catheters) Reference Maki, Kluger and Crnich11,Reference Mermel21,Reference O’Horo, Maki, Krupp and Safdar22

    1. a. Peripheral arterial catheters, short-term peripheral venous catheters and midline catheters are not included in most surveillance systems although they are associated with risk of bloodstream infection. Future surveillance systems should consider including bloodstream infections associated with these types of catheters.

    2. b. If considering further infection prevention interventions due to concern for an increase in infections, hospitals may want to consider extending their surveillance programs to include all types of catheters used to gauge the size of the problem.

  3. 3. Standard, nonantimicrobial transparent dressings and CLABSI risk

    1. a. A meta-analysis reported an association between CLABSI and transparent dressing use; however, the source studies for the meta-analysis reporting this association were of low quality. Reference Webster, Gillies, O’Riordan, Sherriff and Rickard223

  4. 4. The impact of using chlorhexidine-based products on bacterial resistance to chlorhexidine

    1. a. Widespread use of chlorhexidine-based products (eg, use of chlorhexidine bathing, antisepsis, and dressings) may promote reduced chlorhexidine susceptibility. Reference Batra, Cooper, Whiteley, Patel, Wyncoll and Edgeworth224 However, testing for chlorhexidine susceptibility is not standardized. The clinical impact of reduced chlorhexidine susceptibility is unknown.

  5. 5. Sutureless securement

    1. a. The impact of sutureless securement devices in reducing CLABSI is unknown. Reference Rickard, Edwards and Spooner225,Reference Karpanen, Casey and Whitehouse226

  6. 6. Impact of silver zeolite-impregnated umbilical catheters in preterm infants (applicable in countries where it is approved for use in children) Reference Bertini, Elia, Ceciarini and Dani227

    1. a. One randomized study suggests that antimicrobial-impregnated umbilical catheters appear to be safe and effective in NICU patients. Reference Bertini, Elia, Ceciarini and Dani228

  7. 7. Necessity of mechanical disinfection of a catheter hub, needleless connector, and injection port before accessing the catheter when antiseptic-containing caps are being used.

    1. a. It is unknown whether the application and removal of an antiseptic-containing cap provides the same benefit to reducing risk of CLABSI as manual disinfection. Future research is needed to determine if using such a cap will obviate the need for manual disinfection before accessing a catheter.

Section 5: Performance measures

Internal reporting

These performance measures are intended to support internal hospital quality improvement efforts Reference Bizzarro, Sabo and Noonan229,Reference Sawyer, Weeks and Goeschel230 and do not necessarily address external reporting needs.

The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinion of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for CLABSI.

Process measures (Table 3)

  1. 1. Compliance with CVC insertion guidelines as documented on an insertion checklist

    1. a. Assess compliance with the checklist in all hospital settings where CVCs are inserted (eg, ICUs, ED, OR, radiology, general patient care units) and assign HCP familiar with CVCs to this task.

    2. b. Documenting compliance using the insertion checklist upholds accountability and compliance with the proper procedure steps and identifies gaps to be mitigated. The Institute for Healthcare Improvement (IHI) provides an example of a central catheter checklist. 231

    3. c. Documentation of CVC insertion procedures in compliance with appropriate hand hygiene, use of maximal sterile barrier precautions, and use of chlorhexidine-based cutaneous antisepsis of the insertion site:

      1. i. Numerator: Number of CVC insertions that have documented the use of all 3 interventions (hand hygiene, maximal barrier precautions, and chlorhexidine-based cutaneous antiseptic use) performed at the time of CVC insertion.

      2. ii. Denominator: Number of all CVC insertions.

      3. iii. Multiply by 100 so that the measure is expressed as a percentage.

  2. 2. Compliance with documentation of daily assessment regarding the need for continuing CVC access.

    1. a. Measure the percentage of patients with a CVC where there is documentation of daily assessment:

      1. i. Numerator: Number of patients with a CVC who have documentation of daily assessment.

      2. ii. Denominator: Number of patients with a CVC.

      3. iii. Multiply by 100 so that the measure is expressed as a percentage.

  3. 3. Simulation of catheter maintenance as an alternative to address HCP competency Reference Fakih, Jones and Rey232,Reference Fakih, Jones and Rey233

    1. i. Numerator: Number of HCP properly simulating the aseptic infusion of medications.

    2. ii. Denominator: Number of HCP simulating the aseptic infusion of medications.

    3. iii. Multiply by 100 so that the measure is expressed as a percentage.

  4. 4. Device utilization can be evaluated over time to assess any changes. Utilization may be compared at the hospital and unit level. It provides a surrogate for patient exposure risk. Reference Fakih, Gould and Trautner234 The standardized utilization ratio (SUR) is an NHSN measure that accounts for facility- and location-level factors that may affect device use.

    1. i. SUR: Observed device days divided by predicted device days.

Table 3. CLABSI Prevention Process Measures

Outcome measures (See Table 4)

  1. 1. CLABSI rate: Use NHSN definitions.

    1. a. Numerator: Number of CLABSIs in each unit assessed (using NHSN definitions).

    2. b. Denominator: Total number of catheter days in each unit assessed (using NHSN definitions).

    3. c. Multiply by 1,000 so that the measure is expressed as number of CLABSIs per 1,000 catheter days.

  2. 2. Risk adjustment: Stratify CLABSI rates by type of patient-care unit. Reference Widmer, Nettleman, Flint and Wenzel235Reference Pittet and Wenzel237

    1. a. Report comparisons based on historic data and NHSN data, if available. Reference Sunkesula, Kundrapu, Knighton, Cadnum and Donskey167

    2. b. Use the NHSN device standardized infection ratio (dSIR) to evaluate hospital and unit CLABSI rates.

      1. i. dSIR: Observed CLABSI events divided by predicted CLABSI events based on actual device days.

    3. c. Consider measures that address device risk at the patient population level. A population SIR (pSIR) Reference Fakih, Huang and Bufalino238 accounts for both device SIR and SUR, reflecting both the care of the device, and interventions to reduce utilization.

      1. i. pSIR: Observed CLABSI events divided by predicted CLABSI events based on predicted device days.

Table 4. CLABSI Prevention Outcome Measures

External reporting

Many challenges exist in providing useful information to consumers and other stakeholders and in preventing unintended consequences of public reporting of HAIs. Reference Wong, Rupp and Mermel239,Reference Aswani, Reagan, Jin, Pronovost and Goeschel240 Recommendations for public reporting of HAIs have been provided by the Healthcare Infection Control Practices Advisory Committee (HICPAC), Reference Talbot, Bratzler and Carrico241 the Healthcare-Associated Infection Working Group of the Joint Public Policy Committee, Reference Evans, Kralovic, Simbartl, Jain and Roselle242 and the National Quality Forum. Reference Hamill, Reed and Fogel243

State and federal requirements

  1. 1. Hospitals in states that have mandatory reporting requirements for CLABSI must collect and report the data required by the state.

  2. 2. For information on state and federal requirements, contact your state or local health department.

External quality initiatives

  1. 1. Hospitals that participate in external quality initiatives or state programs must collect and report the data required by the initiative or the program.

  2. 2. Problems with interrater reliability may affect comparisons between different institutions.

Section 6: Implementation of CLABSI prevention strategies

Prevention of CLABSI depends on integrating best practices to reduce the risk of infection and incorporating a culture to support implementation. Hospitals should address technical and socioadaptive components Reference Chopra, Flanders and Saint244 to CLABSI prevention, including formal training of HCP on indications, placement, and maintenance of devices, in addition to regular assessment of competencies. Reference Fakih, Heavens, Ratcliffe and Hendrich245

One example of a widely used model in the United States, known as the Four Es (ie, engage, educate, execute, and evaluate Reference Owings, Graves, Johnson, Gilliam, Gipson and Hakim246 ), involves summarizing evidence, identifying local barriers to implementation, measuring performance, and ensuring that patients receive the infection prevention intervention Reference Pronovost, Berenholtz and Needham247 by addressing knowledge, critical thinking, behavior and psychomotor skills, as well as attitudes and beliefs of all members of the healthcare team involved with the insertion and care of CVCs. Reference Safdar and Abad248,Reference Smith, Kirksey, Becker and Brown249 Facilities may consider utilizing tools to promote high-reliability processes (eg, Lean Six Sigma) and to enhance teamwork (eg, Team STEPPS).

Engage

Historically, efforts have been centered around having a champion to support CLABSI reduction initiatives. Champions are often very effective in initial phases of adoption, but their efforts may not be enough for integration of processes and sustainability. Reference Hendy and Barlow250 It is important to engage both frontline and senior leadership champions in the process and outcome improvement plan, Reference Weaver, Lubomksi, Wilson, Pfoh, Martinez and Dy251 but institutionalizing the work and garnering the support of stakeholder groups facilitates successful, long-lasting results. Reference Fakih, Krein, Edson, Watson, Battles and Saint252

Educate

HCP, patients, and caregivers involved in care of a CVC should be trained in and competent, relative to their role, with the following:

  1. 1. Appropriate indications prior to insertion.

  2. 2. Use of full barrier precautions at the time of insertion.

  3. 3. Daily evaluation of necessity of the device.

Execute

A standardized competency assessment checklist should be used to assess and document competency of each individual performing CVC insertion and procedures related to care and maintenance (eg, dressing changes). Reference Wathen, Kshettry and Krishnaney253Reference Evans and Dodge255 In addition, education of the patient and/or family, as appropriate, is required for all CVC care procedures especially when transfer to an alternative setting (eg, home care, ambulatory setting) is planned. Reference Segreti, Garcia-Houchins and Gorski256,Reference Nailon, Rupp and Lyden257

Evaluate

Evaluation involves both process and outcome measurement. Reference Wheeler, Giaccone and Hutchinson258 Multidisciplinary teams should set clear goals and identify the key factors to be measured. It is important for members of the healthcare team to receive feedback on their performance. Feedback should include periodic (eg, monthly, quarterly) communication (eg, e-mail messages, written reports) of process measurement data via posters, reports, or other forms of communication with graphs showing cumulative compliance with process measures. Reference Marra, Cal and Durao259Reference Assanasen, Edmond and Bearman262 Differences between age groups should also be considered (eg, neonates, pediatrics, and adults). Reference Powers and Wirtschafter260,Reference Miller, Griswold and Harris263,Reference Stevens and Schulman264 Central line data can be used to capture trends over time. The standardized utilization ratio (SUR) provides a method for the hospital’s units to compare themselves to others with similar characteristics. CLABSI events are important to discuss with the different members of the team caring for the patient to have a clear understanding of gaps and ways to mitigate them in the future.

Acknowledgments

We appreciate Sarah Rolli, Bern University Hospital, for her help with document editing and formatting.

Disclaimer

The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Conflicts of interest

The following disclosures reflect what has been reported to SHEA. To provide thorough transparency, SHEA requires full disclosure of all relationships, regardless of relevancy to the topic. Such relationships as potential conflicts of interest are evaluated in a review process that includes assessment by the SHEA Conflict of Interest Committee and may include the Board of Trustees and Editor of Infection Control and Hospital Epidemiology. The assessment of disclosed relationships for possible conflicts of interest has been based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration).

N.B. received a Mobility grant from the Swiss National Science Foundation (grant nos. P400PM_183865 and P4P4PM_194449) and a grant from the Bangerter-Rhyner Foundation. J.M. is the recipient of a project grant on surgical site infections from the Swiss National Science Foundation (grant no. 32003B_179500, “Understanding the drivers of surgical site infection: Investigating and modeling the Swissnoso surveillance data”). L.M. served as an advisor/consultant for Marvao Medical Devices. L.H. served as an advisor/consultant for B Braun Medical, BD Medical, Atrion Medical, Nexus Medical, Teleflex. M.E.R. served as an advisor/consultant for 3M, Becton Dickinson, and Cetius, and Teleflex, and received honoraria from Teleflex. All other authors report no conflicts of interest related to this article.

Footnotes

a

Authors of equal contribution.

References

Marschall, J, Mermel, LA, Fakih, M, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:753771.CrossRefGoogle ScholarPubMed
The Society for Healthcare Epidemiology of America (SHEA) Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents 2021. SHEA website. https://shea-online.org/wp-content/uploads/2022/02/2022-Handbook-Update-Approved-Posted.pdf. Published 2021. Accessed March 22, 2022.Google Scholar
Digiovine, B, Chenoweth, C, Watts, C, Higgins, M. The attributable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. Am J Respir Crit Care Med 1999;160:976981.CrossRefGoogle ScholarPubMed
Dimick, JB, Pelz, RK, Consunji, R, Swoboda, SM, Hendrix, CW, Lipsett, PA. Increased resource use associated with catheter-related bloodstream infection in the surgical intensive care unit. Arch Surg 2001;136:229234.CrossRefGoogle ScholarPubMed
Goudie, A, Dynan, L, Brady, PW, Rettiganti, M. Attributable cost and length of stay for central line-associated bloodstream infections. Pediatrics 2014;133:e1525e1532.CrossRefGoogle ScholarPubMed
Leistner, R, Hirsemann, E, Bloch, A, Gastmeier, P, Geffers, C. Costs and prolonged length of stay of central venous catheter–associated bloodstream infections (CVC BSI): a matched prospective cohort study. Infection 2014;42:3136.CrossRefGoogle ScholarPubMed
Stevens, V, Geiger, K, Concannon, C, Nelson, RE, Brown, J, Dumyati, G. Inpatient costs, mortality and 30-day readmission in patients with central line-associated bloodstream infections. Clin Microbiol Infect 2014;20:O318O324.CrossRefGoogle ScholarPubMed
Ziegler, MJ, Pellegrini, DC, Safdar, N. Attributable mortality of central line-associated bloodstream infection: systematic review and meta-analysis. Infection 2015;43:2936.CrossRefGoogle ScholarPubMed
Dube, WC, Jacob, JT, Zheng, Z, et al. Comparison of Rates of central line-associated bloodstream infections in patients with 1 vs 2 central venous catheters. JAMA Network Open 2020;3:e200396.CrossRefGoogle ScholarPubMed
Mermel, LA. How should surveillance systems account for concurrent intravascular catheters? JAMA Netw Open 2020;3:e200400.CrossRefGoogle ScholarPubMed
Maki, DG, Kluger, DM, Crnich, CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:11591171.CrossRefGoogle ScholarPubMed
European Centre for Disease Prevention and Control. Point Prevalence Survey of Healthcare-Associated Infections and Antimicrobial use in European Acute-Care Hospitals. Stockholm, Sweden: ECDC; 2013.Google Scholar
Marschall, J, Leone, C, Jones, M, Nihill, D, Fraser, VJ, Warren, DK. Catheter-associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study. Infect Control Hosp Epidemiol 2007;28:905909.CrossRefGoogle ScholarPubMed
Vital signs: central line-associated bloodstream infections—United States, 2001, 2008, and 2009. Morb Mortal Wkly Rep 2011;60:243248.Google Scholar
Kallen, AJ, Patel, PR, O’Grady, NP. Preventing catheter-related bloodstream infections outside the intensive care unit: expanding prevention to new settings. Clin Infect Dis 2010;51:335341.CrossRefGoogle ScholarPubMed
Zingg, W, Sandoz, L, Inan, C, et al. Hospital-wide survey of the use of central venous catheters. J Hosp Infect 2011;77:304308.CrossRefGoogle ScholarPubMed
Rhee, Y, Heung, M, Chen, B, Chenoweth, CE. Central line-associated bloodstream infections in non-ICU inpatient wards: a 2-year analysis. Infect Control Hosp Epidemiol 2015;36:424430.CrossRefGoogle ScholarPubMed
Nguyen, DB, Shugart, A, Lines, C, et al. National Healthcare Safety Network (NHSN) Dialysis Event Surveillance Report for 2014. Clin J Am Soc Nephrol 2017;12:11391146.CrossRefGoogle Scholar
Loftus, RW, Brown, JR, Koff, MD, et al. Multiple reservoirs contribute to intraoperative bacterial transmission. Anesth Analg 2012;114:12361248.CrossRefGoogle ScholarPubMed
Zakhour, R, Chaftari, AM, Raad, II. Catheter-related infections in patients with haematological malignancies: novel preventive and therapeutic strategies. Lancet Infect Dis 2016;16:e241e250.CrossRefGoogle ScholarPubMed
Mermel, LA. Short-term peripheral venous catheter-related bloodstream infections: a systematic review. Clin Infect Dis 2017;65:17571762.CrossRefGoogle ScholarPubMed
O’Horo, JC, Maki, DG, Krupp, AE, Safdar, N. Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis. Crit Care Med 2014;42:13341339.CrossRefGoogle ScholarPubMed
Almuneef, MA, Memish, ZA, Balkhy, HH, Hijazi, O, Cunningham, G, Francis, C. Rate, risk factors, and outcomes of catheter-related bloodstream infection in a paediatric intensive care unit in Saudi Arabia. J Hosp Infect 2006;62:207213.CrossRefGoogle Scholar
Alonso-Echanove, J, Edwards, JR, Richards, MJ, et al. Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units. Infect Control Hosp Epidemiol 2003;24:916925.CrossRefGoogle ScholarPubMed
Lorente, L, Henry, C, Martin, MM, Jimenez, A, Mora, ML. Central venous catheter–related infection in a prospective and observational study of 2,595 catheters. Crit Care 2005;9:R631R635.CrossRefGoogle Scholar
Rey, C, Alvarez, F, De-La-Rua, V, et al. Intervention to reduce catheter-related bloodstream infections in a pediatric intensive care unit. Intensive Care Med 2011;37:678685.CrossRefGoogle Scholar
Lorente, L, Jimenez, A, Naranjo, C, et al. Higher incidence of catheter-related bacteremia in jugular site with tracheostomy than in femoral site. Infect Control Hosp Epidemiol 2010;31:311313.CrossRefGoogle ScholarPubMed
Callister, D, Limchaiyawat, P, Eells, SJ, Miller, LG. Risk factors for central line-associated bloodstream infections in the era of prevention bundles. Infect Control Hosp Epidemiol 2015;36:214216.CrossRefGoogle ScholarPubMed
Milstone, AM, Reich, NG, Advani, S, et al. Catheter dwell time and CLABSIs in neonates with PICCs: a multicenter cohort study. Pediatrics 2013;132:e1609e1615.CrossRefGoogle ScholarPubMed
Templeton, A, Schlegel, M, Fleisch, F, et al. Multilumen central venous catheters increase risk for catheter-related bloodstream infection: prospective surveillance study. Infection 2008;36:322327.CrossRefGoogle ScholarPubMed
Pongruangporn, M, Ajenjo, MC, Russo, AJ, et al. Patient- and device-specific risk factors for peripherally inserted central venous catheter–related bloodstream infections. Infect Control Hosp Epidemiol 2013;34:184189.CrossRefGoogle ScholarPubMed
Chopra, V, Ratz, D, Kuhn, L, Lopus, T, Chenoweth, C, Krein, S. PICC-associated bloodstream infections: prevalence, patterns, and predictors. Am J Med 2014;127:319328.CrossRefGoogle ScholarPubMed
Parienti, JJ, Mongardon, N, Megarbane, B, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med 2015;373:12201229.CrossRefGoogle ScholarPubMed
Fridkin, SK, Pear, SM, Williamson, TH, Galgiani, JN, Jarvis, WR. The role of understaffing in central venous catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 1996;17:150158.Google ScholarPubMed
Cimiotti, JP, Haas, J, Saiman, L, Larson, EL. Impact of staffing on bloodstream infections in the neonatal intensive care unit. Arch Pediatr Adolesc Med 2006;160:832836.CrossRefGoogle ScholarPubMed
Leistner, R, Thurnagel, S, Schwab, F, Piening, B, Gastmeier, P, Geffers, C. The impact of staffing on central venous catheter-associated bloodstream infections in preterm neonates—results of nation-wide cohort study in Germany. Antimicrob Resist Infect Control 2013;2:11.CrossRefGoogle ScholarPubMed
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;286:700707.CrossRefGoogle ScholarPubMed
Raad, I, Darouiche, R, Dupuis, J, et al. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections. A randomized, double-blind trial. The Texas Medical Center Catheter Study Group. Ann Intern Med 1997;127:267274.CrossRefGoogle ScholarPubMed
Hanna, H, Benjamin, R, Chatzinikolaou, I, et al. Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial. J Clin Oncol 2004;22:3163–171.CrossRefGoogle ScholarPubMed
Lorente, L, Lecuona, M, Jimenez, A, et al. Efficiency of chlorhexidine-silver sulfadiazine-impregnated venous catheters at subclavian sites. Am J Infect Control 2015;43:711714.CrossRefGoogle ScholarPubMed
Richards, B, Chaboyer, W, Bladen, T, Schluter, PJ. Effect of central venous catheter type on infections: a prospective clinical trial. J Hosp Infect 2003;54:1017.CrossRefGoogle ScholarPubMed
Mimoz, O, Lucet, JC, Kerforne, T, et al. Skin antisepsis with chlorhexidine-alcohol versus povidone iodine-alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. Lancet 2015;386:20692077.CrossRefGoogle ScholarPubMed
Yasuda, H, Sanui, M, Abe, T, et al. Comparison of the efficacy of three topical antiseptic solutions for the prevention of catheter colonization: a multicenter randomized controlled study. Crit Care 2017;21:320.CrossRefGoogle ScholarPubMed
Timsit, JF, Schwebel, C, Bouadma, L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:12311241.CrossRefGoogle ScholarPubMed
Timsit, JF, Mimoz, O, Mourvillier, B, et al. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med 2012;186:12721278.CrossRefGoogle ScholarPubMed
National Healthcare Safety Network. Bloodstream Infection event (central line-associated bloodstream infection and non–central line-associated bloodstream infection. Centers for Disease Control and Prevention website. https://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf. Updated January 2022. Accessed March 22, 2022.Google Scholar
Grooth, HJ, Timsit, JF, Mermel, L, et al. Validity of surrogate endpoints assessing central venous catheter-related infection: evidence from individual- and study-level analyses. Clin Microbiol Infect 2020;26:563571.CrossRefGoogle ScholarPubMed
Niedner, MF. The harder you look, the more you find: catheter-associated bloodstream infection surveillance variability. Am J Infect Control 2010;38:585595.CrossRefGoogle ScholarPubMed
Tomlinson, D, Mermel, LA, Ethier, MC, Matlow, A, Gillmeister, B, Sung, L. Defining bloodstream infections related to central venous catheters in patients with cancer: a systematic review. Clin Infect Dis 2011;53:697710.CrossRefGoogle ScholarPubMed
Mayer, J, Greene, T, Howell, J, Ying, J, Rubin, MA, Trick, WE, et al. Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance. Clin Infect Dis 2012;55:364370.CrossRefGoogle ScholarPubMed
Mermel, LA, Allon, M, Bouza, E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:145.CrossRefGoogle ScholarPubMed
O’Grady, NP, Alexander, M, Dellinger, EP, et al. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recom Rep 2002;51:129.Google ScholarPubMed
O’Grady, NP, Alexander, M, Burns, LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis 2011;52:e162e193.CrossRefGoogle ScholarPubMed
Masse, J, Elkalioubie, A, Blazejewski, C, et al. Colonization pressure as a risk factor of ICU-acquired multidrug-resistant bacteria: a prospective observational study. Eur J Clin Microbiol Infect Dis 2017;36:797805.CrossRefGoogle ScholarPubMed
Saint, S. Chapter 16. Prevention of intravascular catheterassociated infections. In: Making Health Care Safer. Agency for Healthcare Research and Quality website. www.ahrq.gov/clinic/ptsafety/. Published 2001. Accessed March 22, 2022.Google Scholar
Huang, EY, Chen, C, Abdullah, F, et al. Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review. J Pediatr Surg 2011;46:20002011.CrossRefGoogle ScholarPubMed
OTILUS. Preventing central line-associated bloodstream infection: global challenges, a global perspective. The Joint Commission website. https://www.jointcommission.org/-/media/tjc/documents/resources/hai/clabsi_monographpdf.pdf. Updated May 2012. Accessed March 22, 2022.Google Scholar
Barnes, S, Olmsted, RN, Monsees, E, et al. Guide to preventing central line-associated bloodstream infections. Association for Professionals in Infection Control and Epidemiology (APIC) website. https://apic.org/Resource_/TinyMceFileManager/2015/APIC_CLABSI_WEB.pdf. Published 2015. Accessed March 22, 2022.Google Scholar
Gorski, LA, Hadaway, L, Hagle, ME, et al. Infusion Therapy Standards of Practice, Eighth Edition. J Infusion Nurs 2021;44:S1S224.CrossRefGoogle Scholar
Bloodstream infection event (central line-associated bloodstream infection and non–central line-associated bloodstream infection). Centers for Disease Control and Prevention website. https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf. Published 2019. Accessed March 22, 2022.Google Scholar
Tejedor, SC, Garrett, G, Jacob, JT, et al. Electronic documentation of central venous catheter days: validation is essential. Infect Control Hosp Epidemiol 2013;34:900907.CrossRefGoogle ScholarPubMed
Woeltje, KF, McMullen, KM, Butler, AM, Goris, AJ, Doherty, JA. Electronic surveillance for healthcare-associated central line-associated bloodstream infections outside the intensive care unit. Infect Control Hosp Epidemiol 2011;32:10861090.CrossRefGoogle ScholarPubMed
Pronovost, PJ, Watson, SR, Goeschel, CA, Hyzy, RC, Berenholtz, SM. Sustaining reductions in central line-associated bloodstream infections in michigan intensive care units: a 10-year analysis. Am J Med Qual 2016;31:197202.CrossRefGoogle ScholarPubMed
Centers for Disease Control and Prevention. Vital signs: central line-associated bloodstream infections—United States, 2001, 2008, and 2009. Morb Mortal Wkly Rep 2011;60:243248.Google Scholar
Kim, JS, Holtom, P, Vigen, C. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences. Am J Infect Control 2011;39:640646.CrossRefGoogle ScholarPubMed
Halton, KA, Cook, D, Paterson, DL, Safdar, N, Graves, N. Cost-effectiveness of a central venous catheter care bundle. PLoS One 2010;5:e12815.CrossRefGoogle ScholarPubMed
Tang, HJ, Lin, HL, Lin, YH, Leung, PO, Chuang, YC, Lai, CC. The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infect Dis 2014;14:356.CrossRefGoogle ScholarPubMed
Ista, E, van der Hoven, B, Kornelisse, RF, et al. Effectiveness of insertion and maintenance bundles to prevent central line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis 2016;16:724734.CrossRefGoogle ScholarPubMed
Richter, JP, McAlearney, AS. Targeted implementation of the Comprehensive Unit-Based Safety Program through an assessment of safety culture to minimize central line-associated bloodstream infections. Health Care Manage Rev 2018;43:4249.CrossRefGoogle ScholarPubMed
Furuya, EY, Dick, A, Perencevich, EN, Pogorzelska, M, Goldmann, D, Stone, PW. Central-line bundle implementation in US intensive care units and impact on bloodstream infections. PLoS One 2011;6:e15452.CrossRefGoogle ScholarPubMed
Guerin, K, Wagner, J, Rains, K, Bessesen, M. Reduction in central line-associated bloodstream infections by implementation of a postinsertion care bundle. Am J Infect Control 2010;38:430433.CrossRefGoogle ScholarPubMed
Miller, MR, Niedner, MF, Huskins, WC, et al. Reducing PICU central line-associated bloodstream infections: 3-year results. Pediatrics 2011;128:e1077e1083.CrossRefGoogle ScholarPubMed
O’Neil, C, Ball, K, Wood, H, et al. A central-line care maintenance bundle for the prevention of central line-associated bloodstream infection in non–intensive care unit settings. Infect Control Hosp Epidemiol 2016;37:692698.CrossRefGoogle ScholarPubMed
Sherertz, RJ, Ely, EW, Westbrook, DM, et al. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132:641648.CrossRefGoogle ScholarPubMed
Eggimann, P, Harbarth, S, Constantin, MN, Touveneau, S, Chevrolet, JC, Pittet, D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care. Lancet 2000;355:18641868.CrossRefGoogle ScholarPubMed
Coopersmith, CM, Rebmann, TL, Zack, JE, et al. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med 2002;30:5964.CrossRefGoogle ScholarPubMed
Warren, DK, Zack, JE, Cox, MJ, Cohen, MM, Fraser, VJ. An educational intervention to prevent catheter-associated bloodstream infections in a nonteaching, community medical center. Crit Care Med 2003;31:19591963.CrossRefGoogle Scholar
Warren, DK, Zack, JE, Mayfield, JL, et al. The effect of an education program on the incidence of central venous catheter–associated bloodstream infection in a medical ICU. Chest 2004;126:16121618.CrossRefGoogle Scholar
Lobo, RD, Levin, AS, Oliveira, MS, et al. Evaluation of interventions to reduce catheter-associated bloodstream infection: continuous tailored education versus one basic lecture. Am J Infect Control 2010;38:440448.CrossRefGoogle ScholarPubMed
Cherry, MG, Brown, JM, Neal, T, Ben Shaw, N. What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? Med Teach 2010;32:198218.CrossRefGoogle ScholarPubMed
Joint Commission Resources. Assessing Hospital Staff Competence. Oakbrook Terrace, IL: Joint Commission International; 2007.Google Scholar
Barsuk, JH, Cohen, ER, Potts, S, et al. Dissemination of a simulation-based mastery learning intervention reduces central line-associated bloodstream infections. BMJ Qual Saf 2014;23:749756.CrossRefGoogle ScholarPubMed
Cartier, V, Inan, C, Zingg, W, Delhumeau, C, Walder, B, Savoldelli, GL. Simulation-based medical education training improves short and long-term competency in, and knowledge of central venous catheter insertion: a before and after intervention study. Eur J Anaesthesiol 2016;33:568574.CrossRefGoogle Scholar
Khouli, H, Jahnes, K, Shapiro, J, et al. Performance of medical residents in sterile techniques during central vein catheterization: randomized trial of efficacy of simulation-based training. Chest 2011;139:8087.CrossRefGoogle ScholarPubMed
Ma, IW, Brindle, ME, Ronksley, PE, Lorenzetti, DL, Sauve, RS, Ghali, WA. Use of simulation-based education to improve outcomes of central venous catheterization: a systematic review and meta-analysis. Acad Med 2011;86:11371147.CrossRefGoogle ScholarPubMed
Bleasdale, SC, Trick, WE, Gonzalez, IM, Lyles, RD, Hayden, MK, Weinstein, RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007;167:20732079.CrossRefGoogle ScholarPubMed
Milstone, AM, Elward, A, Song, X, et al. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. Lancet 2013;381:10991106.CrossRefGoogle ScholarPubMed
Climo, MW, Yokoe, DS, Warren, DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med 2013;368:533542.CrossRefGoogle ScholarPubMed
Noto, MJ, Domenico, HJ, Byrne, DW, et al. Chlorhexidine bathing and healthcare-associated infections: a randomized clinical trial. JAMA 2015;313:369378.CrossRefGoogle ScholarPubMed
Afonso, E, Blot, K, Blot, S. Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: a systematic review and meta-analysis of randomised crossover trials. Euro Surveill 2016;21:30400.CrossRefGoogle ScholarPubMed
Munoz-Price, LS, Hota, B, Stemer, A, Weinstein, RA. Prevention of bloodstream infections by use of daily chlorhexidine baths for patients at a long-term acute-care hospital. Infect Control Hosp Epidemiol 2009;30:10311035.CrossRefGoogle Scholar
Medina, A, Serratt, T, Pelter, M, Brancamp, T. Decreasing central line-associated bloodstream infections in the non-ICU population. J Nurs Care Qual 2014;29:133140.CrossRefGoogle ScholarPubMed
Huang, SS, Septimus, E, Kleinman, K, et al. Chlorhexidine versus routine bathing to prevent multidrug-resistant organisms and all-cause bloodstream infections in general medical and surgical units (ABATE Infection trial): a cluster-randomised trial. Lancet 2019;393:12051215.CrossRefGoogle ScholarPubMed
Tien, KL, Sheng, WH, Shieh, SC, et al. Chlorhexidine bathing to prevent central line-associated bloodstream infections in hematology units: a prospective, controlled cohort study. Clin Infect Dis 2020;71:556563.CrossRefGoogle Scholar
Zerr, DM, Milstone, AM, Dvorak, CC, et al. Chlorhexidine gluconate bathing in children with cancer or those undergoing hematopoietic stem cell transplantation: a double-blinded randomized controlled trial from the Children’s Oncology Group. Cancer 2020;127:5666.CrossRefGoogle ScholarPubMed
Milstone, AM, Bamford, P, Aucott, SW, Tang, N, White, KR, Bearer, CF. Chlorhexidine inhibits L1 cell adhesion molecule-mediated neurite outgrowth in vitro. Pediatr Res 2014;75:813.CrossRefGoogle ScholarPubMed
Kieran, EA, O’Sullivan, A, Miletin, J, Twomey, AR, Knowles, SJ, O’Donnell, CPF. 2% chlorhexidine-70% isopropyl alcohol versus 10% povidone-iodine for insertion site cleaning before central-line insertion in preterm infants: a randomised trial. Arch Dis Child Fetal Neonatal Ed 2018;103:F101F106.CrossRefGoogle ScholarPubMed
Neri, I, Ravaioli, GM, Faldella, G, Capretti, MG, Arcuri, S, Patrizi, A. Chlorhexidine-induced chemical burns in very-low-birthweight infants. J Pediatr 2017;191:262265.CrossRefGoogle Scholar
Chandonnet, CJ, Toole, C, Young, V, et al. Safety of biweekly chlorhexidine gluconate bathing in infants 36 to 48 weeks’ postmenstrual age. Am J Crit Care 2019;28:451459.CrossRefGoogle ScholarPubMed
Kampf, G. Acquired resistance to chlorhexidine—is it time to establish an ‘antiseptic stewardship’ initiative? J Hosp Infect 2016;94:213227.CrossRefGoogle ScholarPubMed
Wichmann, D, Belmar Campos, CE, et al. Efficacy of introducing a checklist to reduce central venous line associated bloodstream infections in the ICU caring for adult patients. BMC Infect Dis 2018;18:267.CrossRefGoogle ScholarPubMed
Elgohari, S, Wilson, J, Saei, A, Sheridan, EA, Lamagni, T. Impact of national policies on the microbial aetiology of surgical site infections in acute NHS hospitals in England: analysis of trends between 2000 and 2013 using multicentre prospective cohort data. Epidemiol Infect 2017;145:957969.CrossRefGoogle Scholar
Yilmaz, G, Koksal, I, Aydin, K, Caylan, R, Sucu, N, Aksoy, F. Risk factors of catheter-related bloodstream infections in parenteral nutrition catheterization. J Parenter Enteral Nutr 2007;31:284287.CrossRefGoogle ScholarPubMed
Boyce, JM, Pittet, D. 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;51:145.Google ScholarPubMed
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;33:392397.CrossRefGoogle ScholarPubMed
Capretti, MG, Sandri, F, Tridapalli, E, Galletti, S, Petracci, E, Faldella, G. Impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants. Am J Infect Control 2008;36:430435.CrossRefGoogle ScholarPubMed
van der Kooi, T, Sax, H, Pittet, D, et al. Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections. Intensive Care Med 2018;44:4860.CrossRefGoogle ScholarPubMed
Arvaniti, K, Lathyris, D, Blot, S, Apostolidou-Kiouti, F, Koulenti, D, Haidich, AB. Cumulative evidence of randomized controlled and observational studies on catheter-related infection risk of central venous catheter insertion site in ICU patients: a pairwise and network meta-analysis. Crit Care Med 2017;45:e437e448.CrossRefGoogle ScholarPubMed
Parienti, JJ. Catheter-related bloodstream infection in jugular versus subclavian central catheterization. Crit Care Med 2017;45:e734e735.CrossRefGoogle ScholarPubMed
Timsit, JF, Bouadma, L, Mimoz, O, et al. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients. Causal analysis of two randomized trials. Am J Respir Crit Care Med 2013;188:12321239.CrossRefGoogle ScholarPubMed
Ullman, AJ, Bernstein, SJ, Brown, E, et al. The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC. Pediatrics 2020;145:S269S84.CrossRefGoogle Scholar
Chau, A, Hernandez, JA, Pimpalwar, S, Ashton, D, Kukreja, K. Equivalent success and complication rates of tunneled common femoral venous catheter placed in the interventional suite vs. at patient bedside. Pediatr Radiol 2018;48:889894.CrossRefGoogle ScholarPubMed
Gaballah, M, Krishnamurthy, G, Berman, JI, et al. Lower extremity vascular access in neonates and infants: a single institutional experience. J Vasc Interv Radiol 2015;26:16601668.CrossRefGoogle ScholarPubMed
Chopra, V, O’Horo, JC, Rogers, MA, Maki, DG, Safdar, N. The risk of bloodstream infection associated with peripherally inserted central catheters compared with central venous catheters in adults: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 2013;34:908918.CrossRefGoogle ScholarPubMed
Ajenjo, MC, Morley, JC, Russo, AJ, et al. Peripherally inserted central venous catheter-associated bloodstream infections in hospitalized adult patients. Infect Control Hosp Epidemiol 2011;32:125130.CrossRefGoogle ScholarPubMed
Swaminathan, L, Flanders, S, Horowitz, J, Zhang, Q, O’Malley, M, Chopra, V. Safety and outcomes of midline catheters vs peripherally inserted central catheters for patients with short-term indications: a multicenter study. JAMA Intern Med 2022;182:5058.CrossRefGoogle ScholarPubMed
Mushtaq, A, Navalkele, B, Kaur, M, et al. Comparison of complications in midlines versus central venous catheters: Are midlines safer than central venous lines? Am J Infect Control 2018;46:788792.CrossRefGoogle ScholarPubMed
Berenholtz, SM, Pronovost, PJ, Lipsett, PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32:20142020.CrossRefGoogle ScholarPubMed
Karakitsos, D, Labropoulos, N, De Groot, E, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in critical care patients. Crit Care 2006;10:R162.CrossRefGoogle ScholarPubMed
Brass, P, Hellmich, M, Kolodziej, L, Schick, G, Smith, AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev 2015;1:CD006962.Google ScholarPubMed
Hind, D, Calvert, N, McWilliams, R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361.CrossRefGoogle ScholarPubMed
Buetti, N, Mimoz, O, Mermel, L, et al. Ultrasound guidance and risk for central venous catheter-related infections in the ICU. A post hoc analysis of individual data of three multicentric randomized trials. Clin Infect Dis 2021;73(5):e1054e1061.CrossRefGoogle Scholar
Mermel, LA, McCormick, RD, Springman, SR, Maki, DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med 1991;91:197S205S.CrossRefGoogle ScholarPubMed
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;15:231238.CrossRefGoogle ScholarPubMed
Hu, KK, Lipsky, BA, Veenstra, DL, Saint, S. Using maximal sterile barriers to prevent central venous catheter-related infection: a systematic evidence-based review. Am J Infect Control 2004;32:142146.CrossRefGoogle ScholarPubMed
Ishikawa, Y, Kiyama, T, Haga, Y, et al. Maximal sterile barrier precautions do not reduce catheter-related bloodstream infections in general surgery units: a multi-institutional randomized controlled trial. Ann Surg 2010;251:620623.CrossRefGoogle Scholar
Burrell, AR, McLaws, ML, Murgo, M, Calabria, E, Pantle, AC, Herkes, R. Aseptic insertion of central venous lines to reduce bacteraemia. Med J Aust 2011;194:583587.CrossRefGoogle ScholarPubMed
Lee, DH, Jung, KY, Choi, YH. Use of maximal sterile barrier precautions and/or antimicrobial-coated catheters to reduce the risk of central venous catheter-related bloodstream infection. Infect Control Hosp Epidemiol 2008;29:947950.CrossRefGoogle ScholarPubMed
Garland, JS, Buck, RK, Maloney, P, et al. Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial. Pediatr Infect Dis J 1995;14:510516.CrossRefGoogle ScholarPubMed
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;31:10011007.CrossRefGoogle ScholarPubMed
Chaiyakunapruk, N, Veenstra, DL, Lipsky, BA, Saint, S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med 2002;136:792801.CrossRefGoogle ScholarPubMed
Lai, NM, Lai, NA, O’Riordan, E, Chaiyakunapruk, N, Taylor, JE, Tan, K. Skin antisepsis for reducing central venous catheter-related infections. Cochrane Database Syst Rev 2016;7:CD010140.Google ScholarPubMed
Pages, J, Hazera, P, Megarbane, B, et al. Comparison of alcoholic chlorhexidine and povidone-iodine cutaneous antiseptics for the prevention of central venous catheter-related infection: a cohort and quasi-experimental multicenter study. Intensive Care Med 2016;42:14181426.CrossRefGoogle ScholarPubMed
Masuyama, T, Yasuda, H, Sanui, M, Lefor, AK. Effect of skin antiseptic solutions on the incidence of catheter-related bloodstream infection: a systematic review and network meta-analysis. J Hosp Infect 2021;110:156164.CrossRefGoogle ScholarPubMed
Garland, JS, Alex, CP, Mueller, CD, et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001;107:14311436.CrossRefGoogle ScholarPubMed
Levy, I, Katz, J, Solter, E, et al. Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J 2005;24:676679.CrossRefGoogle ScholarPubMed
Ho, KM, Litton, E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis. J Antimicrob Chemother 2006;58:281287.CrossRefGoogle ScholarPubMed
Timsit, JF, Schwebel, C, Bouadma, L, et al. Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009;301:12311241.CrossRefGoogle ScholarPubMed
Ruschulte, H, Franke, M, Gastmeier, P, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Ann Hematol 2009;88:267272.CrossRefGoogle ScholarPubMed
Camins, BC, Richmond, AM, Dyer, KL, et al. A crossover intervention trial evaluating the efficacy of a chlorhexidine-impregnated sponge in reducing catheter-related bloodstream infections among patients undergoing hemodialysis. Infect Control Hosp Epidemiol 2010;31:11181123.CrossRefGoogle ScholarPubMed
Ullman, AJ, Cooke, ML, Mitchell, M, et al. Dressing and securement for central venous access devices (CVADs): a Cochrane systematic review. Int J Nurs Stud 2016;59:177196.CrossRefGoogle ScholarPubMed
Puig-Asensio, M, Marra, AR, Childs, CA, Kukla, ME, Perencevich, EN, Schweizer, ML. Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis. Infect Control Hosp Epidemiol 2020;41:13881395.CrossRefGoogle ScholarPubMed
Righetti, M, Palmieri, N, Bracchi, O, et al. Tegaderm CHG dressing significantly improves catheter-related infection rate in hemodialysis patients. J Vasc Access 2016;17:417422.CrossRefGoogle Scholar
Apata, IW, Hanfelt, J, Bailey, JL, Niyyar, VD. Chlorhexidine-impregnated transparent dressings decrease catheter-related infections in hemodialysis patients: a quality improvement project. J Vasc Access 2017;18:103108.CrossRefGoogle ScholarPubMed
Maki, DG, Stolz, SS, Wheeler, S, Mermel, LA. A prospective, randomized trial of gauze and two polyurethane dressings for site care of pulmonary artery catheters: implications for catheter management. Crit Care Med 1994;22:17291737.CrossRefGoogle ScholarPubMed
Rasero, L, Degl’Innocenti M, Mocali M. Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients:results of a randomized, multicenter study. Haematologica 2000;85:275279.Google Scholar
Timsit, JF, Bouadma, L, Ruckly, S, et al. Dressing disruption is a major risk factor for catheter-related infections. Crit Care Med 2012;40:17071714.CrossRefGoogle ScholarPubMed
Gavin, NC, Webster, J, Chan, RJ, Rickard, CM. Frequency of dressing changes for central venous access devices on catheter-related infections. Cochrane Database Syst Rev 2016;2:CD009213.Google ScholarPubMed
Short, KL. Implementation of a central-line maintenance bundle for dislodgement and infection prevention in the NICU. Adv Neonatal Care 2019;19:145150.CrossRefGoogle ScholarPubMed
Salzman, MB, Isenberg, HD, Rubin, LG. Use of disinfectants to reduce microbial contamination of hubs of vascular catheters. J Clin Microbiol 1993;31:475479.CrossRefGoogle ScholarPubMed
Luebke, MA, Arduino, MJ, Duda, DL, et al. Comparison of the microbial barrier properties of a needleless and a conventional needle-based intravenous access system. Am J Infect Control 1998;26:437441.CrossRefGoogle Scholar
Casey, AL, Worthington, T, Lambert, PA, Quinn, D, Faroqui, MH, Elliott, TS. A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector. J Hosp Infect 2003;54:288293.CrossRefGoogle ScholarPubMed
Munoz-Price, LS, Dezfulian, C, Wyckoff, M, et al. Effectiveness of stepwise interventions targeted to decrease central catheter-associated bloodstream infections. Crit Care Med 2012;40:14641469.CrossRefGoogle ScholarPubMed
Soothill, JS, Bravery, K, Ho, A, Macqueen, S, Collins, J, Lock, P. A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: a pediatric single center before/after study on a hemopoietic stem cell transplant ward. Am J Infect Control 2009;37:626630.CrossRefGoogle Scholar
Hong, H, Morrow, DF, Sandora, TJ, Priebe, GP. Disinfection of needleless connectors with chlorhexidine-alcohol provides long-lasting residual disinfectant activity. Am J Infect Control 2013;41(8):e77e79.CrossRefGoogle ScholarPubMed
Rupp, ME, Yu, S, Huerta, T, et al. Adequate disinfection of a split-septum needleless intravascular connector with a 5-second alcohol scrub. Infect Control Hosp Epidemiol 2012;33:661665.CrossRefGoogle ScholarPubMed
Simmons, S, Bryson, C, Porter, S. “Scrub the hub”: cleaning duration and reduction in bacterial load on central venous catheters. Crit Care Nurs Q 2011;34:3135.CrossRefGoogle ScholarPubMed
Hankins, R, Majorant, OD, Rupp, ME, et al. Microbial colonization of intravascular catheter connectors in hospitalized patients. Am J Infect Control 2019;47:14891492.CrossRefGoogle ScholarPubMed
van der Kooi, T, Sax, H, Pittet, D, et al. Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections. Intensive Care Med 2018;44:4860.CrossRefGoogle ScholarPubMed
Rotz, S, Sopirala, MM. Assessment beyond central-line bundle: audits for line necessity in infected central lines in a surgical intensive care unit. Am J Infect Control 2012;40:8889.CrossRefGoogle Scholar
Cload, B, Day, AG, Ilan, R. Evaluation of unnecessary central venous catheters in critically ill patients: a prospective observational study. Can J Anaesth 2010;57:830835.CrossRefGoogle ScholarPubMed
Seguin, P, Laviolle, B, Isslame, S, Coue, A, Malledant, Y. Effectiveness of simple daily sensitization of physicians to the duration of central venous and urinary tract catheterization. Intensive Care Med 2010;36:12021206.CrossRefGoogle Scholar
Faruqi, A, Medefindt, J, Dutta, G, Philip, SA, Tompkins, D, Carey, J. Effect of a multidisciplinary intervention on central-line utilization in an acute-care hospital. Am J Infect Control 2012;40:e211e115.CrossRefGoogle Scholar
Rickard, CM, Marsh, NM, Larsen, EN, et al. Effect of infusion set replacement intervals on catheter-related bloodstream infections (RSVP): a randomised, controlled, equivalence (central venous access device)-non-inferiority (peripheral arterial catheter) trial. Lancet 2021;397:14471458.CrossRefGoogle ScholarPubMed
Gastmeier, P, Geffers, C, Brandt, C, et al. Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections. J Hosp Infect 2006;64:1622.CrossRefGoogle ScholarPubMed
Zingg, W, Sax, H, Inan, C, et al. Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected. J Hosp Infect 2009;73:4146.CrossRefGoogle Scholar
Sunkesula, VCK, Kundrapu, S, Knighton, S, Cadnum, JL, Donskey, CJ. A Randomized trial to determine the impact of an educational patient hand-hygiene intervention on contamination of hospitalized patient’s hands with healthcare-associated pathogens. Infect Control Hosp Epidemiol 2017;38:595597.CrossRefGoogle ScholarPubMed
Lin, MY, Hota, B, Khan, YM, et al. Quality of traditional surveillance for public reporting of nosocomial bloodstream infection rates. JAMA 2010;304:20352041.CrossRefGoogle ScholarPubMed
Wang, H, Tong, H, Liu, H, et al. Effectiveness of antimicrobial-coated central venous catheters for preventing catheter-related bloodstream infections with the implementation of bundles: a systematic review and network meta-analysis. Ann Intensive Care 2018;8:71.CrossRefGoogle Scholar
Chong, HY, Lai, NM, Apisarnthanarak, A, Chaiyakunapruk, N. Comparative efficacy of antimicrobial central venous catheters in reducing catheter-related bloodstream infections in adults: abridged cochrane systematic review and network meta-analysis. Clin Infect Dis 2017;64:S131S140.CrossRefGoogle ScholarPubMed
Novikov, A, Lam, MY, Mermel, LA, Casey, AL, Elliott, TS, Nightingale, P. Impact of catheter antimicrobial coating on species-specific risk of catheter colonization: a meta-analysis. Antimicrob Resist Infect Control 2012;1:40.CrossRefGoogle ScholarPubMed
Gilbert, RE, Mok, Q, Dwan, K, et al. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): a randomised controlled trial. Lancet 2016;387:17321742.CrossRefGoogle ScholarPubMed
Lai, L, Yue, X. Efficacy of antimicrobial-impregnated catheters for prevention of bloodstream infections in pediatric patients: a meta-analysis. Front Pediatr 2021;9:632308.CrossRefGoogle ScholarPubMed
Cherry-Bukowiec, JR, Denchev, K, Dickinson, S, et al. Prevention of catheter-related blood stream infection: back to basics? Surg Infect (Larchmt) 2011;12:2732.CrossRefGoogle ScholarPubMed
Ullman, AJ, Paterson, RS, Schults, JA, et al. Do antimicrobial and antithrombogenic peripherally inserted central catheter (PICC) materials prevent catheter complications? An analysis of 42,562 hospitalized medical patients. Infect Control Hosp Epidemiol 2021. doi: 10.1017/ice.2021.141.Google ScholarPubMed
Guleri, A, Kumar, A, Morgan, RJ, Hartley, M, Roberts, DH. Anaphylaxis to chlorhexidine-coated central venous catheters: a case series and review of the literature. Surg Infect (Larchmt) 2012;13:171174.CrossRefGoogle ScholarPubMed
Carratala, J, Niubo, J, Fernandez-Sevilla, A, et al. Randomized, double-blind trial of an antibiotic-lock technique for prevention of gram-positive central venous catheter-related infection in neutropenic patients with cancer. Antimicrob Agents Chemother 1999;43:22002204.CrossRefGoogle ScholarPubMed
Henrickson, KJ, Axtell, RA, Hoover, SM, et al. Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: a randomized, multicenter, double-blind trial. J Clin Oncol 2000;18:12691278.CrossRefGoogle ScholarPubMed
Safdar, N, Maki, DG. Use of vancomycin-containing lock or flush solutions for prevention of bloodstream infection associated with central venous access devices: a meta-analysis of prospective, randomized trials. Clin Infect Dis 2006;43:474484.CrossRefGoogle ScholarPubMed
Labriola, L, Crott, R, Jadoul, M. Preventing haemodialysis catheter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials. Nephrol Dialysis Transpl 2008;23:16661672.CrossRefGoogle ScholarPubMed
Snaterse, M, Ruger, W, Scholte Op Reimer, WJ, Lucas, C. Antibiotic-based catheter lock solutions for prevention of catheter-related bloodstream infection: a systematic review of randomised controlled trials. J Hosp Infect 2010;75:111.CrossRefGoogle ScholarPubMed
Oliveira, C, Nasr, A, Brindle, M, Wales, PW. Ethanol locks to prevent catheter-related bloodstream infections in parenteral nutrition: a meta-analysis. Pediatrics 2012;129:318329.CrossRefGoogle ScholarPubMed
Zacharioudakis, IM, Zervou, FN, Arvanitis, M, Ziakas, PD, Mermel, LA, Mylonakis, E. Antimicrobial lock solutions as a method to prevent central line-associated bloodstream infections: a meta-analysis of randomized controlled trials. Clin Infect Dis 2014;59:17411749.CrossRefGoogle ScholarPubMed
Sheng, KX, Zhang, P, Li, JW, et al. Comparative efficacy and safety of lock solutions for the prevention of catheter-related complications including infectious and bleeding events in adult haemodialysis patients: a systematic review and network meta-analysis. Clin Microbiol Infect 2020;26:545552.CrossRefGoogle ScholarPubMed
Arechabala, MC, Catoni, MI, Claro, JC, et al. Antimicrobial lock solutions for preventing catheter-related infections in haemodialysis. Cochrane Database Syst Rev 2018;4:CD010597.Google ScholarPubMed
Opilla, MT, Kirby, DF, Edmond, MB. Use of ethanol lock therapy to reduce the incidence of catheter-related bloodstream infections in home parenteral nutrition patients. J Parenter Enteral Nutr 2007;31:302305.CrossRefGoogle ScholarPubMed
Slobbe, L, Doorduijn, JK, Lugtenburg, PJ, et al. Prevention of catheter-related bacteremia with a daily ethanol lock in patients with tunnelled catheters: a randomized, placebo-controlled trial. PLoS One 2010;5:e10840.CrossRefGoogle ScholarPubMed
Cober, MP, Kovacevich, DS, Teitelbaum, DH. Ethanol-lock therapy for the prevention of central venous access device infections in pediatric patients with intestinal failure. J Parenter Enteral Nutr 2011;35:6773.CrossRefGoogle ScholarPubMed
Heng, AE, Abdelkader, MH, Diaconita, M, et al. Impact of short term use of interdialytic 60% ethanol lock solution on tunneled silicone catheter dysfunction. Clin Nephrol 2011;75:534541.CrossRefGoogle ScholarPubMed
Mermel, LA, Alang, N. Adverse effects associated with ethanol catheter lock solutions: a systematic review. J Antimicrob Chemother 2014;69:26112619.CrossRefGoogle ScholarPubMed
Wolf, J, Connell, TG, Allison, KJ, et al. Treatment and secondary prophylaxis with ethanol lock therapy for central line-associated bloodstream infection in paediatric cancer: a randomised, double-blind, controlled trial. Lancet Infect Dis 2018;18:854863.CrossRefGoogle ScholarPubMed
Hemmelgarn, BR, Moist, LM, Lok, CE, et al. Prevention of dialysis catheter malfunction with recombinant tissue plasminogen activator. N Engl J Med 2011;364:303312.CrossRefGoogle ScholarPubMed
Miller, JM, Goetz, AM, Squier, C, Muder, RR. Reduction in nosocomial intravenous device-related bacteremias after institution of an intravenous therapy team. J Intravenous Nurs 1996;19:103106.Google ScholarPubMed
Taylor, T, Massaro, A, Williams, L, et al. Effect of a dedicated percutaneously inserted central catheter team on neonatal catheter-related bloodstream infection. Adv Neonatal Care 2011;11:122128.CrossRefGoogle Scholar
Soifer, NE, Borzak, S, Edlin, BR, Weinstein, RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med 1998;158:473477.CrossRefGoogle ScholarPubMed
Carr, PJ, Higgins, NS, Cooke, ML, Mihala, G, Rickard, CM. Vascular access specialist teams for device insertion and prevention of failure. Cochrane Database Syst Rev 2018;3:CD011429.Google ScholarPubMed
Levin, A, Mason, AJ, Jindal, KK, Fong, IW, Goldstein, MB. Prevention of hemodialysis subclavian vein catheter infections by topical povidone-iodine. Kidney Int 1991;40:934938.CrossRefGoogle ScholarPubMed
Riu, S, Ruiz, CG, Martinez-Vea, A, Peralta, C, Oliver, JA. Spontaneous rupture of polyurethane peritoneal catheter: a possible deleterious effect of mupirocin ointment. Nephrol Dialysis Transpl 1998;13:18701871.CrossRefGoogle ScholarPubMed
Lok, CE, Stanley, KE, Hux, JE, Richardson, R, Tobe, SW, Conly, J. Hemodialysis infection prevention with polysporin ointment. J Am Soc Nephrol 2003;14:169179.CrossRefGoogle ScholarPubMed
Battistella, M, Bhola, C, Lok, CE. Long-term follow-up of the Hemodialysis Infection Prevention with Polysporin Ointment (HIPPO) study: a quality improvement report. Am J Kidney Dis 2011;57:432441.CrossRefGoogle ScholarPubMed
James, MT, Conley, J, Tonelli, M, Manns, BJ, MacRae, J, Hemmelgarn, BR. Meta-analysis: antibiotics for prophylaxis against hemodialysis catheter-related infections. Ann Intern Med 2008;148:596605.CrossRefGoogle ScholarPubMed
Oto, J, Imanaka, H, Konno, M, Nakataki, E, Nishimura, M. A prospective clinical trial on prevention of catheter contamination using the hub protection cap for needleless injection device. Am J Infect Control 2011;39:309313.CrossRefGoogle ScholarPubMed
Sweet, MA, Cumpston, A, Briggs, F, Craig, M, Hamadani, M. Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. Am J Infect Control 2012;40:931934.CrossRefGoogle Scholar
Wright, MO, Tropp, J, Schora, DM, et al. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. Am J Infect Control 2013;41:3338.CrossRefGoogle ScholarPubMed
Loftus, RW, Brindeiro, BS, Kispert, DP, et al. Reduction in intraoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system. Anesth Analg 2012;115:13151323.CrossRefGoogle ScholarPubMed
Hymes, JL, Mooney, A, Van Zandt, C, Lynch, L, Ziebol, R, Killion, D. Dialysis catheter-related bloodstream infections: a cluster-randomized trial of the ClearGuard HD antimicrobial barrier cap. Am J Kidney Dis 2017;69:220227.CrossRefGoogle ScholarPubMed
Brunelli, SM, Van Wyck, DB, Njord, L, Ziebol, RJ, Lynch, LE, Killion, DP. Cluster-randomized trial of devices to prevent catheter-related bloodstream infection. J Am Soc Nephrol 2018;29:13361343.CrossRefGoogle ScholarPubMed
Flynn, JM, Larsen, EN, Keogh, S, Ullman, AJ, Rickard, CM. Methods for microbial needleless connector decontamination: a systematic review and meta-analysis. Am J Infect Control 2019;47:956962.CrossRefGoogle ScholarPubMed
McKee, R, Dunsmuir, R, Whitby, M, Garden, OJ. Does antibiotic prophylaxis at the time of catheter insertion reduce the incidence of catheter-related sepsis in intravenous nutrition? J Hosp Infect 1985;6:419425.CrossRefGoogle ScholarPubMed
Ranson, MR, Oppenheim, BA, Jackson, A, Kamthan, AG, Scarffe, JH. Double-blind placebo controlled study of vancomycin prophylaxis for central venous catheter insertion in cancer patients. J Hosp Infect 1990;15:95102.CrossRefGoogle ScholarPubMed
Sandoe, JA, Kumar, B, Stoddart, B, et al. Effect of extended perioperative antibiotic prophylaxis on intravascular catheter colonization and infection in cardiothoracic surgery patients. J Antimicrob Chemother 2003;52:877879.CrossRefGoogle ScholarPubMed
Karanlik, H, Kurul, S, Saip, P, et al. The role of antibiotic prophylaxis in totally implantable venous access device placement: results of a single-center prospective randomized trial. Am J Surg 2011;202:1015.CrossRefGoogle ScholarPubMed
van de Wetering, MD, van Woensel, JB, Lawrie, TA. Prophylactic antibiotics for preventing gram-positive infections associated with long-term central venous catheters in oncology patients. Cochrane Database Syst Rev 2013:CD003295.Google ScholarPubMed
Cook, D, Randolph, A, Kernerman, P, et al. Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med 1997;25:14171424.CrossRefGoogle ScholarPubMed
Maragakis, LL, Bradley, KL, Song, X, et al. Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol 2006;27:6770.CrossRefGoogle ScholarPubMed
Field, K, McFarlane, C, Cheng, AC, et al. Incidence of catheter-related bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an Australian hematology-oncology unit. Infect Control Hosp Epidemiol 2007;28:610613.CrossRefGoogle Scholar
Salgado, CD, Chinnes, L, Paczesny, TH, Cantey, JR. Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute-care hospital. Infect Control Hosp Epidemiol 2007;28:684688.CrossRefGoogle Scholar
Rupp, ME, Sholtz, LA, Jourdan, DR, et al. Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve. Clin Infect Dis 2007;44:14081414.CrossRefGoogle ScholarPubMed
Jarvis, WR, Murphy, C, Hall, KK, et al. Health care-associated bloodstream infections associated with negative- or positive-pressure or displacement mechanical valve needleless connectors. Clin Infect Dis 2009;49:18211827.CrossRefGoogle ScholarPubMed
Rosenthal, VD. Impact of needle-free connectors compared with 3-way stopcocks on catheter-related bloodstream infection rates: a meta-analysis. Am J Infect Control 2020;48:281284.CrossRefGoogle ScholarPubMed
Casey, AL, Karpanen, TJ, Nightingale, P, Cook, M, Elliott, TS. Microbiological comparison of a silver-coated and a non-coated needleless intravascular connector in clinical use. J Hosp Infect 2012;80:299303.CrossRefGoogle Scholar
Jacob, JT, Chernetsky Tejedor, S, Dent Reyes, M, et al. Comparison of a silver-coated needleless connector and a standard needleless connector for the prevention of central line-associated bloodstream infections. Infect Control Hosp Epidemiol 2015;36:294301.CrossRefGoogle Scholar
Webster, J, Gillies, D, O’Riordan, E, Sherriff, KL, Rickard, CM. Gauze and tape and transparent polyurethane dressings for central venous catheters. Cochrane Database Syst Rev 2011:CD003827.Google ScholarPubMed
Batra, R, Cooper, BS, Whiteley, C, Patel, AK, Wyncoll, D, Edgeworth, JD. Efficacy and limitation of a chlorhexidine-based decolonization strategy in preventing transmission of methicillin-resistant Staphylococcus aureus in an intensive care unit. Clin Infect Dis 2010;50:210217.CrossRefGoogle Scholar
Rickard, CM, Edwards, M, Spooner, AJ, et al. A 4-arm randomized controlled pilot trial of innovative solutions for jugular central venous access device securement in 221 cardiac surgical patients. J Crit Care 2016;36:3542.CrossRefGoogle ScholarPubMed
Karpanen, TJ, Casey, AL, Whitehouse, T, et al. A clinical evaluation of two central venous catheter stabilization systems. Ann Intensive Care 2019;9:49.CrossRefGoogle ScholarPubMed
Bertini, G, Elia, S, Ceciarini, F, Dani, C. Reduction of catheter-related bloodstream infections in preterm infants by the use of catheters with the AgION antimicrobial system. Early Hum Dev 2013;89:2125.CrossRefGoogle ScholarPubMed
Bertini, G, Elia, S, Ceciarini, F, Dani, C. Reduction of catheter-related bloodstream infections in preterm infants by the use of catheters with the AgION antimicrobial system. Early Hum Dev 2013;89:2125.CrossRefGoogle ScholarPubMed
Bizzarro, MJ, Sabo, B, Noonan, M, et al. A quality improvement initiative to reduce central line-associated bloodstream infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2010;31:241248.CrossRefGoogle Scholar
Sawyer, M, Weeks, K, Goeschel, CA, et al. Using evidence, rigorous measurement, and collaboration to eliminate central catheter-associated bloodstream infections. Crit Care Med 2010;38:S292S298.CrossRefGoogle ScholarPubMed
Central-line insertion checklist: Virginia Mason Medical Center example. Institute for Healthcare Improvement website. http://www.ihi.org/resources/Pages/Tools/CentralLineInsertionChecklist.aspx. Accessed March 22, 2022.Google Scholar
Fakih, MG, Jones, K, Rey, JE, et al. Sustained improvements in peripheral venous catheter care in non-intensive care units: a quasi-experimental controlled study of education and feedback. Infect Control Hosp Epidemiol 2012;33:449455.CrossRefGoogle Scholar
Fakih, MG, Jones, K, Rey, JE, et al. Peripheral venous catheter care in the emergency department: education and feedback lead to marked improvements. Am J Infect Control 2013;41:531536.CrossRefGoogle ScholarPubMed
Fakih, MG, Gould, CV, Trautner, BW, et al. Beyond infection: device utilization ratio as a performance measure for urinary catheter harm. Infect Control Hosp Epidemiol 2016;37:327333.CrossRefGoogle ScholarPubMed
Widmer, AF, Nettleman, M, Flint, K, Wenzel, RP. The clinical impact of culturing central venous catheters. A prospective study. Arch Intern Med 1992;152:12991302.CrossRefGoogle ScholarPubMed
Raad, II, Baba, M, Bodey, GP. Diagnosis of catheter-related infections: the role of surveillance and targeted quantitative skin cultures. Clin Infect Dis 1995;20:593597.CrossRefGoogle ScholarPubMed
Pittet, D, Wenzel, RP. Nosocomial bloodstream infections. Secular trends in rates, mortality, and contribution to total hospital deaths. Arch Intern Med 1995;155:11771184.CrossRefGoogle ScholarPubMed
Fakih, MG, Huang, RH, Bufalino, A, et al. The case for a population standardized infection ratio (SIR): a metric that marries the device SIR to the standardized utilization ratio (SUR). Infect Control Hosp Epidemiol 2019;40:979982.CrossRefGoogle Scholar
Wong, ES, Rupp, ME, Mermel, L, et al. Public disclosure of healthcare-associated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2005;26:210212.CrossRefGoogle Scholar
Aswani, MS, Reagan, J, Jin, L, Pronovost, PJ, Goeschel, C. Variation in public reporting of central line-associated bloodstream infections by state. Am J Med Qual 2011;26:387395.CrossRefGoogle ScholarPubMed
Talbot, TR, Bratzler, DW, Carrico, RM, et al. Public reporting of healthcare-associated surveillance data: recommendations from the healthcare infection control practices advisory committee. Ann Intern Med 2013;159:631635.CrossRefGoogle Scholar
Evans, ME, Kralovic, SM, Simbartl, LA, Jain, R, Roselle, GA. Eight years of decreased methicillin-resistant Staphylococcus aureus healthcare-associated infections associated with a Veterans’ Affairs prevention initiative. Am J Infect Control 2017;45:1316.CrossRefGoogle Scholar
Hamill, ME, Reed, CR, Fogel, SL, et al. Contact isolation precautions in trauma patients: an analysis of infectious complications. Surg Infect (Larchmt) 2017;18:273281.CrossRefGoogle ScholarPubMed
Chopra, V, Flanders, SA, Saint, S, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med 2015;163:S1S40.CrossRefGoogle ScholarPubMed
Fakih, MG, Heavens, M, Ratcliffe, CJ, Hendrich, A. First step to reducing infection risk as a system: evaluation of infection prevention processes for 71 hospitals. Am J Infect Control 2013;41:950954.CrossRefGoogle ScholarPubMed
Owings, A, Graves, J, Johnson, S, Gilliam, C, Gipson, M, Hakim, H. Leadership line care rounds: application of the engage, educate, execute, and evaluate improvement model for the prevention of central line-associated bloodstream infections in children with cancer. Am J Infect Control 2018;46:229231.CrossRefGoogle ScholarPubMed
Pronovost, PJ, Berenholtz, SM, Needham, DM. Translating evidence into practice: a model for large scale knowledge translation. BMJ 2008;337:a1714.CrossRefGoogle Scholar
Safdar, N, Abad, C. Educational interventions for prevention of healthcare-associated infection: a systematic review. Crit Care Med 2008;36:933940.CrossRefGoogle ScholarPubMed
Smith, JS, Kirksey, KM, Becker, H, Brown, A. Autonomy and self-efficacy as influencing factors in nurses’ behavioral intention to disinfect needleless intravenous systems. J Infus Nurs 2011;34:193200.CrossRefGoogle ScholarPubMed
Hendy, J, Barlow, J. The role of the organizational champion in achieving health system change. Social Sci Med 2012;74:348355.CrossRefGoogle ScholarPubMed
Weaver, SJ, Lubomksi, LH, Wilson, RF, Pfoh, ER, Martinez, KA, Dy, SM. Promoting a culture of safety as a patient safety strategy: a systematic review. Ann Intern Med 2013;158:369374.CrossRefGoogle ScholarPubMed
Fakih, MG, Krein, SL, Edson, B, Watson, SR, Battles, JB, Saint, S. Engaging healthcare workers to prevent catheter-associated urinary tract infection and avert patient harm. Am J Infect Control 2014;42:S223S229.CrossRefGoogle ScholarPubMed
Wathen, C, Kshettry, VR, Krishnaney, A, et al. The association between operating room personnel and turnover with surgical site infection in more than 12,00 neurosurgical cases. Neurosurgery 2016;79:889894.CrossRefGoogle Scholar
Huang, GC, Newman, LR, Schwartzstein, RM, et al. Procedural competence in internal medicine residents: validity of a central venous catheter insertion assessment instrument. Acad Med 2009;84:11271134.CrossRefGoogle ScholarPubMed
Evans, LV, Dodge, KL. Simulation and patient safety: evaluative checklists for central venous catheter insertion. Qual Saf Health Care 2010;19 suppl 3:i42i46.CrossRefGoogle Scholar
Segreti, J, Garcia-Houchins, S, Gorski, L, et al. Consensus conference on prevention of central line-associated bloodstream infections: 2009. J Infus Nurs 2011;34:126133.CrossRefGoogle ScholarPubMed
Nailon, RE, Rupp, ME, Lyden, E. A day in the life of a CVAD. J Infusion Nurs 2019;42:125131.CrossRefGoogle Scholar
Wheeler, DS, Giaccone, MJ, Hutchinson, N, et al. A hospital-wide quality-improvement collaborative to reduce catheter-associated bloodstream infections. Pediatrics 2011;128:e995e1004.CrossRefGoogle ScholarPubMed
Marra, AR, Cal, RG, Durao, MS, et al. Impact of a program to prevent central line-associated bloodstream infection in the zero tolerance era. Am J Infect Control 2010;38:434439.CrossRefGoogle ScholarPubMed
Powers, RJ, Wirtschafter, DW. Decreasing central line-associated bloodstream infection in neonatal intensive care. Clin Perinatol 2010;37:247272.CrossRefGoogle ScholarPubMed
Berhe, M, Edmond, MB, Bearman, G. Measurement and feedback of infection control process measures in the intensive care unit: Impact on compliance. Am J Infect Control 2006;34:537539.CrossRefGoogle ScholarPubMed
Assanasen, S, Edmond, M, Bearman, G. Impact of 2 different levels of performance feedback on compliance with infection control process measures in 2 intensive care units. Am J Infect Control 2008;36:407413.CrossRefGoogle ScholarPubMed
Miller, MR, Griswold, M, Harris, JM, 2nd, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 2010;125:206213.CrossRefGoogle ScholarPubMed
Stevens, TP, Schulman, J. Evidence-based approach to preventing central line-associated bloodstream infection in the NICU. Acta Paediatr Suppl 2012;101:1116.CrossRefGoogle ScholarPubMed
Guyatt, GH, Oxman, AD, Vist, GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336:924926.CrossRefGoogle ScholarPubMed
Canadian Task Force on Preventive Health Care website. http://canadiantaskforce.ca/methods/grade/. Accessed December 31, 2021.Google Scholar
Figure 0

Table 1. Summary of Recommendations to Prevent CLABSI

Figure 1

Table 2. Quality of Evidencea

Figure 2

Table 3. CLABSI Prevention Process Measures

Figure 3

Table 4. CLABSI Prevention Outcome Measures

You have Access Open access