Using the Central Line Bundle Hand Hygiene Remove Unnecessary Lines Use of Maximal Barrier Precautions Chlorhexidine for Skin Antisepsis Avoid femoral lines Report CLABSI rates to the units Celebrate success!!

1. CLABSI
Karthik Ponnappan T MD DM
Organ Transplant Anaesthesia and
Critical Care

2. The Problem
Patient
Safety
Healthcare
Costs

3. • 46% decrease in CLABSIs in U.S. from 2008-2013
• 30,100 central line-associated bloodstream
infections (CLABSI) still occur in U.S. acute care
facilities each year

4. Definition
• A pathogen isolated from a blood culture (a single culture for organisms
which are not commonly present on skin and two or more blood culture
for organisms which are commonly present on the skin)
– in a patient with signs and symptoms of infection
– who has a central line in place at the time of the identification
– or within 48 h before the infection develops
Such infections cannot be related to any other source for infection that the
patient may have or was incubating when the patient was admitted
Centers for Disease Control and Prevention (CDC). Vital signs:central line-associated blood stream infections–United States
Morb Mortal Wkly Rep.2011

6. • Catheter colonization:
– The patient has no signs and symptoms of infection but a
quantitative or semiquantitative culture of the catheter tip or
catheter hub yields significant growth of a microorganism

7. • Exit site infection:
– These infections manifest erythema, induration, and/or
tenderness within 2 cm of the catheter exit site, and exudate
at the exit site yields a microorganism

8. • Tunnel infection:
– Tenderness, erythema, and/or induration are present more
than 2 cm from the exit site along the subcutaneous tract of a
tunneled catheter with or without concomitant bloodstream
infection

9. Pathogenesis

10. Diagnosis

11. Goal: Preventing CLABSI
• Using the Central Line Bundle
– Hand Hygiene
– Remove Unnecessary Lines
– Use of Maximal Barrier Precautions
– Chlorhexidine for Skin Antisepsis
– Avoid femoral lines
• Report CLABSI rates to the units
• Celebrate success!!

13. Hand Hygiene
The single most important factor to reduce
healthcare-associated infections
• Chlorhexidine >> soap and water, alcohol rubs
• Hand hygiene for every time line is accessed
• CLABSI rates decreased from 4.08 per 1000 central line days to 0.42 per
1000 central line days after education and implementation of proper
hand hygiene practices
Doebbeling BN et al. Comparative efficacy of alternative handwashing agents in reducing nosocomial infections in intensive care units. NEJM
1992
Walker JL et al. Hospital hand hygiene compliance improves with increased monitoring and immediate feedback. Am J Infect Control. 2014
Johnson L et al. A multifactorial action plan improves hand hygiene adherence and significantly reduces central line-associated bloodstream
infections. Am J Infect Control. 2014

14. Skin Preparation
• Chlorhexidine rather than povidone-iodine
– 1.6 % decrease in CLABSIs
– 0.23 % decrease in mortality
– saving $113 per catheter used
Chaiyakunapruk N, Veenstra DL, Lipsky BA, Sullivan SD, Saint S.Vascular catheter site care: the clinical and economic
benefits of chlorhexidine gluconate compared with povidone iodine. Clin Infect Dis. 2003

15. Full barrier precautions
• Full body drape for the patient
• Cap, mask, sterile gown, and sterile gloves by the
care providers
• Lower CLABSI rate
Tang H-J et al. The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infect Dis.
2014

16. Insertion Site
• Avoidance of the femoral site
– Associated with the flora of the skin
– in pediatrics- no difference
– DVT risk
• No RCT demonstrating a difference in the risk of
CLABSI between the sites
– Due to strict adherence to guidelines (US, Europe)
Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as
compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis.
Crit Care Med. 2012

17. Removal of unnecessary lines
• Prompt removal of the central line
• 26.2 % of catheter days were idle, with no medical
indication for continued use
• Risk of CLABSI
– 2.1 per 1000 catheter days at line days 1–5
– to 10.2 per 1000 catheter days at line days 16–30
Burdeu G, Currey J, Pilcher D. Idle central venous catheter-days pose infection risk for patients
after discharge from intensive care. Am J Infect Control. 2014

18. Other interventions
• Needleless intravenous
connectors
• Split septum
Tabak YP, Jarvis WR, Sun X, Crosby CT, Johannes RS. Meta analysis on central line-associated
bloodstream infections associated with a needleless intravenous connector with a new
engineering design. Am J Infect Control. 2014

20. • chlorhexidine-
impregnated dressings
and patches
• antibiotic- or
chlorhexidine
impregnated catheters
Safdar N et al. Chlorhexidine-impregnated dressing for prevention of catheter-related
bloodstream infection: a meta-analysis. Crit Care Med. 2014

21. Antibiotic lock therapy
• for prophylaxis( salvage)
• Upto 48 hours

22. CLABSI in limited resource setting

26. Quality Improvement Initiatives
• Matching Michigan
• Keystone ICU
• Bacteremia Zero

28. Type of Catheter
• Non-tunneled Central Venous Catheters
• Multilumen catheters  higher rate of colonization
and infection
• Choose a CVC with minimum number of ports
required
Gil RT, Kruse JA, Thill-Baharozian MC, et al: Triple- vs single-lumen central venous catheters: a prospective study in a
critically ill population. Arch Intern Med 1989

29. Antimicrobial Impregnated CVCs
• If CVC needed for >5 to 14 days and CLABSI rates
high
• Limited venous access and a history of CLABSI
• Risk for severe sequelae in case of systemic
infections, such as patients with recently implanted
devices
Casey AL, Mermel LA, Nightingale P, et al: Antimicrobial central venous catheters in adults: a systematic review and meta-
analysis.
Lancet Infect Dis, 2007

30. Peripherally Inserted Central Venous
Catheters
• less infections
• more mechanical
complications
• Can be left in place for
weeks to months
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.

31. Semipermanent tunneled catheters
• The risk of infection
appears to be low
– Chemotherapy
– those requiring long-term
parenteral nutrition
Crnich CJ, Maki DG: The promise of novel technology for the prevention of intravascular device-related bloodstream
infection. II. Long-term devices. Clin Infect Dis, 2002

32. Pulmonary Artery Catheters
• The risk of low if in for
less than 7 days
• Plastic sleeves to cover
the PAC is recommended

33. Peripheral Arterial Catheters
• rates of complications
similar to venous catheters
• Thrombosis  19% to 38%
• Infection  4% to 23%
• increasing risk of infection
after day 4 of
catheterization
• Femoral route has more
infections
• Decreased infection with
chlorhexidine
impregnated dressing
• No study of barrier
precautions
O’Horo JC, Maki DG, Krupp AE, Safdar N. Arterial Catheters as a Source of Bloodstream Infection: A Systematic Review and
Meta-Analysis. Critical care medicine. 2014

34. Catheter Hub Disinfection
• Local disinfection of the with chlorhexidine or 70%
alcohol before access
• allow the antiseptic to dry before accessing the
catheter

35. Catheter Replacement
Peripheral Catheters
• Catheter causing phlebitis
 removed and the tip
cultured
• Recommendations to
remove and change these
catheters to another site
every 72 hours are aimed at
decreasing the risk for
infection and the discomfort
associated with phlebitis
Central Catheters
• Routine rotation does not
reduce rates of infections

36. Infusion-Related Issues
• Local Effects
• acidic, hypertonic, or direct irritants (KCl, certain
• antibiotics, chemotherapeutic agents)
inflammatory response, thrombosis, phlebitis
infectionuse a central catheter
• Infusion Tubing
• Infusion tubing – change every 96 hours
• If blood products used- change every 24 hours

37. In-Line Devices and Filters
• Pressure transducers  water-associated Gram-
negative bacilli, including Pseudomonas, Serratia,
Enterobacter, Citrobacter, and Acinetobacter spp

38. In-Line Devices and Filters
• Use of a closed system rather than stopcocks has
been shown to lead to less contamination
• All catheter hubs, needleless connectors, and
injection ports should be disinfected with a
chlorhexidine preparation before access

39. Contamination of Infusates
• Several Gram-negative bacilli in the acidic
environment of intravenous fluids
• Candida speciestotal parenteral nutrition (TPN)
• Albumin  the growth of bacteria and fungi
• Lipid emulsions corynebacteria and the yeast
Malassezia furfur
Centers for Disease Control and Prevention: Epidemiologic notes and reports. Nosocomial bacteremias associated with
intravenous fluid therapy—USA.Morb Mortal Wkly Rep 1997.

41. Suppurative Phlebitis
• For peripheral catheters needle aspiration or incision
• Central veins confirmed by detection of a thrombus by
CT,MRI,USG
• Surgical or interventional radiological procedures to remove
the thrombus are technically difficult

42. Suppurative Phlebitis
• Most patients will respond to 3 to 4 weeks of
treatment with systemic antimicrobial therapy
• Surgical resection if
– bloodstream infection persists or
– purulence extends beyond the vessel wall

43. Endocarditis
• The aortic and mitral valves are involved most often
• TEE presence and size of vegetations, the valves
involved and their function, and the presence of
myocardial abscesses