HAI: Central Line–Associated Bloodstream Infections

HAI: Central Line–Associated
Bloodstream Infections
Supervised by: Prof. Mahmoud Abu-Ebeeleh
Done by: Dr. Faisal Rawagah

Quick review: types of Catheters
 Vessel cannulated
 Peripheral vein[PIV], Midline catheters, Central vein[CVC], Artery
 Planned duration
 Short-term, Permanent
 Site of insertion [CVC]
 Subclavian, Femoral, Internal jugular, Peripherally inserted central catheter
[PICC]
 Number of lumens
 Single-lumen, Multilumen
 Pathway from skin to vessel
 Subcutaneous port, Tunneled, Nontunneled
 Special features
 Germicide impregnated, Presence or Absence of a cuff
-Weber DJ, Rutala WA. Central line-associated bloodstream infections: prevention and management. Infect Dis Clin North Am. 2011 Mar;25(1):77-102. doi: 10.1016/j.idc.2010.11.012. PMID: 21315995.
-The Washington Manual of Surgery 7th edition, 14 - Common Surgical Procedures, Pages 263- 271
-https://www.uptodate.com/contents/image?imageKey=SURG%2F95494&topicKey=ID%2F13982&search=CLABSI&source=see_link

Central line (CL):
according CDC's National Healthcare Safety Network
 An intravascular catheter that terminates at or close to the heart, OR in one of the great vessels that is
used for infusion, withdrawal of blood, or hemodynamic monitoring.
 Consider the following great vessels when making determinations about CLABSI events and counting
CL device days:
 Aorta
 Pulmonary artery
 Superior vena cava
 Inferior vena cava
 Brachiocephalic veins
 Internal jugular veins
 Subclavian veins
 External iliac veins
 Common iliac veins
 Femoral veins
 In neonates, the umbilical artery/vein.
CDC's National Healthcare Safety Network- https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf

Central Venous Access Device
 Defined as: A catheter inserted into a venous great vessel, which includes the superior vena
cava, inferior vena cava, internal jugular vein, subclavian vein, iliac vein, common femoral
vein, or brachiocephalic vein.
 History:
 1929, 25-year-old Werner Forssmann, a German surgical resident, punctured his own left antecubital
vein and passed a 4-Fr ureteric catheter 35 cm centrally.
 In the 1940s Andre Counard and Dickinson Richards refined Forssmann’s technique into a routinely
used clinical tool that was instrumental in cardiovascular research and physiology.
 In 1956, Forssmann, Counard, and Richards received the Noble Prize in Medicine for their achievements
in central venous access.
 In 1945, the concept of intravenous feeding in children was introduced.
 In the early 1960s, catheters were developed for hemodialysis.
 In the late 1960s and early 1970s, The concept of total parenteral nutrition was introduced.
https://www.uptodate.com/contents/overview-of-central-venous-access-in-adults
-Beheshti MV. A concise history of central venous access. Tech Vasc Interv Radiol. 2011 Dec;14(4):184-5. doi: 10.1053/j.tvir.2011.05.002. PMID: 22099008.

Definitions
 Central line-associated bloodstream infection (CLABSI)
 Bloodstream infection (BSI) in a patient with a central venous catheter (CVC), without another attributable source of
infection, that occurs when the CVC has been in place for more than 2 calendar days or removed the day before the
BSI.
 Catheter-related bloodstream infection (CRBSI)
 Clinical signs of sepsis and positive peripheral blood culture in absence of an obvious source other than CVC with
one of the following:
 Positive semi-quantitative (>15 CFU) or quantitative (>10³ CFU) culture from a catheter segment with the same organisms isolated
peripherally.
 Simultaneous quantitative blood cultures with a ratio of ≥3:1 (CVC vs. peripheral).
 Time to culture positivity difference more than 2h between CVC cultures and peripheral cultures.
-Bell T, O'Grady NP. Prevention of Central Line-Associated Bloodstream Infections. Infect Dis Clin North Am. 2017 Sep;31(3):551-559. doi: 10.1016/j.idc.2017.05.007. Epub 2017 Jul 5. PMID: 28687213; PMCID: PMC5666696.
-Laura M. Selby, Mark E. Rupp, Kelly A. Cawcutt, Prevention of Central-Line Associated Bloodstream Infections: 2021 Update, Infectious Disease Clinics of North America, Volume 35, Issue 4, 2021, Pages 841-856, ISSN 0891-5520, ISBN
9780323813693, https://doi.org/10.1016/j.idc.2021.07.004.

Pathogenesis
-Weber DJ, Rutala WA. Central line-associated bloodstream infections: prevention and management. Infect Dis Clin North Am. 2011 Mar;25(1):77-102. doi: 10.1016/j.idc.2010.11.012. PMID: 21315995
-Jordi Camps, Simona Iftimie, Anabel García-Heredia, Antoni Castro, Jorge Joven, Paraoxonases and infectious diseases, Clinical Biochemistry, Volume 50, Issues 13–14, 2017, Pages 804-811, ISSN 0009-9120,
 Skin-catheter interface (extraluminal route).
 Shortterm use central venous catheters (ie, duration
less than 7–10 days)
 Contamination of a hub (endoluminal route)
 Long-term use central venous catheters.
 Bacteremia from a secondary site (less common)
 eg, Urinary tract infection with bacteremia
 Pneumonia
 Contaminated infusate
 Manufacturer (intrinsic contamination)
 During manipulation facility (extrinsic contamination)

Risk Factors
 Prolonged hospitalization before catheterization
 Prolonged duration of catheterization
 Heavy microbial colonization at the insertion site
 Heavy microbial colonization of the catheter hub
 Internal jugular catheterization
 Femoral catheterization in adults
 Neutropenia
 Prematurity (ie, early gestational age)
 Reduced nurse-to-patient ratio in the ICU
 Total parenteral nutrition
 Substandard catheter care (eg, excessive manipulation of the catheter)
 Transfusion of blood products (in children)
-Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL, Yokoe DS; Society for Healthcare Epidemiology of America. Strategies to prevent central line-associated
bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jul;35(7):753-71. doi: 10.1086/676533. PMID: 24915204

Reduced risk factors
 Female gender vs Male
 Subclavian site vs Femoral
 Subcutaneous venous port vs noncuffed
 Antibiotic administration
 Minocycline-rifampin-impregnated catheters
 Single lumen catheters vs Multilumen
-Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL, Yokoe DS; Society for Healthcare Epidemiology of America. Strategies to prevent central line-associated bloodstream
infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jul;35(7):753-71. doi: 10.1086/676533. PMID: 24915204
-The Washington Manual of Surgery 7th edition, 14 - Common Surgical Procedures, Pages 263- 271
-Bell T, O'Grady NP. Prevention of Central Line-Associated Bloodstream Infections. Infect Dis Clin North Am. 2017 Sep;31(3):551-559. doi: 10.1016/j.idc.2017.05.007. Epub 2017 Jul 5. PMID: 28687213; PMCID: PMC5666696

Epidemiology
according CDC's National Healthcare Safety Network 2015-2017 Adult Data
 The CLABSI is 25.3% of all HAI
 United States, CLABSI rate in ICU is estimated
to be 0.8 per 1000 central line days
 International Nosocomial Infection Control
Consortium (INICC) surveillance data from
January 2010 through December 2015 (703
intensive care units in 50 countries) reported a
CLABSI rate of 4.1 per 1000 central line days.
 About 24% increase in CLABSI between 2019 and
2020
 Largest increase in ICU (50%)
-Weiner-Lastinger, L., Abner, S., Edwards, J., Kallen, A., Karlsson, M., Magill, S., . . . Dudeck, M. (2020). Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: Summary of data reported to the National
Healthcare Safety Network, 2015–2017. Infection Control & Hospital Epidemiology, 41(1), 1-18. doi:10.1017/ice.2019.296
-Haddadin Y, Annamaraju P, Regunath H. Central Line Associated Blood Stream Infections. 2021 Aug 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28613641
-2020 National and State Healthcare-Associated Infections Progress Report- https://www.cdc.gov/hai/pdfs/progress-report/2020-Progress-Report-Executive-Summary-H.pdf

Pathogens
-Weiner-Lastinger, L., Abner, S., Edwards, J., Kallen, A., Karlsson, M.,
Magill, S., . . . Dudeck, M. (2020). Antimicrobial-resistant pathogens
associated with adult healthcare-associated infections: Summary of
data reported to the National Healthcare Safety Network, 2015–
2017. Infection Control & Hospital Epidemiology, 41(1), 1-18.
doi:10.1017/ice.2019.296
 Staphylococcus
 Shortterm use CL (less than
7–10 days)
 Candida
 Most common in hospital
wards and ICUs (25%)
 E. coli
 Most common in oncology
units
 Enterococcus
 Made up a higher proportion
in long-term acute-care
hospitals (12%)

Prevention
 CLABSIs substantially increase
morbidity, mortality, length of hospital
stay, and dramatically increased
hospital costs.

Is CVC is a must?
 The first step in preventing vascular
catheter infections is to optimize the
choice of catheter based on the
patient’s clinical need.
 Length of expected need
 Indications for therapeutic infusions
 Patient monitoring
 Difficult vascular access
-Laura M. Selby, Mark E. Rupp, Kelly A. Cawcutt, Prevention of Central-Line Associated Bloodstream
Infections: 2021 Update, Infectious Disease Clinics of North America, Volume 35, Issue 4, 2021,
Pages 841-856, ISSN 0891-5520, ISBN 9780323813693, https://doi.org/10.1016/j.idc.2021.07.004.
Diagram

Use of bundled approaches
 Insertion kit
 Hand hygiene
 Skin preparation
 Maximal barrier precautions
 Sterile gown and gloves
 Surgical mask
 Head cover
 Sterile drape over the patient’s
 Chlorohexidine-impregnated dressing
 Checklist
-Laura M. Selby, Mark E. Rupp, Kelly A. Cawcutt, Prevention of Central-Line Associated Bloodstream Infections: 2021 Update, Infectious Disease Clinics of North America, Volume 35, Issue 4, 2021, Pages 841-856, ISSN 0891-5520, ISBN 9780323813693,
https://doi.org/10.1016/j.idc.2021.07.004.

Types of Catheters and Techniques and Devices
to Prevent Infection
 Antimicrobial-coated catheters
 When to use?
 More than 5 days
 Rates of CLABSI remain high
 High risk for CLABSI
 SubTypes
 Silver sulfadiazine/chlorhexidine and minocycyline/rifampin
 Metal-based antimicrobials such as a silver or platinum product
-https://onlinelibrary.wiley.com/doi/full/10.1002/gch2.201700068

 Hub cleaning, connectors, and accessing catheters
 15-second scrub with 70% isopropyl alcohol
 Lever lock vs Luer lock system catheter
 Needleless connectors
 Alcohol-containing passive hub disinfection caps
 Closed vs Open intravenous infusions systems

 Dressing and dressing changes
 Sterile gauze dressings
 every 48 hours
 Transparent semipermeable dressings
 Weekly
 Soiled, loose, or damp dressings should be changed promptly
 Chlorhexidine-impregnated dressings
 Administration (IV) sets
 should be changed no more than every 96 hours
 Except:
 Parenteral nutrition administration; every 24 hours
 Administer blood every 4 hours or at the completion of a unit
Tegaderm

 Antimicrobial locks
 Long-term vascular catheter use
 Patients with prior CRBSI
 Types:
 Heparin saline solution
 Citrate and Ethylene diamine tetra-acetic acid based solutions (EDTA)
 antibiotic EDTA combination catheter lock solutions
 Minocycline-EDTA (M-EDTA)
-Chaftari, A., Viola, G., Rosenblatt, J., Hachem, R., & Raad, I. (2019). Advances in the prevention and management of central-line–associated bloodstream infections: The role of chelator-based catheter locks. Infection Control & Hospital
Epidemiology, 40(9), 1036-1045. doi:10.1017/ice.2019.162.

 Chlorhexidine gluconate baths
 In or outside of the intensive care unit also
have lower rates of CLABSI and CRBSI
 S aureus to chlorhexidine tolerance may be
developed
-Laura M. Selby, Mark E. Rupp, Kelly A. Cawcutt, Prevention of Central-Line Associated Bloodstream Infections: 2021 Update, Infectious Disease Clinics of North America, Volume 35, Issue 4, 2021, Pages 841-856, ISSN 0891-5520, ISBN
9780323813693, https://doi.org/10.1016/j.idc.2021.07.004.
-https://www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-ape3.html

CLABSI and COVID19 Pandemic
 Increased rates of CLABSI and BSI in both COVID positive and non–COVID-infected individuals.
 About 24% increase in CLABSI between 2019 and 2020
 Largest increase in ICU (50%)
 More catheter days per patient
 Staffing shortages; lower nurse to patient ratios
 Changes in behaviors;
 Moving intravenous pumps outside of rooms, long tubing extensions, more tubing connectors, and an increased
number of possible contamination sites.
 Increase in prone position ventilation; make it more difficult to access.
 CVCs were placed emergently; higher rates of femoral catheters were used.

 Closed ICU vs Open ICU
 Site selection for catheterization
 Do all catheter placements require US guidance?
 What kind of venous catheter should be used?
 Single vs multi-lumen catheters
 Antimicrobial-coated catheters
 Catheter Removal as soon as they are no longer necessary
 Guidewire Exchange
 new venous puncture site is preferred.
 Insertion Technique; sterile insertion technique is absolutely crucial.
 Catheter Dressing and Maintenance.

 Five evidence-based procedures
recommended by the CDC and identified
as having the greatest effect on the rate
of CRBSI and the lowest barriers to
implementation.
 Handwashing
 Using full-barrier precautions during the
insertion of CVC
 Cleaning the skin with chlorhexidine
 Avoiding the femoral site if possible
 Removing unnecessary catheters

Diagnosis; Background
 Exit-site infections
 Erythema, induration, and/or tenderness within 2 cm of the catheter exit site.
 Fever and pus discharge from the exit site.
 Tunnel infections
 Tenderness, erythema, and/or induration greater than 2 cm from the catheter exit site,
and along the subcutaneous track of a tunneled catheter
 Pocket infections; infected fluid in the subcutaneous pocket of a total implanted
intravascular device.
 Tenderness, erythema, and/or induration over the pocket.
 Catheter colonization; catheter tip, subcutaneous catheter segment, or catheter
hub.
 High-grade bacteremia or fungemia.
 Abrupt onset of symptoms/signs of sepsis without obvious source.

Confirm diagnosis of CRBSI
according IDSA Guideline
(Infectious Diseases Society of America)
 Simultaneous quantitative blood cultures drawn through the CVC and peripheral
vein.
 At least a 3-fold greater colony count from catheter hub than that from the peripheral
vein.
 Differential time to positivity with the growth of microbes from a blood sample drawn
from a catheter hub at least 2 hours before microbial growth is detected in a blood
sample obtained from a peripheral vein.
 Positive semi-quantitative >15 colony-forming units (CFU) or quantitative >10³ CFU culture
from a 5 cm catheter segment with the same organisms isolated peripherally.
-Bell T, O'Grady NP. Prevention of Central Line-Associated Bloodstream Infections. Infect Dis Clin North Am. 2017 Sep;31(3):551-559. doi: 10.1016/j.idc.2017.05.007. Epub 2017 Jul 5. PMID: 28687213; PMCID: PMC5666696.

Approach to Management
 Short-term CVC related BSI
 Uncomplicated:
 BSI and fever resolves within 72 hours in a
patient who has:
 No intravascular hardware
 No evidence of endocarditis or
suppurative thrombophlebitis.
 For infections due to S aureus patient is
also without malignancy or
immunosuppression.
 Complicated
 Suppurative thrombophlebitis,
endocarditis, or osteomyelitis
 Remove catheter and treat with systemic
antibiotics for 4–6 weeks; 6–8 weeks for
osteomyelitis in adults.
• 1. Coagulase-negative staphylococci
Remove catheter and treat with systemic antibiotics for 5–7 days.
If catheter is retained, treat with a systemic antibiotic and antibiotic
lock therapy for 10–14 days.
• 2. Staphylococcus aureus
Remove catheter and treat with systemic antibiotics for 14 days.
• 3. Enterococcus spp
• 4. Gram-negative bacilli
• 5. Candida spp
Remove catheter and treat with antifungal therapy for 14 days after
the first negativeblood culture.

Approach to Management
 Long-term central venous catheter or port-related bacteremia or fungemia.
• 1. Coagulase-negative Staphylococcus
May retain catheter/port and use systemic antibiotics for 10–14 days.
Remove catheter or port if there is clinical deterioration, persisting or relapsing
bacteremia; workup for complicated infection and treat accordingly.
• 2. Staphylococcus aureus
Remove the infected catheter/port and treat with 4–6 weeks of antimicrobial therapy,
unless the patient has exceptions listed in Guideline.
• 3. Enterococcus spp
May retain catheter/port and use systemic antibiotic lock therapy for 7–14 days.
Remove catheter or port if there is clinical deterioration, persisting or relapsing bacteremia; workup for complicated infection and treat accordingly.
• 4. Gram-negative bacilli
Remove catheter/port and treat for 7–14 days.
For catheter/port salvage, use systemic and antibiotic lock therapy for 10–14 days; if no
response, remove catheter/port, rule out endocarditis or suppurative thrombophlebitis,
and if not present treat with antibiotics for 10–14 days.
• 5. Candida spp
Remove catheter/port and treat with antifungal therapy for 14 days after the first
negative blood culture.

Empiric therapy
 Gram-positive cocci vancomycin is the drug of choice.
 Methicillin-resistant S aureus (MRSA) Daptomycin.
 Gram-negative bacilli fourth-generation cephalosporin, carbapenem, or b-
lactam/b-lactamase combination with or without an aminoglycoside.
 Converge P. aeruginosa in patients who are neutropenic, septic, or known to be
colonized.
 Converge gram-negative bacilli and Candida spp
 Critically ill patients with a femoral line.
 Total parenteral nutrition (TPN).
 Prolonged use of broad-spectrum antibiotics.
 Hematologic malignancy.
 Stem cell transplantation.
 Solid organ transplantation.
 Multisite colonization with Candida spp.

Catheter Removal
 Long-term catheters should be removed if:
 Severe sepsis.
 Suppurative thrombophlebitis.
 Endocarditis.
 Bloodstream infection that continues despite more than 72 hours of antimicrobial therapy to
which the infecting pathogens are susceptible.
 S aureus, P aeruginosa, fungi, or mycobacteria.
 Catheter salvage in select patients:
 Limited vascular access options and who require long-term intravascular access for survival.
 Both systemic and lock therapy should be used.
 Additional blood cultures should be obtained and the catheter removed if blood culture
results remain positive following 72 hours or more of appropriate antibiotic therapy.

Candidemia
Bassetti M, Giacobbe DR, Vena A, Wolff M. Diagnosis and Treatment of Candidemia in the Intensive Care Unit. Semin Respir Crit Care Med. 2019 Aug;40(4):524-539. doi: 10.1055/s-0039-1693704. Epub 2019 Oct 4. PMID: 31585478.

Risk Prediction Models
 Paphitou
 At least one among three possible predisposing (diabetes, TPN prior to ICU admission, new-onset hemodialysis) plus
ICU stay longer than 4 days, use of broad-spectrum antibiotics, and no use of antifungals from day -7 to +3 with
respect to ICU admission.
 Ostrosky-Zeichner (cohort of 2,890 ICU patients)
 Combination of antibiotic therapy and presence of CVC in the first 3 days of ICU stay plus at least two among surgery,
immunosuppression, pancreatitis, total parenteral nutrition, and steroid use.
 Guillamet (2,597 patients with severe sepsis or septic shock)(cohort of 352 ICU patients)
 Prior antibiotics within 30 days (+2 points), CVC (+2 points), admission from a nursing home (+2 points), total
parenteral nutrition (+2 points), admission from another hospital (+1 point), mechanical ventilation (+1 point), and
lung as the presumed source of sepsis (-6 points).
 1.2% for a cumulative score of –6 points and 43% for a cumulative score of +8 points
 León (cohort of 1,699 ICU patients)
 Multifocal Candida colonization (+1 point), surgery on ICU admission (+1 point), severe sepsis (+2 points), and total
parenteral nutrition (+1 point).
 (>2.5 points)

Laboratory tests
 Blood Cultur
 Antigen/Antibody Detectiones
 (1,3)-β-D-Glucan
 Mannan and Antimannan
 C. albicans germtube antigen (CAGTA)
 Polymerase Chain Reaction (PCR)
Bassetti M, Giacobbe DR, Vena A, Wolff M. Diagnosis and Treatment of Candidemia in the Intensive Care Unit. Semin Respir Crit Care Med. 2019
Aug;40(4):524-539. doi: 10.1055/s-0039-1693704. Epub 2019 Oct 4. PMID: 31585478.

Drugs

References
 Weber DJ, Rutala WA. Central line-associated bloodstream infections: prevention and management. Infect Dis Clin North Am. 2011 Mar;25(1):77-102. doi: 10.1016/j.idc.2010.11.012. PMID: 21315995.
 The Washington Manual of Surgery 7th edition, 14 - Common Surgical Procedures, Pages 263- 271
 CDC's National Healthcare Safety Network- https://www.cdc.gov/nhsn/pdfs/pscmanual/4psc_clabscurrent.pdf
 https://www.uptodate.com/contents/overview-of-central-venous-access-in-adults
 Beheshti MV. A concise history of central venous access. Tech Vasc Interv Radiol. 2011 Dec;14(4):184-5. doi: 10.1053/j.tvir.2011.05.002. PMID: 22099008.
 Bell T, O'Grady NP. Prevention of Central Line-Associated Bloodstream Infections. Infect Dis Clin North Am. 2017 Sep;31(3):551-559. doi: 10.1016/j.idc.2017.05.007. Epub 2017 Jul 5. PMID: 28687213; PMCID:
PMC5666696.
 Laura M. Selby, Mark E. Rupp, Kelly A. Cawcutt, Prevention of Central-Line Associated Bloodstream Infections: 2021 Update, Infectious Disease Clinics of North America, Volume 35, Issue 4, 2021, Pages 841-
856, ISSN 0891-5520, ISBN 9780323813693, https://doi.org/10.1016/j.idc.2021.07.004.
 Jordi Camps, Simona Iftimie, Anabel García-Heredia, Antoni Castro, Jorge Joven, Paraoxonases and infectious diseases, Clinical Biochemistry, Volume 50, Issues 13–14, 2017, Pages 804-811, ISSN 0009-9120
 Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL, Yokoe DS; Society for Healthcare Epidemiology of America. Strategies to prevent central line-
associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014 Jul;35(7):753-71. doi: 10.1086/676533. PMID: 24915204
 Weiner-Lastinger, L., Abner, S., Edwards, J., Kallen, A., Karlsson, M., Magill, S., . . . Dudeck, M. (2020). Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: Summary of data
reported to the National Healthcare Safety Network, 2015–2017. Infection Control & Hospital Epidemiology, 41(1), 1-18. doi:10.1017/ice.2019.296
 2020 National and State Healthcare-Associated Infections Progress Report- https://www.cdc.gov/hai/pdfs/progress-report/2020-Progress-Report-Executive-Summary-H.pdf
 Haddadin Y, Annamaraju P, Regunath H. Central Line Associated Blood Stream Infections. 2021 Aug 22. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–. PMID: 28613641
 Chaftari, A., Viola, G., Rosenblatt, J., Hachem, R., & Raad, I. (2019). Advances in the prevention and management of central-line–associated bloodstream infections: The role of chelator-based catheter
locks. Infection Control & Hospital Epidemiology, 40(9), 1036-1045. doi:10.1017/ice.2019.162.
 Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections
in the ICU. N Engl J Med. 2006 Dec 28;355(26):2725-32. doi: 10.1056/NEJMoa061115. Erratum in: N Engl J Med. 2007 Jun 21;356(25):2660. PMID: 17192537.
 https://www.ahrq.gov/hai/universal-icu-decolonization/universal-icu-ape3.html
 Bassetti M, Giacobbe DR, Vena A, Wolff M. Diagnosis and Treatment of Candidemia in the Intensive Care Unit. Semin Respir Crit Care Med. 2019 Aug;40(4):524-539. doi: 10.1055/s-0039-1693704. Epub 2019
Oct 4. PMID: 31585478.
 Lutwick L, Al-Maani AS, Mehtar S, Memish Z, Rosenthal VD, Dramowski A, Lui G, Osman T, Bulabula A, Bearman G. Managing and preventing vascular catheter infections: A position paper of the international
society for infectious diseases. Int J Infect Dis. 2019 Jul;84:22-29. doi: 10.1016/j.ijid.2019.04.014. Epub 2019 Apr 18. PMID: 31005622.

Thank you
Supervised by:
Prof. Mahmoud Abu-Ebeeleh
Cardiothoracic surgery consultant
Done by:
Dr. Faisal Rawagah
Critical Care Fellow
Jordan University Hospital 16.12.2021

HAI: Central Line–Associated Bloodstream Infections

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