Skip to main content

Eliminating Infections in the ICU: CLABSI

Current Infectious Disease Reports volume 17, Article number: 35 (2015) Cite this article

Abstract

Central line-associated bloodstream infections (CLABSI) are one of the leading causes of death in the USA and around the world. As a preventable healthcare-associated infection, they are associated with significant morbidity and excess costs to the healthcare system. Effective and long-term CLABSI prevention requires a multifaceted approach, involving evidence-based best practices coupled with effective implementation strategies. Currently recommended practices are supported by evidence and are simple, such as appropriate hand hygiene, use of full barrier precautions, avoidance of femoral lines, skin antisepsis, and removal of unnecessary lines. The most successful and sustained improvements in CLABSI rates further utilize an adaptive component to align provider behaviors with consistent and reliable use of evidence-based practices. Great success has been achieved in reducing CLABSI rates in the USA and elsewhere over the past decade, but more is needed. This article aims to review the initiatives undertaken to reduce CLABSI and summarizes the sentinel and recent literature regarding CLABSI and its prevention.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. The Joint Commission. Preventing central line-associated bloodstream infections. 2012. at <http://www.jointcommission.org/topics/clabsi_toolkit.aspx> Accessed December 9, 2014.

  2. Eliminating CLABSI: a national patient safety imperative. September 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/cusp/clabsi-update/index.html. Accessed December 9, 2014.

  3. Centers for Disease Control (CDC). Public health focus: surveillance, prevention, and control of nosocomial infections. MMWR Morb Mortal Wkly Rep. 1992;41(42):783–7.

  4. Umscheid CA et al. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32:101–14.

    PubMed  Article  Google Scholar 

  5. Siempos II, Kopterides P, Tsangaris I, Dimopoulou I, Armaganidis AE. Impact of catheter-related bloodstream infections on the mortality of critically ill patients: a meta-analysis. Crit Care Med. 2009;37:2283–9.

    PubMed  Article  Google Scholar 

  6. Wenzel RP, Edmond MB. The impact of hospital-acquired bloodstream infections. Emerg Infect Dis. 2001;7(2):174–7.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  7. Centers for Disease Control and Prevention (CDC). Vital signs: central line-associated blood stream infections--United States, 2001, 2008, and 2009.MMWR Morb Mortal Wkly Rep. 2011;60(8):243-8.

  8. Stevens V et al. Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections. Clin Microbiol Infect. 2014;20:O318–24.

    CAS  PubMed  Article  Google Scholar 

  9. Herzer KR, Niessen L, Constenla DO, Ward WJ, Pronovost PJ. Cost-effectiveness of a quality improvement programme to reduce central line-associated bloodstream infections in intensive care units in the USA. BMJ Open. 2014;4:e006065. Decision tree analysis of an existing large-scale program on the economic costs related to central line associated blood stream infections from the perspective of US hospitals.

    PubMed Central  PubMed  Article  Google Scholar 

  10. 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;160:976–81.

    CAS  PubMed  Article  Google Scholar 

  11. Rosenthal VD et al. International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004–2009. Am J Infect Control. 2012;40:396–407.

    PubMed  Article  Google Scholar 

  12. Goudie A, Dynan L, Brady PW, Rettiganti M. Attributable cost and length of stay for central line-associated bloodstream infections. Pediatrics. 2014;133:e1525–32.

    PubMed Central  PubMed  Article  Google Scholar 

  13. Edwards JR et al. National Healthcare Safety Network (NHSN) report: data summary for 2006 through 2008, issued December 2009. Am J Infect Control. 2009;37:783–805.

    PubMed  Article  Google Scholar 

  14. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309–32.

    PubMed  Article  Google Scholar 

  15. O’Grady, Alexander, M, Burns LA, et al. CDC guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. at <http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html> Accessed December 9, 2014.

  16. Pratt RJ et al. epic2: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2007;65 Suppl 1:S1–64.

    PubMed  Article  Google Scholar 

  17. Wolf H-H et al. Central venous catheter-related infections in hematology and oncology: guidelines of the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Oncology (DGHO). Ann Hematol. 2008;87:863–76.

    PubMed  Article  Google Scholar 

  18. Hoggard J, Saad T, Schon D, Vesely TM, Royer T. Guidelines for venous access in patients with chronic kidney disease: a position statement from the American society of diagnostic and interventional nephrology clinical practice committee and the association for vascular access. Semin Dial. 2008;21:186–91.

    PubMed  Article  Google Scholar 

  19. Marschall J et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29 Suppl 1:S22–30.

    PubMed  Article  Google Scholar 

  20. Pronovost P et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32.

    CAS  PubMed  Article  Google Scholar 

  21. Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132:391–402.

    CAS  PubMed  Article  Google Scholar 

  22. Berenholtz SM et al. Eliminating central line-associated bloodstream infections: a national patient safety imperative. Infect Control Hosp Epidemiol. 2014;35:56–62. A collaborative cohort study evaulating the impact of the national "On the CUSP: Stop BSI" program on central line associated bloodstream infection rates amongst participating ICUs across the US.

    PubMed  Article  Google Scholar 

  23. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73:305–15.

    CAS  PubMed  Article  Google Scholar 

  24. Casewell M, Phillips I. Hands as route of transmission for Klebsiella species. Br Med J. 1977;2:1315–7.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  25. WHO guidelines on hand hygiene in healthcare. at <http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf> Accessed December 9, 2014.

  26. Guideline for hand hygiene in health-care settings. at <http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf> Accessed December 9, 2014.

  27. Doebbeling BN et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med. 1992;327:88–93.

    CAS  PubMed  Article  Google Scholar 

  28. Walker JL et al. Hospital hand hygiene compliance improves with increased monitoring and immediate feedback. Am J Infect Control. 2014;42:1074–8.

    PubMed  Article  Google Scholar 

  29. MacDonald A, Dinah F, MacKenzie D, Wilson A. Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs. J Hosp Infect. 2004;56:56–63.

    CAS  PubMed  Article  Google Scholar 

  30. Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Infect. 2001;48(Suppl A):S40–6.

    PubMed  Article  Google Scholar 

  31. Pessoa-Silva CL et al. Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics. 2007;120:e382–90.

    PubMed  Article  Google Scholar 

  32. 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;33:392–7.

    PubMed  Article  Google Scholar 

  33. 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;42:1146–51.

    PubMed  Article  Google Scholar 

  34. Macias JH et al. Chlorhexidine is a better antiseptic than povidone iodine and sodium hypochlorite because of its substantive effect. Am J Infect Control. 2013;41:634–7.

    CAS  PubMed  Article  Google Scholar 

  35. Paglialonga F et al. Reduction in catheter-related infections after switching from povidone-iodine to chlorhexidine for the exit-site care of tunneled central venous catheters in children on hemodialysis. Hemodial Int. 2014;18 Suppl 1:S13–8.

    PubMed  Article  Google Scholar 

  36. Yamamoto N et al. Efficacy of 1.0% chlorhexidine-gluconate ethanol compared with 10% povidone-iodine for long-term central venous catheter care in hematology departments: a prospective study. Am J Infect Control. 2014;42:574–6.

    CAS  PubMed  Article  Google Scholar 

  37. 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;136:792–801.

    CAS  PubMed  Article  Google Scholar 

  38. Vallés J et al. Prospective randomized trial of 3 antiseptic solutions for prevention of catheter colonization in an intensive care unit for adult patients. Infect Control Hosp Epidemiol. 2008;29:847–53.

    PubMed  Article  Google Scholar 

  39. Goudet V et al. Comparison of four skin preparation strategies to prevent catheter-related infection in intensive care unit (CLEAN trial): a study protocol for a randomized controlled trial. Trials. 2013;14:114.

    PubMed Central  PubMed  Article  Google Scholar 

  40. 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;37:764–71.

    CAS  PubMed  Article  Google Scholar 

  41. Noto MJ et al. Chlorhexidine bathing and health care-associated infections. JAMA. 2015;313:369–78.

    CAS  PubMed  Article  Google Scholar 

  42. Raad II et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15:231–8.

    CAS  PubMed  Article  Google Scholar 

  43. O’Grady NP et al. Guidelines for the prevention of intravascular catheter-related infections. Clin infect Dis : Off Publ Infect Dis Soc Am. 2011;52:e162–93.

    Article  Google Scholar 

  44. Pronovost P. Interventions to decrease catheter-related bloodstream infections in the ICU: the Keystone Intensive Care Unit Project. Am J Infect Control. 2008;36(10):S171.e1–5. doi: 10.1016/j.ajic.2008.10.008.

  45. Carrer S et al. Effect of different sterile barrier precautions and central venous catheter dressing on the skin colonization around the insertion site. Minerva Anestesiol. 2005;71:197–206.

    CAS  PubMed  Google Scholar 

  46. Tang H-J et al. The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infect Dis. 2014;14:356.

    PubMed Central  PubMed  Article  Google Scholar 

  47. 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;40:2479–85.

    PubMed  Article  Google Scholar 

  48. Weeks KR, Hsu Y-J, Yang T, Sawyer M, Marsteller JA. Influence of a multifaceted intervention on central line days in intensive care units: results of a national multisite study. Am J Infect Control. 2014;42:S197–202.

    PubMed  Article  Google Scholar 

  49. McLaws M-L, Berry G. Nonuniform risk of bloodstream infection with increasing central venous catheter-days. Infect Control Hosp Epidemiol. 2005;26:715–9.

    PubMed  Article  Google Scholar 

  50. Concannon C, van Wijngaarden E, Stevens V, Dumyati G. The effect of multiple concurrent central venous catheters on central line-associated bloodstream infections. Infect Control Hosp Epidemiol. 2014;35:1140–6.

    PubMed  Article  Google Scholar 

  51. 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;42:453–5.

    PubMed  Article  Google Scholar 

  52. Fong KS et al. Intensity of vascular catheter use in critical care: impact on catheter-associated bloodstream infection rates and association with severity of illness. Infect Control Hosp Epidemiol. 2012;33:1268–70.

    PubMed  Article  Google Scholar 

  53. Lorente L et al. Cost/benefit analysis of chlorhexidine-silver sulfadiazine-impregnated venous catheters for femoral access. Am J Infect Control. 2014;42:1130–2.

    PubMed  Article  Google Scholar 

  54. Baskin KM et al. Long-term central venous access in pediatric patients at high risk: conventional versus antibiotic-impregnated catheters. J Vasc Interv Radiol. 2014;25:411–8.

    PubMed  Article  Google Scholar 

  55. 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;42:1278–84.

    PubMed  Article  Google Scholar 

  56. Safdar N et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis*. Crit Care Med. 2014;42:1703–13.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  57. Khattak AZ, Ross R, Ngo T, Shoemaker CT. A randomized controlled evaluation of absorption of silver with the use of silver alginate (Algidex) patches in very low birth weight (VLBW) infants with central lines. J Perinatol. 2010;30:337–42.

    CAS  PubMed  Article  Google Scholar 

  58. Hill ML, Baldwin L, Slaughter JC, Walsh WF, Weitkamp J-H. A silver-alginate-coated dressing to reduce peripherally inserted central catheter (PICC) infections in NICU patients: a pilot randomized controlled trial. J Perinatol. 2010;30:469–73.

    CAS  PubMed  Article  Google Scholar 

  59. Institute of Medicine (IOM). Transforming health care quality. (2003). at <http://iom.edu/Reports/2003/Priority-Areas-for-National-Action-Transforming-Health-Care-Quality.aspx> Accessed December 9, 2014.

  60. 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. 2015. doi:10.1177/1062860614568647. Analysis of data from March 2004 to December 2013 regarding central line associated bloodstream infection rates in ICUs from the Michigan Keystone ICU project, showing long-term sustainability for large-scale improvement projects.

    Google Scholar 

  61. Waters HR et al. The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual. 2011;26(5):333–9. doi: 10.1177/1062860611410685.

  62. Lipitz-Snyderman A et al. Impact of a statewide intensive care unit quality improvement initiative on hospital mortality and length of stay: retrospective comparative analysis. BMJ. 2011;342:d219.

    PubMed Central  PubMed  Article  Google Scholar 

  63. Lin DM, Weeks K, Holzmueller CG, Pronovost PJ, Pham JC. Maintaining and sustaining the On the CUSP: stop BSI model in Hawaii. Jt Comm J Qual Patient Saf. 2013;39:51–60.

    CAS  PubMed  Google Scholar 

  64. Walz JM et al. The Bundle “Plus”: the effect of a multidisciplinary team approach to eradicate central line-associated bloodstream infections. Anesth Analg. 2013. doi:10.1213/ANE.0b013e3182a8b01b.

    Google Scholar 

  65. Hong AL et al. Decreasing central-line-associated bloodstream infections in Connecticut intensive care units. J Healthc Qual. 2013;35(5):78–87. doi: 10.1111/j.1945-1474.2012.00210.x.

  66. Marsteller JA et al. A multicenter, phased, cluster-randomized controlled trial to reduce central line-associated bloodstream infections in intensive care units*. Crit Care Med. 2012;40:2933–9.

    PubMed  Article  Google Scholar 

  67. National action plan to prevent healthcare-associated infections: road map to elimination. Department of Health and Human Services web site. 2009. at <http://www.health.gov/hai/prevent_hai.asp> Accessed December 9, 2014.

  68. WHO. Bacteriemia Zero. at <http://www.who.int/patientsafety/implementation/bsi/bacteriemia_zero/en/> Accessed December 9, 2014.

  69. Palomar M et al. Impact of a national multimodal intervention to prevent catheter-related bloodstream infection in the ICU: the Spanish experience. Crit Care Med. 2013;41:2364–72.

    PubMed  Article  Google Scholar 

  70. Bion J et al. “Matching Michigan”: a 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf. 2012. doi:10.1136/bmjqs-2012-001325.

    PubMed Central  PubMed  Google Scholar 

  71. Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implement Sci. 2013;8:70.

    PubMed Central  PubMed  Article  Google Scholar 

  72. Dixon-Woods M, Leslie M, Bion J, Tarrant C. What counts? An ethnographic study of infection data reported to a patient safety program. Milbank Q. 2012;90:548–91.

    PubMed Central  PubMed  Article  Google Scholar 

  73. Blot K, Bergs J, Vogelaers D, Blot S, Vandijck D. Prevention of central line-associated bloodstream infections through quality improvement interventions: a systematic review and meta-analysis. Clin Infect Dis. 2014. doi:10.1093/cid/ciu239. Examination of the impact of quality improvement interventions on central line associated bloodstream infections in adult ICUs, suggesting their beneficial impact, particularly when care bundles and checklists are used.

    PubMed  Google Scholar 

  74. Weaver SJ, Weeks K, Pham JC, Pronovost PJ. On the CUSP: Stop BSI: evaluating the relationship between central line-associated bloodstream infection rate and patient safety climate profile. Am J Infect Control. 2014;42:S203–8.

    PubMed  Article  Google Scholar 

  75. Marsteller JA, Hsu Y-J, Weeks K. Evaluating the impact of mandatory public reporting on participation and performance in a program to reduce central line-associated bloodstream infections: evidence from a national patient safety collaborative. Am J Infect Control. 2014;42:S209–15.

    PubMed  Article  Google Scholar 

  76. Zingg W et al. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PLoS One. 2014;9, e93898.

    PubMed Central  PubMed  Article  Google Scholar 

  77. Ziegler MJ, Pellegrini DC, Safdar N. Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis. Infection. 2014. doi:10.1007/s15010-014-0689-y. Analysis of case control and cohort studies to identify the attributable mortality of central line associated bloodstream infections, demonstrating their association with a significantly increased risk of death.

    PubMed  Google Scholar 

  78. Scott RD et al. CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 Million during 1990–2008. Health Aff (Millwood). 2014;33:1040–7.

    Article  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Peter Pronovost, Asad Latif, and Muhammad Sohail Halim have no relevant disclosures to report.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by the author.

Author information

Affiliations

  1. Department of Anesthesiology and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, 600 North Wolfe Street, Meyer 297-A, Baltimore, MD, 21287, USA

    Asad Latif & Peter J. Pronovost

  2. Aga Khan University Hospital, Karachi, Pakistan

    Muhammad Sohail Halim

Authors
  1. Asad Latif
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Muhammad Sohail Halim
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Peter J. Pronovost
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Asad Latif.

Additional information

This article is part of the Topical Collection on Sepsis and ICU

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Latif, A., Halim, M.S. & Pronovost, P.J. Eliminating Infections in the ICU: CLABSI. Curr Infect Dis Rep 17, 35 (2015). https://doi.org/10.1007/s11908-015-0491-8

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11908-015-0491-8

Keywords

  • Central line-associated bloodstream infection
  • Healthcare-acquired infections
  • Quality improvement
  • Patient safety
  • Critical care
  • Best practices