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.
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The Joint Commission. Preventing central line-associated bloodstream infections. 2012. at <http://www.jointcommission.org/topics/clabsi_toolkit.aspx> Accessed December 9, 2014.
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.
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.
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.
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.
Wenzel RP, Edmond MB. The impact of hospital-acquired bloodstream infections. Emerg Infect Dis. 2001;7(2):174–7.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Pronovost P et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–32.
Mermel LA. Prevention of intravascular catheter-related infections. Ann Intern Med. 2000;132:391–402.
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.
Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73:305–15.
Casewell M, Phillips I. Hands as route of transmission for Klebsiella species. Br Med J. 1977;2:1315–7.
WHO guidelines on hand hygiene in healthcare. at <http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf> Accessed December 9, 2014.
Guideline for hand hygiene in health-care settings. at <http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf> Accessed December 9, 2014.
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.
Walker JL et al. Hospital hand hygiene compliance improves with increased monitoring and immediate feedback. Am J Infect Control. 2014;42:1074–8.
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.
Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Infect. 2001;48(Suppl A):S40–6.
Pessoa-Silva CL et al. Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics. 2007;120:e382–90.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Noto MJ et al. Chlorhexidine bathing and health care-associated infections. JAMA. 2015;313:369–78.
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.
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.
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.
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.
Tang H-J et al. The impact of central line insertion bundle on central line-associated bloodstream infection. BMC Infect Dis. 2014;14:356.
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.
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.
McLaws M-L, Berry G. Nonuniform risk of bloodstream infection with increasing central venous catheter-days. Infect Control Hosp Epidemiol. 2005;26:715–9.
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.
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.
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.
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.
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.
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.
Safdar N et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis*. Crit Care Med. 2014;42:1703–13.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
WHO. Bacteriemia Zero. at <http://www.who.int/patientsafety/implementation/bsi/bacteriemia_zero/en/> Accessed December 9, 2014.
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.
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.
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.
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.
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.
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.
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.
Zingg W et al. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PLoS One. 2014;9, e93898.
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.
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.
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Peter Pronovost, Asad Latif, and Muhammad Sohail Halim have no relevant disclosures to report.
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This article is part of the Topical Collection on Sepsis and ICU
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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
- Central line-associated bloodstream infection
- Healthcare-acquired infections
- Quality improvement
- Patient safety
- Critical care
- Best practices