Prevention of Central Line associated Bloodstream Infections

Recommendations

1. Peripheral Catheters and Midline Catheters

In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible. (Good Practice Statement)

In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site. (Good Practice Statement)

Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration). (Strong Recommendation)

Avoid the use of steel needles for the administration of fluids and medications that might cause tissue necrosis if extravasation occurs. (Strong Recommendation)

Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. (Good Practice Statement)

Evaluate the catheter insertion site daily by palpation through the dressing to recognze tenderness and by inspection if a transparent dressing is in use. (Good Practice Statement)

Remove peripheral venous catheters if there are signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter. (Strong Recommendation)

2. Central Venous Catheters

Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein stenosis, hemothorax, thrombosis). (Strong Recommendation)

Avoid using the femoral vein for central venous access in adult patients. (Strong Recommendation)

If no risk, use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for non-tunneled CVC placement. (Strong Recommendation)

Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis. (Strong Recommendation)

Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis. (Strong Recommendation)

Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulations attempts and mechanical complications. (Strong Recommendation)

Use a CVC with the minimum number of ports or lumens essential for the patient management. (Strong Recommendation)

Promptly remove any intravascular catheter that is no longer essential. (Strong Recommendation)

When adherence to aseptic technique cannot be ensured (i.e., catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e., within 48 hours. (Strong Recommendation)

3. Hand Hygiene, gloves and Aseptic Technique

Perform hand hygiene procedures, either by washing hands with soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. (Strong Recommendation)

Maintain aseptic technique for the insertion and care of intravascular catheters. (Strong Recommendation)

Wear clean gloves, rather than sterile gloves, for the insertion of peripheral intravascular catheters, if the access site is not touched after the application of skin antiseptics. (Weak Recommendation)

Sterile gloves should be worn for the insertion of arterial, central, and midline catheters. (Strong Recommendation)

Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. (Good Practice Statement)

Wear either clean or sterile gloves when changing the dressing on intravascular catheters. (Weak Recommendation)

Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange. (Strong Recommendation)

4. Skin Preparation

Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion. (Strong Recommendation)

Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. (Strong Recommendation)

Antiseptics should be allowed to dry according to the manufacturer’s recommendation prior to placing the catheter. (Strong Recommendation)

5. Catheter Site Dressing Regimens

Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site. (Strong Recommendation)

Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. (Strong Recommendation)

Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance. (Strong Recommendation)

Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower). (Strong Recommendation)

Replace dressings used on short-term CVC sites every 2 days for gauze dressings. (Good Practice Statement)

Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. (Strong Recommendation)

Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. (Strong Recommendation)

Encourage patients to report any changes in their catheter site or any new discomfort to their provider. (Good Practice Statement)

6. Antibiotic/Antiseptic Prophylaxis

Do not administer systemic antimicrobial prophylaxis routinely before insertion or during use of an intravascular catheter to prevent catheter colonization or CRBSI. (Strong Recommendation)

Use a 2% chlorhexidine wash for daily skin cleansing to reduce CRBSI. (Good Practice Statement)

Use povidone iodine antiseptic ointment or bacitracin/gramicidin/ polymyxin B ointment at the hemodialysis catheter exit site after catheter insertion and at the end of each dialysis session only if this ointment does not interact with the material of the hemodialysis catheter per manufacturer’s recommendation. (Strong Recommendation)

7. Replacement of Peripheral and Midline Catheters

There is no need to replace peripheral catheters more frequently than every 72-96 hours to reduce risk of infection and phlebitis in adults. (Strong Recommendation)

Replace peripheral catheters in children only when clinically indicated. (Strong Recommendation)

Replace midline catheters only when there is a specific indication. (Good Practice Statement)

8. Replacement of CVCs, Including PICCs and Haemodialysis Catheters

Do not routinely replace CVCs, PICCs, hemodialysis catheters, or pulmonary artery catheters to prevent catheter-related infections. (Strong Recommendation)

Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. (Good Practice Statement)

Do not use guidewire exchanges routinely for non-tunneled catheters to prevent infection. (Strong Recommendation)

Do not use guidewire exchanges to replace a non-tunneled catheter suspected of infection. (Strong Recommendation)

Use a guidewire exchange to replace a malfunctioning non-tunneled catheter if no evidence of infection is present. (Strong Recommendation)

Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. (Good Practice Statement)

9. Umbilical Catheters

Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency in the lower extremities, or thrombosis are present. (Good Practice Statement)

Remove and do not replace umbilical venous catheters if any signs of CRBSI or thrombosis are present. (Good Practice Statement)

Cleanse the umbilical insertion site with an antiseptic before catheter insertion. Avoid tincture of iodine because of the potential effect on the neonatal thyroid. Other iodine-containing products (e.g., povidone iodine) can be used. (Strong Recommendation)

Do not use topical antibiotic ointment or creams on umbilical catheter insertion sites because of the potential to promote fungal infections and antimicrobial resistance. (Strong Recommendation)

Add low-doses of heparin (0.25—1.0 U/ml) to the fluid infused through umbilical arterial catheters (Strong Recommendation)

Remove umbilical catheters as soon as possible when no longer needed or when any sign of vascular insufficiency to the lower extremities is observed. Optimally, umbilical artery catheters should not be left in place >5 days. (Good Practice Statement)

Umbilical venous catheters should be removed as soon as possible when no longer needed but can be used up to 14 days if managed aseptically. (Good Practice Statement)

An umbilical catheter may be replaced if it is malfunctioning, and there is no other indication for catheter removal, and the total duration of catheterization has not exceeded 5 days for an umbilical artery catheter or 14 days for an umbilical vein catheter. (Good Practice Statement)

10. Peripheral Arterial Catheters and Pressure Monitoring Devices for Adult and Paediatric Patients

In adults, use of the radial, brachial or dorsalis pedis sites is preferred over the femoral or axillary sites of insertion to reduce the risk of infection. (Strong Recommendation)

In children, the brachial site should not be used. The radial, dorsalis pedis, and posterior tibial sites are preferred over the femoral or axillary sites of insertion. (Good Practice Statement)

A minimum of a cap, mask, sterile gloves and a small sterile fenestrated drape should be used during peripheral arterial catheter insertion. (Strong Recommendation)

During axillary or femoral artery catheter insertion, maximal sterile barriers precautions should be used. (Good Practice Statement)

Replace arterial catheters only when there is a clinical indication. (Good Practice Statement)

Remove the arterial catheter as soon as it is no longer needed. (Good Practice Statement)

Use disposable, rather than reusable, transducer assemblies when possible. (Strong Recommendation)

Do not routinely replace arterial catheters to prevent catheter-related infections. (Good Practice Statement)

Replace disposable or reusable transducers at 96-hour intervals. Replace other components of the system (including the tubing, continuous-flush device, and flush solution) at the time the transducer is replaced. (Strong Recommendation)

Keep all components of the pressure monitoring system (including calibration devices and flush solution) sterile. (Strong Recommendation)

Minimize the number of manipulations of and entries into the pressure monitoring system. Use a closed flush system (i.e., continuous flush), rather than an open system (i.e., one that requires a syringe and stopcock), to maintain the patency of the pressure monitoring catheters. (Good Practice Statement)

When the pressure monitoring system is accessed through a diaphragm, rather than a stopcock, scrub the diaphragm with an appropriate antiseptic before accessing the system. (Strong Recommendation)

Do not administer dextrose-containing solutions or parenteral nutrition fluids through the pressure monitoring circuit. (Strong Recommendation)

Sterilize reusable transducers according to the manufacturers’ instructions if the use of disposable transducers is not feasible. (Strong Recommendation)

11. Replacement of Administration Sets

In patients not receiving blood, blood products or fat emulsions, replace administration sets that are including secondary sets and add-on devices, no more frequently than at 96-hour intervals, but at least every 7 days. (Strong Recommendation)

Replace tubing used to administer blood, blood products, or fat emulsions (those combined with amino acids and glucose in a 3-in-1 admixture or infused separately) within 24 hours of initiating the infusion. (Strong Recommendation)

Replace tubing used to administer propofol infusions every 6 or 12 hours, when the vial is changed or per the manufacturer’s recommendation. (Strong Recommendation)

12. Needleless Intravascular Catheter Systems

Change needleless connectors no more frequently than every 72 hours or according to manufacturers’ recommendations for the purpose of reducing infection rates. (Good Practice Statement)

Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices. (Strong Recommendation)

Use a needleless system to access IV tubing. (Weak Recommendation)

When needleless systems are used, a split septum valve may be preferred over some mechanical valves due to increased risk of infection with the mechanical valves. (Good Practice Statement)

13. Performance Improvement

Use collaborative-based performance improvement initiatives in which multifaceted strategies are “bundled” together to improve compliance with evidence-based recommended practices. (Strong Recommendation)