Importance of Infection Prevention from CLABSI and Use of Care Bundle Checklist

Central Line Associated Blood Stream Infections (CLABSI):

Blood stream infections associated with the use of intravenous catheters carry significant morbidity and mortality. With greater use of these catheters in India, especially in the ICU, there is an urgent need to develop infection prevention guidelines that are based on routine practices.

Majority of Catheter Related Blood Stream Infection (CRBSI) are attributed to central venous catheter than peripheral venous catheters.

A central Line associated blood stream infection is a laboratory confirmed blood stream infection (BSI) in a patient who had a central line within the 48 hours period before the development of BSI, and that is not related to an infection at another site. There is no minimum period of time that the central line must be in place in order for the BSI to be considered central line associated, but there must have been one within 48 hours of onset of infection. Confirmation of CLABSI requires both positive blood culture and a collaborative clinical and microbiologist review of the patient.

The patient has at least one of the following signs and symptoms within 24 hours of a positive blood culture being collected:  

• Fever > 38 °C
• Chills or Rigors
• Hypotension

Central line insertion is a very common procedure in critical care settings, is associated with local bacterial colonization, leading to bacteraemia and sepsis also known as central line associated blood stream infection (CLABSI).    

Diagnosis of such catheter related infection can be made by combination of clinical picture with quantitative culture techniques.

Common organisms causing bloodstream infections:

Escherichia coli, Enterococcus spp., Staphylococcus aureus, Klebsiella spp., Salmonella spp., Candida spp., Pseudomonas spp., Corynebacteria spp., Acinetobacter spp., Coagulase Negative Staphylococcus (CNS).

Checklist for Prevention of Central Line Associated Blood Stream Infections as per CDC Guidelines:

Follow proper insertion practices:

• Perform hand hygiene before insertion.
• Adhere to aseptic technique.
• Use maximal sterile barrier precautions (i.e., mask, cap, gown, sterile gloves, and sterile full body drape).
• Choose the best insertion site to minimize infections and non-infectious complications based on individual patient characteristics.
• Avoid femoral site in obese adult patients.
• Prepare the insertion site with >0.5% chlorhexidine with alcohol.
• Place a sterile gauze dressing or a sterile, transparent, semipermeable dressing over the insertion site.
• For patients 18 years of age or older, use a chlorhexidine impregnated dressing with an FDA cleared label that specifies a clinical indication for reducing CLABSI for short term non-tunneled catheters unless the facility is demonstrating success at preventing CLABSI with baseline prevention practices.

Handle and maintain central lines appropriately:

• Comply with hand hygiene requirements.
• Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis.
• Scrub the access port or hub with friction immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol).
• Use only sterile devices to access catheters.
• Immediately replace dressings that are wet, soiled, or dislodged.
• Perform routine dressing changes using aseptic technique with clean or sterile gloves.
• Change gauze dressings at least every two days or semipermeable dressings at least every seven days.
• For patients 18 years of age or older, use a chlorhexidine impregnated dressing with an FDA cleared label that specifies a clinical indication for reducing CLABSI for short-term non-tunneled catheters unless the facility is demonstrating success at preventing CLABSI with baseline prevention practices.
• Change administrations sets for continuous infusions no more frequently than every 4 days, but at least every 7 days.
• If blood or blood products or fat emulsions are administered change tubing every 24 hours.
• If propofol is administered, change tubing every 6-12 hours or when the vial is changed.

Promptly remove unnecessary central lines:

• Perform daily audits to assess whether each central line is still needed.

For Healthcare Organizations:

• Educate healthcare personnel about indications for central lines, proper procedures for insertion and maintenance, and appropriate infection prevention measures.
• Designate personnel who demonstrate competency for the insertion and maintenance of central lines.
• Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of central lines.
• Provide a checklist to clinicians to ensure adherence to aseptic insertion practices.
• Re-educate personnel at regular intervals about central line insertion, handling and maintenance, and whenever related policies, procedures, supplies, or equipment changes.
• Empower staff to stop non-emergent insertion if proper procedures are not followed.
• Ensure efficient access to supplies for central line insertion and maintenance (i.e. create a bundle with all needed supplies).
• Use hospital-specific or collaborative-based performance measures to ensure compliance with recommended practices.

Supplemental strategies for consideration:

• Antimicrobial/Antiseptic impregnated catheters
• Antiseptic impregnated caps for access ports 

Care Bundle Checklist for CLABSI: 

Written by:

Dr. Praveen Bajpai

Director of Ingenious Healthcare Consultants Pvt. Ltd.
Founder of Skill Sathi

MBA in Hospital administration, PG Diploma in Quality Accreditation, PG Diploma in Medico Legal System, M. Phil in Hospital Mgmt. from BITS Pilani, P.hD in Management, Certified NABH Auditor, Certified NABL Auditor, Certified Auditor for Clinical Audits, Green Belt in Six Sigma, Certified in Hospital Infection Control Practices, Certified trainer for International Patient Safety Goals, Certified Auditor for JCI 7th Edition Standards 

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