1. Central Line-associated Bloodstream Infection (CLABSI) Prevention
Holly Taylor, MPH, CIC

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3. Financial Disclosures
Nothing to disclose

4. Objectives At the conclusion of this webinar, you will be able to:
Identify patient and institutional risks to the development of CLABSI
Describe 2 mechanisms for the development of CLABSI
Identify 3 maintenance-based interventions used to decrease CLABSI

5. Overview
Define CLABSI and describe its role in patient morbidity and mortality
Discuss evidence-based CLABSI prevention measures
Bundle-based approach
Technology used for CLABSI prevention

6. Background
Central line-associated bloodstream infections (CLABSIs) are a contributor to:
Increased risk of morbidity and mortality
Estimated 82,000 infections and up to 28,000 attributable deaths in the US annually
Increased healthcare costs
Attributable costs of $5,734 - $25,546 per episode
Sources: Estimating health care-associated infections and deaths in US hospitals, Public Health Rep 2007; 122:160-6
The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention.Atlanta. 2009
Association for Professionals in Infection Control and Epidemiology Guide for the Elimination of Catheter-related Bloodstream Infections, 2009

7. The New Frontier: Public Reporting
Required for all acute care hospital ICUs
Implications for hospital reimbursement based on FY 2015 value-based purchasing
Opportunities to damage healthcare facilities’ reputations

8. Definitions Surveillance definition used for public reporting
Central line-associated bloodstream infection (CLABSI)
Catheter-related bloodstream infection (CRBSI)
Surveillance definition used for public reporting
Restricted to application in patients with central lines
Sensitive definition that likely overestimates the number of events that occur
Definitive clinical diagnosis
Uses very rigorous diagnostic criteria
Includes infections caused by all types of intravascular catheters
Sources: National Healthcare Safety Network LCBI Event Protocol, Accessed: October 21, 2013
Infectious Disease Society of America, Guidelines for the Management of Intravascular Catheter Related Infections, 2008
Association for Professionals in Infection Control and Epidemiology Guide for the Elimination of Catheter-related Bloodstream Infections, 2009

9. CLABSI Prevention – Insertion
Initial efforts to prevent CLABSI focused on central line insertion
Michigan Keystone Project is one of the most notable and successful initiatives reducing CLABSI with focus on the central line insertion bundle
Joint Commission National Patient Safety Goal requirement for formalized central line insertion checklist for insertion bundle components
Source: Pronovost P. Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study; BMJ 2010; 340:c309

10. Central Line Insertion Bundle
Hand hygiene
Maximum sterile barrier precautions
Sterile Gloves
Sterile Gown
Mask
Head Covering
Full Sterile Body Drape
Skin cleansing with CHG
Avoid the femoral site when possible

11. Current Issues in CLABSI Prevention
Many hospitals have effectively implemented the central line insertion bundle and continue to have infections.
Ongoing research and recommendations related to maintenance of central lines

12. Basic Components of Central Line Maintenance Bundles
Key Category IA and IB Recommendations:
Hand Hygiene prior to any catheter manipulation
Disinfect catheter hubs prior to access
Replace gauze dressings every 2 days and transparent dressings every 7 days
Replace dressings whenever they are loose, damp, or soiled
Change administration sets used for routine infusions no more frequently than every 96 hours but no less than every 7 days
Additional interventions may be implemented based on local data and the pathogenesis of CLABSI
Sources: CDC HICPAC Guidelines for the Prevention of Intravascular Catheter-related Infections, 2011

13. Pathogenesis of CLABSI
Intralumenal
Contamination
Extralumenal
Contamination
Source: The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices. Clin Infect Dis 2002;34(9):1232–1242

14. Infection Prevention Strategies Targeting Methods of Contamination
Extralumenal Contamination
Intralumenal Contamination
Antimicrobial central lines
Chlorhexidine gluconage (CHG) impregnated technologies
Daily CHG bathing
Needleless access devices
Catheter hub disinfection
Active vs. Passive

15. Pathogenesis of CLABSI
Extralumenal
Contamination
Source: The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices. Clin Infect Dis 2002;34(9):1232–1242

16. Extralumenal Contamination
Contributes to about 40% of CLABSIs with short- term non-cuffed central lines
Looked at
Sources: The pathogeneisis of catheter-related bloodstream infection with noncuffed short-term central venous catheters. Intensive Care Medicine 2004; 30: 62-67

17. Extralumenal Contamination - Antimicrobial central lines
Aimed at reducing catheter colonization and biofilm formation on central lines
Two types of antimicrobial impregnated central lines
CHG/Silver Sulfadiazine
Minocycline/Rifampin

18. Extralumenal Contamination - Antimicrobial central lines
Aimed at reducing catheter colonization and biofilm formation on central lines
Two types of antimicrobial impregnated central lines
CHG/Silver Sulfadiazine
Minocycline/Rifampin

19. Extralumenal Contamination - Antimicrobial central lines
Method of impregnation
Outside of the catheter
Inner lumen and outside of the catheter
Can produce allergic reactions

20. Extralumenal Contamination – Antimicrobial impregnated central lines
Use a chlorhexidine/silver sulfadiazine or minocycline/rifampin - impregnated CVC in patients whose catheter is expected to remain in place >5 days if, after successful implementation of a comprehensive strategy to reduce rates of CLABSI, the CLABSI rate is not decreasing.
(Category IA)
Sources: CDC HICPAC Guidelines for the Prevention of Intravascular Catheter-related Infections, 2011

21. Extralumenal Contamination - CHG Impregnated Technologies
CHG-impregnated disk
Placed at the insertion site
of the catheter against the skin
Releases CHG for 7 days
Replaced with each dressing change

22. Extralumenal Contamination - CHG Impregnated Technologies
CHG impregnated dressing
Newer technology than the CHG-impregnated disc
Integrated CHG and dressing
technology

23. Extralumenal contamination CHG Impregnated Technologies
Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months of age if the CLABSI rate is not decreasing despite adherence to basic prevention measures (Category IB)
No recommendation is made for other types of chlorhexidine dressings (unresolved issue)
Sources: CDC HICPAC Guidelines for the Prevention of Intravascular Catheter-related Infections, 2011

24. Extralumenal Contamination - CHG Bathing

25. Extralumenal Contamination - CHG Bathing
Performed using either 2% CHG impregnated cloths or 4% liquid CHG
Has been demonstrated in multiple studies to decrease the risk of bloodstream infections as well as the acquisition of multidrug-resistant organism infections
Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007; 167:2073–9
The Effect of daily bathing with chlorhexidine on the acquisition of methicilin-resistant Staphylococcus aureus, vancomycin-resistant Enteroroccus and healthcare-associated bloodstream infections: Results of a quasi-expiermental multicenter trial. Crit Care Med 2009; 37(5):

26. Extralumenal Contamination - CHG Bathing
Use a 2% chlorhexidine wash for daily skin cleansing to reduce CLABSI (Category II).
Recommended for implementation after implementing the basic bundle elements and a decrease in CLABSI has not been achieved
Sources: CDC HICPAC Guidelines for the Prevention of Intravascular Catheter-related Infections, 2011

27. Pathogenesis of CLABSI
Intralumenal
Contamination
Source: The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices. Clin Infect Dis 2002;34(9):1232–1242

28. Infection Prevention Strategies Targeting Methods of Contamination
Extralumenal Contamination
Intralumenal Contamination
Antimicrobial central lines
Chlorhexidine gluconage (CHG) impregnated technologies
Daily CHG bathing
Needleless access devices
Catheter hub disinfection
Active vs. Passive

29. Intralumenal Contamination – Needleless access devices
Key features:
External Design
Valve
Mechanical
Split Septum
Fluid displacement
Positive
Negative
Neutral
Dead Space

30. Intralumenal Contamination – Needleless access devices
External Design Features
Access Point
Concave vs. flush vs. convex
Visibility
Transparent vs. Opaque

31. Intralumenal Contamination – Needleless access devices
Valve Design
Split Septum
No internal moving parts
Direct fluid pathway
Photo Source: Needleless Connectors for IV Catheters. American Journal of Nursing (11): 32-44

32. Intralumenal Contamination – Needleless access devices
Valve Design
Mechanical
Contains a moving centerpiece
Can allow for negative, neutral,
or positive fluid displacement
Photo Source: Needleless Connectors for IV Catheters. American Journal of Nursing (11): 32-44

33. Intralumenal Contamination – Needleless access devices
Fluid Displacement
Negative Displacement
Allows for blood to reflux into the needleless connector as the access device is disconnected (split septum valves are negative displacement)
Neutral Displacement
Does not allow blood to reflux into the needleless connector when disconnecting
Positive Displacement
Holds extra fluid in the connector that pushes into the catheter lumen when disconnecting

34. Intralumenal Contamination – Needleless access devices
Dead Space
Occurs in needleless connectors with complex fluid pathways
Does not allow for complete flushing of the needleless connector
Can harbor bacteria and promote biofilm formation
Dead Space

35. Intralumenal Contamination – Needleless access devices
Infection Risk
Multiple reports of increased CLABSI rates following the implementation of mechanical positive displacement needleless connectors
CDC recommends that 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
Sources: CDC HICPAC Guidelines for the Prevention of Intravascular Catheter-related Infections, 2011
Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve. Clin Infect Dis 2007; 44:1408–14; Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital. Infect Control Hosp Epidemiol 2007; 28:684–8 ; Increased catheter-related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol 2006; 27:67–70. Incidence of catheter-related bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an Australian hematology-oncology unit. Infect Control Hosp Epidemiol 2007; 28:610–3

36. Intralumenal Contamination – Catheter Hub Disinfection
Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (Category IA)
Traditional Method
“Scrub the hub”
Active method for disinfection
Antiseptic solution used to scrub the end of the needleless access device prior to access
Source: CDC HICPAC Guidelines for the Prevention of Intravascular Catheter-related Infections, 2011

37. Intralumenal Contamination – Catheter Hub Disinfection
Duration of scrub
Study evaluated time of scrub and
cfu/mL of bacteria recovered after various times scrubbing the hub
Findings not statistically
significant, but strongly suggest
a trend
Source: “Scrub the Hub” Cleaning Duration and Reduction in Bacterial Load on Central Venous Catheters. Crit Care Nurs Q 2011; 31(1): 31-35

38. Intralumenal Contamination – Catheter Hub Disinfection
Newer technologies
Alcohol impregnated protectors
Allows for passive disinfection of the needleless connector
One-time use

39. Intralumenal Contamination – Catheter Hub Disinfection
New literature emerging suggesting that these devices may help reduce CLABSI rates
Control Period: 16 CLABSIs/6851 central line days
Rate: 2.3 infections/1000 central line days
Intervention Period: 1 CLABSI/3005 central line days
Rate: 0.3 infections/1000 central line days
Relative risk: %CI (0.02 – 1.07) p = 0.03
Source: Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit Am J Infect Control 2012 Dec;40(10):931-4

40. Summary
CLABSIs continue to be a major contributor to patient harm in healthcare institutions
Public reporting, increasing regulatory focus, and financial impacts continue to push healthcare organizations to eliminate CLABSI
The traditional insertion bundle may not eliminate CLABSI in all patients

41. Summary
Increasing focus on central line maintenance practices with responsible use of maintenance technologies will help continue CLABSI reduction

42. Questions?
Holly Taylor, MPH, CIC

43. - Click on “Bloodstream Infections” - Login or register for an account
To obtain your nursing or respiratory therapy Continuing Education Unit, please visit:
- Click on “Bloodstream Infections” - Login or register for an account
If you have any questions about accreditation, please or call (301) x 771