II. Epidemiology
- Central Lines are responsible for >250,000 infections per year in U.S.
- Occurs in 16,000 ICU patients annually in U.S. with 4000 related deaths/year
- Rate of infection 0.8 per 1000 Central Line days
- Femoral lines have historically been most associated with catheter related infection
- More recent studies have found no increased infection risk with femoral lines
- Attribute earlier infection association with less sterile technique
- Parienti (2008) JAMA 299(20): 2413-22 [PubMed]
- Marik (2012) Crit Care Med 40(8): 2479-85 [PubMed]
- Antibiotic-impregnated catheter reduces infection rate
III. Pathophysiology
- Colonizing skin Bacteria spread along the intravenous catheter
- Catheter hub contamination
IV. Risk Factors
- Younger age (esp. neonates)
- Male gender
- Immunodeficiency
- Prolonged hospitalization prior to Central Line Placement
- Multilumen catheters
- Parenteral nutrition
V. Causes
- Catheter Types
- Temporary Central IV Access (e.g. Internal Jugular Central Line, Subclavian Central Line)
- Peripherally Inserted Central Catheters (PICC Line)
- Hemodialysis catheters
- Organisms
- Staphylococcus aureus
- Coagulase negative Staphylococcus
- Enterococcus
VI. Management
- Non-tunneled catheter (PICC Lines, IV Lines, Central Lines)
- Remove catheter (esp. MRSA)
- Vancomycin (preferred) OR
- Daptomycin 6 mg/kg IV q24 hours
- Tunneled catheter
- Empiric therapy (MRSA, Staphylococcus epidermidis)
- Vancomycin
- Consider Vancomycin-resistant Lactobacillus coverage (e.g. Penicillin, Ampicillin, Clindamycin)
- Burn or Neutropenia
- Vancomycin AND
- Cefepime or Ceftazidime or Zosyn
- Long-term alimentation
- Add Candida coverage (e.g. Voriconazole, Anidulafungin)
- Consider Malassezia furfur coverage related to Intralipid (Fluconazole)
- Empiric therapy (MRSA, Staphylococcus epidermidis)
- References
- (2016) Sanford Guide, accessed 4/8/2016
VII. Prevention
- Only insert a Central Line or PICC Line when absolutely necessary
- Should not be inserted only for convenience (e.g. frequent blood draws)
- Consider line types with lower infection risk
- Subclavian Central Line
- Tunneled catheter flushed or locked with Heparin-antibiotic mix
- Consider in neutropenic patients in centers with CLABSI rate >15%
- van den Bosch (2021) Cochrane Database Syst Rev (10):CD003295 [PubMed]
- Reassess the need for Central Line access daily and discontinue when no longer needed
- Insertion should be done under sterile conditions (lowers infection risk by 6 fold)
- Clinician wearing a cap and mask, sterile gown and gloves
- Nearby assistants should wear at least a cap and mask
- Full-length sterile drape
-
Chlorhexidine
- Methods (all are recommended)
- Chlorhexidine Skin Preparation prior to procedure
- Chlorhexidine-impregnated dressing (e.g. Biopatch) at insertion site
- Chlorhexidine baths in the Intensive Care Unit
- Efficacy
- Chlorhexidine is better disinfectant than Povidone Iodine (Betadine)
- Chlorhexidine gluconate reduces infection rate (cuts infection rate as much as 50%)
- Chlorhexidine is cost effective
- Chaiyakunapruk (2003) Clin Infect Dis 37:764-71 [PubMed]
- Methods (all are recommended)
- Other measures
- Replace transparent dressings weekly
- Replace intravenous tubing every 4 to 7 days
