Central Line-Associated Bloodstream Infection

Aka: Central Line-Associated Bloodstream Infection, Catheter Related Bloodstream Infection, Intravascular Catheter-Related Infection, CRBI

1. See Also
   1. Health Care-Associated Infection
   2. Intravenous Access
   3. Peripheral IV Access
   4. Central IV Access
   5. Intraosseous Access
   6. Ultrasound-Guided Internal Jugular Vein Catheterization
   7. Ultrasound-Guided Antecubital Line
   8. Umbilical Artery Catheter
   9. Umbilical Vein Catheter
   10. Bloodstream Infections in Hemodialysis
2. Epidemiology
   1. Central Lines are responsible for >250,000 infections per year in U.S.
   2. Occurs in 16,000 ICU patients annually in U.S. with 4000 related deaths/year
      1. Rate of infection 0.8 per 1000 Central Line days
   3. Femoral lines have historically been most associated with catheter related infection
      1. Lorente (2005) Crit Care 9(6): R631-5 [PubMed]
      2. Merrer (2001) JAMA 286(6):700-7 [PubMed]
   4. More recent studies have found no increased infection risk with femoral lines
      1. Attribute earlier infection association with less sterile technique
      2. Parienti (2008) JAMA 299(20): 2413-22 [PubMed]
      3. Marik (2012) Crit Care Med 40(8): 2479-85 [PubMed]
   5. Antibiotic-impregnated catheter reduces infection rate
      1. Hanna (2003) Chest 124:1030-8 [PubMed]
3. Pathophysiology
   1. Colonizing skin Bacteria spread along the intravenous catheter
   2. Catheter hub contamination
4. Risk Factors
   1. Younger age (esp. neonates)
   2. Male gender
   3. Immunodeficiency
   4. Prolonged hospitalization prior to Central Line Placement
   5. Multilumen catheters
   6. Parenteral nutrition
5. Causes
   1. Catheter Types
      1. Temporary Central IV Access (e.g. Internal Jugular Central Line, Subclavian Central Line)
      2. Peripherally Inserted Central Catheters (PICC Line)
      3. Hemodialysis catheters
   2. Organisms
      1. Staphylococcus aureus
      2. Coagulase negative Staphylococcus
      3. Enterococcus
6. Management
   1. Non-tunneled catheter (PICC Lines, IV Lines, Central Lines)
      1. Remove catheter (esp. MRSA)
      2. Vancomycin (preferred) OR
      3. Daptomycin 6 mg/kg IV q24 hours
   2. Tunneled catheter
      1. Empiric therapy (MRSA, Staphylococcus epidermidis)
         1. Vancomycin
         2. Consider Vancomycin-resistant Lactobacillus coverage (e.g. Penicillin, Ampicillin, Clindamycin)
      2. Burn or Neutropenia
         1. Vancomycin AND
         2. Cefepime or Ceftazidime or Zosyn
      3. Long-term alimentation
         1. Add Candida coverage (e.g. Voriconazole, Anidulafungin)
         2. Consider Malassezia furfur coverage related to Intralipid (Fluconazole)
   3. References
      1. (2016) Sanford Guide, accessed 4/8/2016
7. Prevention
   1. Only insert a Central Line or PICC Line when absolutely necessary
      1. Should not be inserted only for convenience (e.g. frequent blood draws)
   2. Consider line types with lower infection risk
      1. Subclavian Central Line
      2. Tunneled catheter flushed or locked with Heparin-antibiotic mix
         1. Consider in neutropenic patients in centers with CLABSI rate >15%
         2. van den Bosch (2021) Cochrane Database Syst Rev (10):CD003295 [PubMed]
   3. Reassess the need for Central Line access daily and discontinue when no longer needed
   4. Insertion should be done under sterile conditions (lowers infection risk by 6 fold)
      1. Clinician wearing a cap and mask, sterile gown and gloves
      2. Nearby assistants should wear at least a cap and mask
      3. Full-length sterile drape
   5. Chlorhexidine
      1. Methods (all are recommended)
         1. Chlorhexidine Skin Preparation prior to procedure
         2. Chlorhexidine-impregnated dressing (e.g. Biopatch) at insertion site
         3. Chlorhexidine baths in the Intensive Care Unit
      2. Efficacy
         1. Chlorhexidine is better disinfectant than Povidone Iodine (Betadine)
         2. Chlorhexidine gluconate reduces infection rate (cuts infection rate as much as 50%)
         3. Chlorhexidine is cost effective
         4. Chaiyakunapruk (2003) Clin Infect Dis 37:764-71 [PubMed]
   6. Other measures
      1. Replace transparent dressings weekly
      2. Replace intravenous tubing every 4 to 7 days
8. References
   1. Cagle (2022) Am Fam Physician 105(3): 262-70 [PubMed]
   2. Hsu (2014) Am Fam Physician 90(6): 377-82 [PubMed]
   3. O'Grady (2011) Clin Infect Dis 52(9): e162-93 [PubMed]