Hand Hygiene
Poor hand hygiene by health care workers is generally thought to be the most common cause of HAIs [12]. Guidelines recommend an alcohol-based waterless product or antiseptic soap and water prior to catheter insertion [13]. The most common underlying etiology of CLABSI is through microorganisms introduced at time of insertion of catheter. This can be extraluminally mediated via skin flora of the patient, or due to lack of hand washing on the inserter’s part and can lead to CLABSI [14]. While a randomized controlled trial would be unethical, several studies have shown when targeted hand hygiene campaigns are held, CLABSI rates tend to decrease [15–17].
Maximal Barrier Precautions
The use of maximal sterile barrier precautions has been associated with less mortality, decreasing catheter colonization, incidence of HAI and cost savings [18–20]. Like most components of the bundle, maximal sterile barrier precautions have rarely been studied alone, but are often a part of a “bundle” or number of interventions [21]. Like hand hygiene, while regularly a part of many hospital’s checklist or bundle process, compliance with this key part of infection prevention can be deficient; one study noted measured maximal sterile barriers compliance to be 44% [22].
Chlorhexidine Skin Antisepsis
Chlorhexidine skin preparation decreases bacterial burden at site of insertion and is thought to reduce infection from this mechanism. Chlorhexidine-alcohol skin preparation has been proven in randomized controlled trials to outperform povidone iodine-alcohol in preventing CLABSI [23,24]. Chlorhexidine skin preparation is considered a technical element of checklists and is thought to be a straightforward and easily implementable action [25]. If a hospital supplies only alcoholic chlorhexidine and doesn’t provide povidone-iodine for skin preparation, then clinicians can be “nudged” towards performing this part of the bundle.
Optimal Catheter Site Selection
For all sites of insertion of CVC, the risk of mechanical and infectious complications depends on the skill and proficiency of operators, the clinical situation, and the availability of ultrasound to help guide placement. These factors are important in determining which anatomical site is best for each patient [26]. The femoral site has been associated with a greater risk of catheter-related infection and catheter-related thrombosis and is not recommended as the initial choice for non-emergent CVC insertion according to national guidelines [13,27]. The internal jugular vein site is associated with a lower risk of severe mechanical complications such as pneumothorax when compared to subclavian vein site [27]. The subclavian vein site is associated with a lower risk of catheter-related blood stream infection and lower rate of thrombosis, but this greatly depends on experience of operator. Experts have proposed that the subclavian site has a lower burden of colonization by bacteria than other sites and is anatomically more protected by catheter dressing; also the subcutaneous course of the central line itself is longer for the subclavian site than other sites and these reasons could contribute to the lower risk of infection [28]. The subclavian site is, however, associated with a higher risk of mechanical complications that can be serious for ICU patients. In general, the femoral vein site should be avoided in non-emergent line placement situations, particularly if the patient is an obese adult [13]. Using ultrasound as a guidance for catheter insertion has also been shown to reduce risk of CLABSI and other mechanical complications and is recommended [29,30].
Daily Review of Line Necessity
Removing unnecessary catheters as soon as possible decreases catheter dwell time and risk of infection. Few studies have concentrated on this step alone in CLABSI prevention, but the studies that have focused on catheter removal usually implement electronic reminders or multidisciplinary catheter rounds (where need for catheter is incorporated into daily rounds or discussed separately by a multidisciplinary group) [5,31].
Additional Considerations
Other basic practices that all hospitals should adopt include the above strategies and providing all inclusive catheter carts or kits, disinfecting hubs in maintenance care of catheters, covering the CVC site with sterile dressings, having recurrent educational interventions and using checklists to assure adherence to the evidence-based bundle (Table) [4,13]. As prevalence of non-ICU central lines has also grown, maintenance care is particularly important in reducing CLABSI. Maintenance bundles that highlight best practices such as aseptic technique, correct hand hygiene, chlorhexidine skin disinfection scrub, antimicrobial bandage application, and catheter hub disinfection have been used with success [32]. Specialized CVC insertion teams with trained personnel have also been recommended [4]. When these basic evidence-based practices are still unable to bring down CLABSI rates for select populations or during an outbreak, supplemental strategies can be tried to reduce CLABSI. These include antimicrobial-impregnated catheters, chlorhexidine-impregnated dressings, and chlorhexidine bathing, which is increasingly being used in the ICU setting [5,13,33].