ICU patients are at risk for CLABSI because of frequent use of multiple catheters, and the comorbidities and acuity of care that these patients have. ICU patients also tend to have lots of manipulation of their catheters and often these catheters are placed in emergent situations [13]. Patients in the non-ICU and outpatient setting are also at risk for CLABSI when they have a central venous catheter. Long courses of antibiotics for disease states such as osteomyelitis and endocarditis often entail central venous catheters. Recent work has shown that PICCs carry as high of a CLABSI risk as short-term CVCs in hospitalized patients [34]. Patients with end-stage renal disease, especially those undergoing maintenance hemodialysis via a tunneled dialysis catheter are particularly vulnerable to CLABSI [13,35].
Risk Factors for CLABSI
A number of studies have reviewed risk factors and epidemiology of CLABSI in the adult and pediatric population. Factors that have been associated with risk of CLABSI in more than one study include prolonged hospitalization before placement of the central line, prolonged duration of the central line, heavy microbial colonization at the site of insertion, heavy microbial colonization of the catheter hub, multiple lumens, internal jugular site catheterization, femoral vein site catheterization, neutropenia of the patient, a reduced nurse to patient ratio in the ICU setting, presence of total parenteral nutrition, and poor maintenance care of the catheter [4,13,36–40]. One study [41] that calculated a score to help predict risk of PICC-CLABSI found that previous CLABSI (within 3 months of PICC insertion) significantly increases risk of repeat CLABSI.
Conclusion
CLABSI is an important cause of morbidity, mortality and cost. There has been remarkable success in prevention of these infections in recent years due to focused efforts on patient safety. As efforts have multiplied to put into place interventions to decrease CLABSI nationally, the CDC published a Vital Signs report discussing the impact of these efforts [42]. It was estimated that over one decade, infection prevention efforts had avoided 25,000 CLABSIs in U.S. ICUs, a 58% reduction in this infection [42]. CLABSI has served as the best example of using evidence-based interventions through an infection prevention bundle or framework to reduce HAIs. Similar approaches are being used to try to reduce catheter-associated urinary tract infection, Clostridium difficile infection, surgical site infection, and ventilator-associated pneumonia, but there have been less distinct successes nationally and internationally for these other HAIs.
The literature emphasizes that there are several evidence-based measures that can prevent CLABSI. These include hand hygiene, using alcoholic chlorhexidine for skin preparation prior to insertion, maximal sterile barrier precautions, avoiding the femoral site for CVC insertion, and removing unnecessary catheters as soon as possible. Support from administration in emphasizing patient safety and HAI prevention along with following evidence-based practice could lead to long-term improvement in CLABSI prevention across hospital systems.
Corresponding author: Payal K. Patel, MD, MPH, Div of Infectious Diseases, Dept of Internal Medicine, VA Ann Arbor Healthcare System, 2215 Fuller Rd, Ann Arbor, MI 48105, payalkp@umich.edu.
