CLABSI Toolkit - Chapter 3

CLABSI Prevention Strategies, Techniques, and Technologies

Chapter 3 focuses on evidence-based strategies and techniques for preventing central line–associated bloodstream infections (CLABSIs). Approaches not recommended for CLABSI prevention are also briefly reviewed.

Key points include the following:

  • Even in resource-poor areas of the world, researchers have found that basic education, and particularly education with feedback of CLABSI rates to staff, can result in lower CLABSI rates. The educational methods chosen should take into consideration the preferred methods of learning, principles of adult education, resources available, cultural norms, and languages spoken by health care personnel.

  • Hand hygiene is a key component of any effective patient safety and infection prevention program. 

  • Aseptic technique, a method used to prevent contamination with microorganisms, is recommended by the evidence-based guidelines for all instances of insertion and care of central venous catheters (CVCs). 

  • When preparing to insert CVCs, health care personnel should be attentive to maximal sterile barrier precautions, skin preparation, catheter selection, and use of catheter kits or carts.

  • Using an insertion checklist can improve adherence to best practices and reduce error. 

  • The insertion process includes catheter site selection, insertion under ultrasound guidance, catheter site dressing regimens, securement devices, and use of a CVC insertion bundle.

  • Proper maintenance of CVCs includes disinfection of catheter hubs, connectors, and injection ports and changing dressings over the site every two days for gauze dressings or every seven days for semipermeable dressings. A dressing should also be changed if it becomes damp, loose, or visibly soiled.

  • Health care personnel must ensure that a patient’s CVC is removed or replaced at the appropriate time and in a safe manner. Such considerations include daily review of line necessity, changing administration system components, and CVC exchanges over a guidewire.

  • Administering parental nutrition presents special considerations for infection prevention. 

Related Tools


Note: The provider’s skill in inserting a CVC is a key component of safety and prevention of CLABSI. It is imperative to assess each individual as competent to perform insertion and removal of a CVC. More manipulations and breach of aseptic technique may occur more often with inexperienced providers. Organization policy must dictate an acceptable number of multiple verified placements under the direct supervision of providers experienced in successfully placing CVCs.

Maximal Sterile Barrier Precautions

Note: Maximal sterile barrier (MSB) precautions require the CVC inserter to wear a mask and cap, a sterile gown, and sterile gloves and to use a large (head-to-toe) sterile drape over the patient during the placement of a CVC or exchange of a catheter over a guidewire.1–5 Several studies have demonstrated the benefit, either alone or as part of multimodal CLABSI prevention strategies, of using MSB precautions during CVC placement to reduce the risk of CLABSIs.

Skin Preparation

Note: The following summarizes current recommendations for skin antisepsis prior to CVC insertion and during dressing changes 1–5:

  • Apply antiseptics to clean skin.
  • Apply alcoholic chlorhexidine, with a chlorhexidine concentration greater than 0.5% in alcohol.
  • If there is a contraindication to chlorhexidine, apply tincture of iodine, an iodophor, or alcohol as an alternative.
  • Allow the antiseptic solution to dry before placing the catheter.

It should be noted, however, than in some countries, chlorhexidine availability may be an issue, in which case povidone-iodine6 or alcoholic chlorhexidine should be used.

Catheter Selection

Use of Catheter Kits or Carts

Maximal Sterile Barrier Precautions

Note: Maximal sterile barrier (MSB) precautions require the CVC inserter to wear a mask and cap, a sterile gown, and sterile gloves and to use a large (head-to-toe) sterile drape over the patient during the placement of a CVC or exchange of a catheter over a guidewire.1–5 Several studies have demonstrated the benefit, either alone or as part of multimodal CLABSI prevention strategies, of using MSB precautions during CVC placement to reduce the risk of CLABSIs.

Skin Preparation

Note: The following summarizes current recommendations for skin antisepsis prior to CVC insertion and during dressing changes 1–5:

  • Apply antiseptics to clean skin.
  • Apply alcoholic chlorhexidine, with a chlorhexidine concentration greater than 0.5% in alcohol.
  • If there is a contraindication to chlorhexidine, apply tincture of iodine, an iodophor, or alcohol as an alternative.
  • Allow the antiseptic solution to dry before placing the catheter.
It should be noted, however, than in some countries, chlorhexidine availability may be an issue, in which case povidone-iodine6 or alcoholic chlorhexidine should be used.

Catheter Selection

Use of Catheter Kits or Carts

Catheter Site Selection

Note:

  • Avoid using the femoral site for CVC access in adult patients.

  • Keep in mind that studies have shown that, unlike in adults, in pediatric patients femoral catheters have a low incidence of mechanical complications and might have an equivalent infection rate to that of nonfemoral catheters.

  • Use a subclavian site rather than a jugular site to minimize infection risks in adult patients. (Note, however, that the literature reflects comparisons of insertion sites before the routine use of ultrasound-guided insertions, so this area is deserving of additional study.)

    • Avoid the subclavian site in hemodialysis patients.

Insertion Under Ultrasound Guidance

Note: Ultrasound guidance has been associated with a higher rate of success at first-attempt insertions compared to blind techniques in several randomized controlled trials and is associated with a decrease in CLABSIs.

Securement Devices (See CLABSI Monograph, page 48)

CVC Insertion Checklist Sample Documents

Use of a CVC Insertion Bundle

  1. Infusion Nurses Society. Infusion Nursing Standards of Practice. J Inf Nurs. 2011 Jan–Feb;34 Suppl 1:S1–110.
  2. O’Grady NP, et al.; Healthcare Infection Control Practices Advisory Committee (HICPAC). Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011 May;52(9):e162–193. Epub 2011 Apr 1.
  3. Marschall J, et al. Strategies to prevent central line–associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008 Oct;29 Suppl 1:S22–30. Erratum in: Infect Control Hosp Epidemiol. 2009 Aug;30(8):815.
  4. Pratt RJ, et al. epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J Hosp Infect. 2007 Feb;65 Suppl 1:S1–64.
  5. Pittiruti M, et al.; ESPEN. ESPEN Guidelines on Parenteral Nutrition: Central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr. 2009 Aug;28(4):365–377. Epub 2009 May 21.
  6. Rosenthal VD. Central line-associated bloodstream infections in limited-resource countries: A review of the literature. Clin Infect Dis. 2009 Dec 15;49(12):1899-1907.
  7. Lee AS, et al.. Impact of combined low-level mupirocin and genotypic chlorhexidine resistance on persistent methicillin-resistant Staphylococcus aureus carriage after decolonization therapy: A case-control study. Clin Infect Dis. 2011 Jun 15;52(12):1422–1430.