Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update

Niccolò Buetti MD, MSc, PhD12a , Jonas Marschall MD, MSc34a , Marci Drees MD, MS56 , Mohamad G. Fakih MD, MPH7 , Lynn Hadaway MEd, RN, NPD-BC, CRNI8, Lisa L. Maragakis MD, MPH9, Elizabeth Monsees PhD, MBA, RN, CIC1011 , Shannon Novosad MD MPH12, Naomi P. O’Grady MD13, Mark E. Rupp MD14 , Joshua Wolf MBBS, PhD, FRACP1516 , Deborah Yokoe MD, MPH17 and Leonard A. Mermel DO, ScM1819 1Infection Control Programme, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland, 2University of Paris, Paris, France, 3Department of Infectious Diseases, Bern University Hospital and University of Bern, Bern, Switzerland, 4Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, United States, 5ChristianaCare, Wilmington, Delaware, United States, 6Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, United States, 7Ascension Healthcare and Wayne State University School of Medicine, Detroit, Michigan, United States, 8Lynn Hadaway Associates, Milner, Georgia, United States, 9Johns Hopkins University School of Medicine, Baltimore, Maryland, United States, 10Children’s Mercy Hospital, Kansas City, Missouri, United States, 11University of Missouri–Kansas City School of Medicine, Kansas City, Missouri, United States,, 12Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States, 13National Institutes of Health, Bethesda, Maryland, United States, 14University of Nebraska Medical Center, Omaha, Nebraska, United States, 15Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, United States, 16Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee, United States, 17University of California–San Francisco, San Francisco, California, United States, 18Warren Alpert Medical School of Brown University, Providence, Rhode Island, United States and 19Rhode Island Hospital, Providence, Rhode Island, United States


Purpose
Previously published guidelines provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates the Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute-Care Hospitals published in 2014. 1 This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Summary of major changes
This section lists major changes from the Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute-Care Hospitals: 2014 Update, 1 including recommendations that have been added, removed, or altered. Recommendations are categorized as essential practices that should be adopted by all acute-care hospitals (in 2014 these were "basic practices," renamed to highlight their importance as foundational for hospitals' HAI prevention programs) or additional approaches that can be considered for use in locations and/or populations within hospitals when CLABSIs are not controlled after implementation of essential practices (in 2014 these were "special approaches"). See Table 1 for a complete summary of the recommendations contained in this document.

Essential practices
• The subclavian vein is considered the preferable site for central venous catheter (CVC) insertion in the intensive care setting to reduce infectious complications. Previously, the primary recommendation was to avoid the femoral vein for access. Although this remains valid, it has been replaced by a positively formulated recommendation regarding the subclavian site. • The recommendation to use ultrasound guidance for catheter insertion is backed by better evidence than was available previously; however, the procedure itself may jeopardize the strict observation of sterile technique. • The use of chlorhexidine-containing dressings is now considered an "essential practice"; in the past, it was listed under special approaches that should only be employed if CLABSI rates remain high despite the implementation of basic practices. • Routine replacement of administration sets not used for blood, blood products, or lipid formulations can be performed at intervals of up to 7 days. Previously, this interval was no longer than 4 days.

Additional approaches
• Antimicrobial ointment for the catheter site, which is geared toward the population of hemodialysis patients, has been moved to "additional practices" given the focus on a specific population. • Despite currently being supported by high-level evidence, antiseptic-containing caps remain an "additional practice" because they are not considered superior to the manual disinfection, an essential practice. • The importance of infusion teams has been highlighted by listing it under "additional practices" (previously considered unresolved).
• Sutureless securement of catheters was not discussed in the previous version of this section.

Intended use
This document was developed following the process outlined in the Handbook for SHEA-Sponsored Guidelines and Expert Guidance Documents. 2 No guideline or expert guidance document can anticipate all clinical situations, and this document is not meant to be a substitute for individual clinical judgment by qualified professionals. This document is based on a synthesis of evidence, theoretical rationale, current practices, practical considerations, writinggroup consensus, and consideration of potential harm, where Before insertion applicable. A summary list of recommendations is provided along with their relevant rationales (see Table 1).

Methods
SHEA recruited 3 subject-matter experts in the prevention of CLABSI to lead the panel of members representing the Compendium partnering organizations: SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, as well as representation by the Centers for Disease Control and Prevention (CDC).
SHEA utilized a consultant medical librarian, who worked with each panel to develop a comprehensive search strategy for PubMed and Embase (January 2012-July 2019; updated to August 2021). Articles' abstracts were reviewed by panel members in a double-blind fashion using the abstract management software, Covidence (Melbourne, Australia), and subsequently reviewed as full text. The Compendium Lead Authors group voted to update the literature findings, and the librarian reran the search to update it to August 2021. Panel members reviewed the abstracts of these articles via Covidence and incorporated relevant references.
Recommendations resulting from this literature review process were classified based on the quality of evidence and the balance between desirable and potential for undesirable effects of various interventions (see Table 2). Panel members met via video conference to discuss literature findings; recommendations; quality of evidence for these recommendations; and classification as essential practices, additional approaches, or unresolved issues. Panel members reviewed and approved the document and its recommendations.
The Compendium Expert Panel, made up of members with broad healthcare epidemiology and infection prevention expertise, reviewed the draft manuscript after consensus had been reached by writing panel members.
Following review and approval by the Expert Panel, the 5 partnering organizations, stakeholder organizations, and the CDC reviewed the document. Prior to dissemination, the guidance document was reviewed and approved by the SHEA Guidelines Committee, the IDSA Standards and Practice Guidelines Committee, and the Boards of SHEA, IDSA, APIC, AHA, and The Joint Commission.
All panel members complied with SHEA and IDSA policies on conflict-of-interest disclosure.

Section 1: Rationale and statements of concern
Burden of outcomes associated with hospital-acquired CLABSI

HIGH
Highly confident that the true effect lies close to that of the estimated size and direction of the effect. Evidence is rated as high quality when there are a wide range of studies with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
MODERATE The true effect is likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different. Evidence is rated as moderate quality when there are only a few studies and some have limitations but not major flaws, there is some variation between studies, and/or the confidence interval of the summary estimate is wide.

LOW
The true effect may be substantially different from the estimated size and direction of the effect. Evidence is rated as low quality when supporting studies have major flaws, there is important variation between studies, the confidence interval of the summary estimate is very wide, and/or there are no rigorous studies.

Infrastructure requirements
Facilities undertaking CLABSI interventions should have the following elements in place: 1. An adequately staffed infection prevention and control program responsible for identifying patients who meet the surveillance definition for CLABSI. 2. Infection prevention staff and, preferably, information technology support to collect and calculate catheter days as a denominator when computing rates of CLABSI and patient days to allow calculation of CVC utilization. Catheter days from information systems should be validated against a manual method, with a margin of error no greater than ±5%. 60-62 3. Resources to provide appropriate education and training. 4. Adequate laboratory support for timely processing of specimens and reporting of results, as specified by the supervisor of the surveillance program.

Section 4: Recommended strategies to prevent CLABSI
Recommendations are categorized as either (1) essential practices that should be adopted by all acute-care hospitals or (2) additional approaches that can be considered in locations and/or populations within hospitals when CLABSIs are not controlled by use of essential practices. Essential practices include recommendations in which the potential to affect CLABSI risk clearly outweighs the potential for undesirable effects. Additional approaches include recommendations in which the intervention is likely to reduce CLABSI risk but there is concern about the risks for undesirable outcomes, recommendations for which the quality of evidence is low, recommendations in which cost-to-benefit ratio may be high, or recommendations in which evidence supports the impact of the intervention in select settings (eg, during outbreaks) or for select patient populations. Hospitals can prioritize their efforts by initially focusing on implementation of the prevention strategies listed as essential practices. If CLABSI surveillance or other risk assessments suggest ongoing opportunities for improvement, hospitals should consider adopting some or all of the prevention approaches listed as additional approaches. These can be implemented in specific locations or patient populations or can be implemented hospital-wide, depending on outcome data, risk assessment, and/or local requirements. Each infection prevention recommendation is given a quality of evidence grade (see Table 2).
Essential practices for preventing CLABSI recommended for all acute-care hospitals Some of the following measures have been combined into a "prevention bundle" that focuses on catheter insertion. 63,64 Numerous studies have documented that use of such bundles is effective, sustainable, and cost-effective in both adults and children. 63,[65][66][67][68] Bundles are most likely to be successful if implemented in a previously established patient safety culture and their success depends on adherence to individual measures. 69 However, data suggests that not all components of bundles may be necessary to achieve an effect on CLABSI rates. 70 After catheter insertion, maintenance bundles have been proposed to ensure optimal catheter care. 71 More data are needed to determine which components of the maintenance bundle are essential in reducing risk. 72,73 Before insertion 1. Provide easy access to an evidence-based list of indications for CVC use to minimize unnecessary CVC placement (Quality of Evidence: LOW) 2. Require education and competency assessment of healthcare personnel (HCP) involved in insertion, care, and maintenance of CVCs about CLABSI prevention (Quality of Evidence: MODERATE) 74-78 a. Include the indications for catheter use, appropriate insertion and maintenance, the risk of CLABSI, and general infection prevention strategies. b. Ensure that all HCP involved in catheter insertion and maintenance complete an educational program on essential practices to prevent CLABSI before performing these duties. 79,80 Periodic retraining with a competency assessment may be of benefit. 81 c. Periodically assess HCP knowledge of and adherence to preventive measures. d. Require all HCP who insert a CVC to undergo a credentialing process (as established by the individual healthcare institution) to ensure their competency before independently inserting a CVC and aseptic technique for accessing and maintaining the CVC thereafter. e. Re-educate when an institution changes components of the infusion system that requires a change in practice (eg, when an institution's change of the needleless connector requires a change in nursing practice). f. Use simulation training for proper catheter insertion and maintenance if available. 82-85 3. Bathe ICU patients >2 months of age with a chlorhexidine preparation on a daily basis (Quality of Evidence: HIGH) 86-90 a. In long-term acute-care hospitals (LTACHs), daily chlorhexidine bathing may also be considered as a preventive measure. 91 b. The role of chlorhexidine bathing in non-ICU patients remains unclear. 92,93 One cluster-randomized study found a significant reduction in device-associated bacteremia with CHG bathing in this patient population 93 ; however, some of these patients also received methicillin-resistant Staphylococcus aureus (MRSA) decolonization, making it difficult to draw firm conclusions regarding CHG bathing alone. Several studies have suggested benefit among adult hematology-oncology patients; however, a similar reduction was not observed for pediatric patients with similar conditions. 94,95 Accordingly, potential benefits and risks, such as increases in resistance and cost, need to be carefully considered. c. The safety and efficacy of routine use of chlorhexidine bathing in infants <2 months of postnatal age remains unclear. 96 Although life-threatening skin injuries from CHG have been reported in very young or very preterm infants, they typically occur in infants with a birthweight <1,000 g who are <7 days postnatal age, and they appear rare in older infants. 97 159 However, reducing CVC utilization may result in increased use of other intravascular catheters with corresponding infection risk. b. Audits to determine whether CVCs are routinely removed after their intended use may be helpful. 160,161 Both simple and multifaceted interventions are effective at reducing unnecessary CVC use. 162,163 6. Routine replacement of administration sets not used for blood, blood products, or lipid formulations can be performed at intervals up to 7 days (Quality of Evidence: HIGH) 164 a. The optimal replacement of intermittently used administration sets is unresolved. 7. Perform surveillance for CLABSI in ICU and non-ICU settings (Quality of Evidence: HIGH) 13,165,166 a. Measure unit-specific incidence of CLABSI (eg, CLABSI per 1,000 catheter days) and report the data on a regular basis to the units, physician and nursing leadership, and hospital administrators overseeing the units. b. Compare CLABSI incidence to historical data for individual units and to national rates (ie, NHSN). 167 c. Audit surveillance as necessary to minimize variation in interobserver reliability. 48,168 Additional approaches for preventing CLABSI Several additional approaches are currently available for use. Perform a CLABSI risk assessment before considering implementation of any of these approaches, taking potential adverse events and costs into consideration. Although it is reasonable to evaluate the utility of technology-based interventions when CLABSI rates are above the institutional-or unit-based threshold, this is also an opportunity to review practices and consider behavioral changes that may be instituted to reduce CLABSI risk. These additional approaches are recommended for use in locations and/or populations within the hospital with unacceptably high CLABSI rates despite implementation of the essential CLABSI prevention strategies listed above. These measures may not be indicated if institutional goals have been consistently achieved. a. Antibiotic and antiseptic locks are created by filling the lumen of the catheter with a supratherapeutic concentration of an antibiotic solution and leaving the solution in place until the catheter hub is re-accessed. Such an approach can reduce the risk of CLABSI. The optimal antimicrobial agent or combination of agents, their concentration, and duration of lock therapy are matters of ongoing research. Due to concerns regarding the potential for the emergence of resistance in exposed organisms, use antimicrobial locks as a preventative strategy for the following: i. Patients with long-term hemodialysis catheters who have a history of recurrent CLABSI. 185 ii. Prophylaxis for patients with limited venous access and a history of recurrent CLABSI. iii. Patients who are at heightened risk of severe sequelae from a CLABSI (eg, patients with recently implanted intravascular devices such as a prosthetic heart valve or aortic graft). b. To minimize systemic toxicity, aspirate rather than flush the antimicrobial lock solution after the dwell time has elapsed. [186][187][188][189] The potential of adverse effects associated with ethanol locks should be carefully considered before use. 190,191 3. Use recombinant tissue plasminogen activating factor (rt-PA) once weekly after hemodialysis in patients undergoing hemodialysis through a CVC (Quality of Evidence: HIGH) 192 4. Utilize infusion or vascular access teams for reducing CLABSI rates (Quality of Evidence: LOW) 193,194 a. Studies have shown that an infusion/vascular access team responsible for insertion and maintenance of peripheral intravenous catheters reduces the risk of bloodstream infections 195 ; however, few studies have been performed regarding the impact of intravenous therapy teams on CLABSI rates. 196

5.
Use antimicrobial ointments for hemodialysis catheter insertion sites (Quality of Evidence: HIGH) [197][198][199][200][201] a. Apply polysporin "triple" (where available) or povidoneiodine ointment to hemodialysis catheter insertion if compatible with the catheter material. b. Ingredients in ointments may interact with the chemical composition of some catheters. Thus, ensure the selected ointment will not interact with the catheter material before any such product is applied to the catheter insertion/exit site. For example, ointments containing glycol should not be applied to insertion/exit sites of polyurethane catheters. c. Mupirocin ointment should not be applied to the catheter insertion site due to the risks of facilitating mupirocin resistance and the potential damage to polyurethane catheters. 6. Use an antiseptic-containing hub/connector cap/port protector to cover connectors (Quality of Evidence: MODERATE) 202-208 a. The utility of routinely disinfecting hub connectors and ports when using antiseptic-containing hub/connector cap/port protectors is unknown.
Approaches that should not be considered a routine part of CLABSI prevention 1. Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (Quality of Evidence: HIGH) [209][210][211][212][213] a. Systemic antimicrobial prophylaxis is not recommended. 2. Do not routinely replace CVCs or arterial catheters (Quality of Evidence: HIGH) 214 a. Routine catheter replacement is not recommended.

Unresolved issues
1. Routine use of needleless connectors as a CLABSI prevention strategy before an assessment of risks, benefits, and education regarding proper use 215-219 a. Multiple devices are currently available but the optimal design for preventing infections is unresolved. The original purpose of needleless connectors was to prevent needlestick injuries during intermittent use. No data are available regarding their use with continuous infusions. Needle-free connectors with 3-way stopcocks may increase the risk of catheter infections. 220 i. Use of silver-coated catheter connectors may be associated with reduced intraluminal contamination in ex vivo catheters and CLABSI. 221,222 Clinical evidence is limited regarding the risk reduction with their routine use or use of other antimicrobial catheter connectors. 2. Surveillance of other types of catheters (eg, peripheral arterial or venous catheters) 11,21,22 a. Peripheral arterial catheters, short-term peripheral venous catheters and midline catheters are not included in most surveillance systems although they are associated with risk of bloodstream infection. Future surveillance systems should consider including bloodstream infections associated with these types of catheters. b. If considering further infection prevention interventions due to concern for an increase in infections, hospitals may want to consider extending their surveillance programs to include all types of catheters used to gauge the size of the problem. 3. Standard, nonantimicrobial transparent dressings and CLABSI risk a. A meta-analysis reported an association between CLABSI and transparent dressing use; however, the source studies for the meta-analysis reporting this association were of low quality. 223 4. The impact of using chlorhexidine-based products on bacterial resistance to chlorhexidine a. Widespread use of chlorhexidine-based products (eg, use of chlorhexidine bathing, antisepsis, and dressings) may promote reduced chlorhexidine susceptibility. 224 However, testing for chlorhexidine susceptibility is not standardized. The clinical impact of reduced chlorhexidine susceptibility is unknown. 5. Sutureless securement a. The impact of sutureless securement devices in reducing CLABSI is unknown. 225,226 6. Impact of silver zeolite-impregnated umbilical catheters in preterm infants (applicable in countries where it is approved for use in children) 227 a. One randomized study suggests that antimicrobial-impregnated umbilical catheters appear to be safe and effective in NICU patients. 228 7. Necessity of mechanical disinfection of a catheter hub, needleless connector, and injection port before accessing the catheter when antiseptic-containing caps are being used. a. It is unknown whether the application and removal of an antiseptic-containing cap provides the same benefit to reducing risk of CLABSI as manual disinfection. Future research is needed to determine if using such a cap will obviate the need for manual disinfection before accessing a catheter.

Internal reporting
These performance measures are intended to support internal hospital quality improvement efforts 229,230 and do not necessarily address external reporting needs. The process and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinion of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for CLABSI. (Table 3) 1. Compliance with CVC insertion guidelines as documented on an insertion checklist a. Assess compliance with the checklist in all hospital settings where CVCs are inserted (eg, ICUs, ED, OR, radiology, general patient care units) and assign HCP familiar with CVCs to this task. b. Documenting compliance using the insertion checklist upholds accountability and compliance with the proper procedure steps and identifies gaps to be mitigated.  External quality initiatives 1. Hospitals that participate in external quality initiatives or state programs must collect and report the data required by the initiative or the program. 2. Problems with interrater reliability may affect comparisons between different institutions.

Section 6: Implementation of CLABSI prevention strategies
Prevention of CLABSI depends on integrating best practices to reduce the risk of infection and incorporating a culture to support implementation. Hospitals should address technical and socioadaptive components 244 to CLABSI prevention, including formal training of HCP on indications, placement, and maintenance of devices, in addition to regular assessment of competencies. 245 One example of a widely used model in the United States, known as the Four Es (ie, engage, educate, execute, and evaluate 246 ), involves summarizing evidence, identifying local barriers to implementation, measuring performance, and ensuring that patients receive the infection prevention intervention 247 by addressing knowledge, critical thinking, behavior and psychomotor skills, as well as attitudes and beliefs of all members of the healthcare team involved with the insertion and care of CVCs. 248,249 Facilities may consider utilizing tools to promote high-reliability processes (eg, Lean Six Sigma) and to enhance teamwork (eg, Team STEPPS).

Engage
Historically, efforts have been centered around having a champion to support CLABSI reduction initiatives. Champions are often very effective in initial phases of adoption, but their efforts may not be enough for integration of processes and sustainability. 250 It is important to engage both frontline and senior leadership champions in the process and outcome improvement plan, 251 but institutionalizing the work and garnering the support of stakeholder groups facilitates successful, long-lasting results. 252 Educate HCP, patients, and caregivers involved in care of a CVC should be trained in and competent, relative to their role, with the following: 1. Appropriate indications prior to insertion. 2. Use of full barrier precautions at the time of insertion. 3. Daily evaluation of necessity of the device.

Execute
A standardized competency assessment checklist should be used to assess and document competency of each individual performing CVC insertion and procedures related to care and maintenance (eg, dressing changes). [253][254][255] In addition, education of the patient and/or family, as appropriate, is required for all CVC care procedures especially when transfer to an alternative setting (eg, home care, ambulatory setting) is planned. 256,257 Evaluate Evaluation involves both process and outcome measurement. 258 Multidisciplinary teams should set clear goals and identify the key factors to be measured. It is important for members of the healthcare team to receive feedback on their performance. Feedback should include periodic (eg, monthly, quarterly) communication (eg, e-mail messages, written reports) of process measurement data via posters, reports, or other forms of communication with graphs showing cumulative compliance with process measures. [259][260][261][262] Differences between age groups should also be considered (eg, neonates, pediatrics, and adults). 260,263,264 Central line data can be used to capture trends over time. The standardized utilization ratio (SUR) provides a method for the hospital's units to compare themselves to others with similar characteristics. CLABSI events are important to discuss with the different members of the team caring for the patient to have a clear understanding of gaps and ways to mitigate them in the future.
Disclaimer. The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Conflicts of interest. The following disclosures reflect what has been reported to SHEA. To provide thorough transparency, SHEA requires full disclosure of all relationships, regardless of relevancy to the topic. Such relationships as potential conflicts of interest are evaluated in a review process that includes assessment by the SHEA Conflict of Interest Committee and may include the Board of Trustees and Editor of Infection Control and Hospital Epidemiology. The assessment of disclosed relationships for possible conflicts of interest has been based on the relative weight of the financial relationship (ie, monetary amount) and the relevance of the relationship (ie, the degree to which an association might reasonably be interpreted by an independent observer as related to the topic or recommendation of consideration). N.B. received a Mobility grant from the Swiss National Science Foundation (grant nos. P400PM_183865 and P4P4PM_194449) and a grant from the Bangerter-Rhyner Foundation. J.M. is the recipient of a project grant on surgical site infections from the Swiss National Science Foundation (grant no. 32003B_179500, "Understanding the drivers of surgical site infection: Investigating and modeling the Swissnoso surveillance data"). L.M. served as an advisor/consultant for Marvao Medical Devices. L.H. served as an advisor/consultant for B Braun Medical, BD Medical, Atrion Medical, Nexus Medical, Teleflex. M.E.R. served as an advisor/consultant for 3M, Becton Dickinson, and Cetius, and Teleflex, and received honoraria from Teleflex. All other authors report no conflicts of interest related to this article.