Central Line-Associated Bloodstream Infection (CLABSI)

Central Line-Associated Bloodstream Infection (CLABSI)

David Ray Velez, MD

Table of Contents

Also Known As “Catheter-Related Bloodstream Infection (CRBSI)”

Definitions
Etiology
Presentation
Diagnosis
Prevention and Treatment

See Also:
*Central Venous Catheter (CVC)

Definitions

Bacteremia: Bacterial Bloodstream Infection (BSI)

Primary Bloodstream Infection (BSI): A Laboratory Confirmed Bloodstream Infection (LCBI) that is Not Secondary to an Infection at Another Body Site

Secondary Bloodstream Infection (BSI): A Laboratory Confirmed Bloodstream Infection (LCBI) that is Thought to Be Seeded from a Site-Specific Infection at Another Body Site

Central Line-Associated Bloodstream Infection (CLABSI): A Laboratory Confirmed Bloodstream Infection (LCBI) Where an Eligible BSI Organism is Identified, and an Eligible Central Line is Present on the LCBI Date of Event (DOE) or the Day Before

  • Eligible Central Line: A Central Line in Place for More than 2 Consecutive Calendar Days (On or After Day #3), Following the First Access of the Central Line, In an Inpatient Location, During the Current Admission
    • Remains Eligible Until the Day After Removal or Patient Discharge
  • LCBI Date of Event (DOE): First Date of Symptoms or the Date of Culture Collection
  • *Per CDC/NHSN Surveillance Definitions

Devices Not Considered Central Lines for NHSN Purposes:

  • Peripheral IV or Midlines
  • Arterial Lines (Unless in the Pulmonary Artery, Aorta, or Umbilical Artery)
  • AV Graft/Fistula
  • Atrial Catheters
  • Ventricular Assist Devices (VAD)
  • Intra-Aortic Balloon Pump (IABP)
  • Extracorporeal Membrane Oxygenation (ECMO)

Etiology

Risk Increases with Duration of Placement (However, There is No Indication for Routine Catheter Changing Based on the Number of Days)

Skin Colonization is the Most Common Source

Most Common Organisms

  • Coagulase-Negative Staphylococci (CoNS/S. epidermidis) – Most Common
  • Staphylococcus aureus – Second Most Common
  • Enterococci
  • Candida
  • Klebsiella
  • Escherichia coli
  • Enterobacter
  • Pseudomonas

Risk Factors

  • Duration of Catheterization
  • Non-Sterile Insertion
  • Poor Catheter Cares
  • Immune Compromised/Neutropenic
  • Malnutrition
  • Multiple Concurrent Central Lines
  • Femoral or Internal Jugular Location (Lowest for Subclavian)

Risk by Type/Site

  • Type:
    • Peripherally Inserted Central Catheter (PICC): 1.1 per 1,000 Catheter Days
    • Cuffed and Tunneled Central Venous Catheter: 1.6 per 1,000 Catheter Days
    • Non-Tunneled Central Venous Catheter (CVC): 2.7 per 1,000 Catheter Days
  • Site:
    • Subclavian (SC) Vein: Generally Considered to Have the Lowest Infection Risk
    • Internal Jugular (IJ) Vein
    • Femoral Vein: Generally Considered to Haver the Highest Infection Risk (Debated)
      • *Increased Risk is Primarily Demonstrated in Older Studies with More Recent Studies Showing Similar Rates to Internal Jugular (IJ) Sites

Presentation

Presentation

  • Fever – Most Common Clinical Manifestation
  • Inflammation or Purulence at the Catheter Insertion Site
    • High Specificity (94-99%)
    • Low Sensitivity (< 5%)
  • Sepsis – Often Sudden Onset
  • Hemodynamic Instability
  • Altered Mental Status
  • Catheter Dysfunction/Intraluminal Clot

Complications

  • Septic Thrombophlebitis
  • Infective Endocarditis
  • Metastatic Infection Due to Septic Embolization
    • Septic Arthritis
    • Osteomyelitis
    • Orthopedic Hardware Infection

Diagnosis

Diagnosis: Obtain Two Peripheral Blood Cultures from Separate Sites Before Antibiotic Initiation

  • Cultures Drawn Peripherally and Not from the Central Line – Increased Risk of Contamination
  • Catheter Tip Cultures are Not Recommended – Low Positive Predictive Value
  • A Single Coagulase-Negative Staphylococci (CoNS) Culture is Often a Contaminant and Should Consider Repeating the Cultures

Consider Echocardiogram to Evaluate for Infective Endocarditis if Bacteremia is Persistent > 48-72 Hours

Prevention and Treatment

Prevention

  • Remove Central Lines as Soon as Possible
  • Use Sterile Technique in Placement
  • Use Ultrasound Guidance
  • Chlorhexidine-Impregnated Dressings
  • Use of Antimicrobial-Impregnated Central Lines
  • Disinfect Hubs and Ports Before Accessing
  • Use an Antiseptic-Containing Hub or Port to Cover Connectors

Interventions Without Proven Benefit

  • Prophylactic Antibiotics
  • Routine Replacement of Central Lines
  • Daily Bathing with Chlorhexidine
  • Securing the Catheter with a Suture – Creates Another Wound

Treatment

  • Preferred Treatment: Catheter Removal and Antibiotics
  • *For CoNS – May Consider Withholding Antibiotics and Just Removing the Central Line – No Increased Risk of Complications or Recurrence
  • If Clinically Unable to Remove the Catheter – Consider Exchange Over a Guidewire After Starting Antibiotics

Antibiotics

  • Start Broad Spectrum and Deescalate Based on Culture Data
  • Duration: 7-14 Days
    • Generally Prefer Longer Durations (14 Days) if Unable to Remove the Central Line or if Endovascular Implants or Orthopedic Hardware are Present
    • Complicated Infections May Require Prolonged Durations Up to 4-6 Weeks
  • Generally Repeat Blood Cultures Every 2-3 Days to Confirm Bacterial Clearance
    • Failure to Achieve Sterilization May Indicate Endocarditis