Preventing Central Line Infections

Central line associated bloodstream infections (CLABSI) occur when pathogens invade the bloodstream via a central line, also called a central venous catheter (CVC). Preventing infections related to central lines is a high priority for hospitals. Not only can patients become quite ill and even die from a central line infection, but the associated costs add billions to the U.S. healthcare system each year. 

What is a central line?

A central line is an IV catheter that empties into a central vein – either the inferior vena cava, the superior vena cava, or, in some cases, even the right atrium.

There are several types of central venous catheters, and the type used varies based on the duration of therapy, type of therapy, and patient condition. 

Implanted catheters are utilized for long-term use such as with chemotherapy. In general, implanted catheters have lower incidence of infection than temporary-access catheters. 

There are two main types of implanted catheters – tunneled catheters and implanted ports. Tunneled catheters are placed under the skin in the subcutaneous tissue and have a short tunneled length of catheter that goes from the site of entry on the skin to the site where it actually penetrates the vein. This makes it harder for pathogens from the surface to get into the vessel and cause a central line infection. 

Another type of implanted catheter is an implanted port, which is entirely beneath the skin. The catheter of an implanted port extends from a subcutaneous infusion port to the point of vessel cannulation. Port insertion is a surgical procedure and they are accessed via a needle puncture through the tissue, which can be uncomfortable for the patient. However, the lower infection risk associated with implanted ports can far outweigh the discomfort.

Looking at temporary or short-term catheters, there are a few key types and varying locations where they can be inserted. If you are interested in diving deeper into this topic, see the robust list of references at the end of this article.

• CVC with femoral vein insertion – A central venous catheter inserted in the femoral vein runs the highest risk of leading to a CLABSI. While there can be some advantages to a femoral line in some cases, these advantages are often overshadowed by the infection risk. In fact, the CDC recommends femoral venous access be avoided in adult patients whenever possible.
  
  A key reason infection risk is so high is simply that the groin is more contaminated with pathogens than other parts of the body. Additionally, gowns or hospital bedding may cover the site much of the time, meaning it could be at risk for less-frequent assessment.
  
  When your patient has a femoral central line, you’ll need to be extra vigilant about infection prevention and, when appropriate, advocate for its safe removal (and possible relocation) as soon as possible.
• CVC with internal jugular vein insertion – A very common site for central line insertion is the internal jugular (IJ). The right internal jugular provides a more direct pathway to the superior vena cava than the left, so that is the side typically used. Factors that put an IJ line at risk for infection are that the dressings tend to loosen more easily than other sites due to patient movement of the neck, the presence of hair on the neck, and the presence of oral secretions (mainly in intubated patients). However, one advantage is that since they’re not covered by gowns or bedding, more frequent, incidental observation naturally occurs.
• CVC with subclavian vein insertion – Of all the centrally placed temporary catheters, the subclavian (SC) site has the lowest infection risk. There’s simply not a lot of movement at this site nor as much chance for oral secretions to reach this area and undermine the integrity of the dressing.
• PICC – A peripherally inserted central catheter (PICC) is a central line inserted in the upper arm. It has a long catheter that reaches from that insertion site to the superior vena cava. Two key benefits of PICC lines are that they can stay in place longer than temporary non-tunneled lines and tend to have lower infection risk. For example, a study published in November, 2022 in the journal Antimicrobial Resistance and Infection Control looked at all PICC lines and central venous catheters used over a two year period in a metropolitan hospital. The CLABSI rate for the CVC group was 6.03 per 1000 catheter days while the CLABSI rate for the PICC group was 1.62 per 1000 catheter days.

Another type of central venous catheter is a temporary hemodialysis catheter, which may also be placed in the internal jugular vein, subclavian vein or femoral vein. Note that these may be tunneled or non-tunneled as well.

Preventing Central Line Infection

Now that you have a general idea of what central lines are and how different types have varying levels of infection risk, here are some ways we work to prevent central line infections (source: Centers for Disease Control and Infusion Nurses Society). 

CVC Insertion Strategies

• The more lumens a central line has, the higher risk for infection. So, a key way to reduce infection right from the start is when the MD chooses a catheter with the least number of lumens possible, while still meeting their needs for vascular access.
• When using a non-tunneled CVC, avoid femoral sites whenever possible and choose subclavian insertion over IJ when appropriate.
• Utilize ultrasound to guide insertion when available to reduce the number of insertion attempts.
• If a CVC is placed during an emergency and sterile procedures cannot be confidently followed, the catheter should be replaced as soon as it is feasible and preferably within 48 hours.
• Sterile technique should be followed for CVC insertion. Many facilities follow the “CLIP” (central line insertion practices) protocol. CLIP protocol involves: 
  • Hand hygiene
  • Prep the skin with chlorhexidine, alcohol or iodine as appropriate for the patient’s age and allergies
  • Wait for the skin prep agent to dry completely before beginning insertion
  • Use maximal sterile barriers throughout the procedure: sterile gown, sterile gloves, cap, mask, and large sterile drape covering the patient’s entire body (the only area exposed is the area of insertion)
• Use of a catheter securement device helps hold the catheter in place and reduces the risk for infection.
• Once the new CVC is in place, avoid connecting previously used IV tubing to the new catheter if at all possible.

CVC Ongoing Care

• A daily assessment of necessity can help ensure patients’ central lines are removed as soon as they are no longer indicated.
• Assess the dressing status as part of your regular head-to-toe assessment.
• Perform hand hygiene and wear gloves when accessing the CVC.
• Change IV tubing no more frequently than every 96 hours and at least every seven days (this can vary by facility). 
• Tubing used for some substances requires more frequent changes. Tubing utilized for propofol should be changed every six to 12 hours (or with every new container – this may vary by facility protocol). TPN and lipid emulsion tubing is changed every 24 hours, and blood product tubing is changed after every two units or within 24 hours (whichever comes first). 
• Change needleless connectors with tubing changes, when soiled, leaking or loose. A mask should be worn for needleless connector changes. Scrub the hub of the catheter for 15 seconds with alcohol and let dry fully before applying the new needleless connector.
• Scrub the hub! Scrub the hub of needleless connectors and any other access sites (Y-sites on IV tubing) with alcohol for 15 seconds and let dry fully before accessing with a sterile syringe.
• Bathe the patient daily with chlorhexidine, and keep the patient in a clean gown and use clean linens.
• Flush the catheter routinely according to facility protocol as well as before and after medication administration.

CVC Dressing Changes

• Some hospitals utilize IV Therapy teams of specially trained RNs who do all central line dressing changes or all PICC line dressing changes. Central line dressing changes should be done only by trained personnel.
• The CVC dressing should be changed when it becomes loose, damp or soiled.
• Gauze occlusive dressings should be changed every 2 days. Semipermeable transparent dressings for short-term catheters should be changed every seven days. Exceptions may be made in some facilities for pediatric patients when the risk of catheter dislodgement outweighs the benefit of applying a new dressing.
• Sterile gloves and a mask are worn when applying a new dressing. The patient and anyone else in the room should also wear a mask.
• Before applying a new dressing, clean the skin with chlorhexidine and allow it to dry fully (for patients 18 years and older).
• The use of a chlorhexidine Biopatch® at the insertion site has been shown to decrease risk of infection.
• Once the new dressing is applied, add your initials, time and dates the next nurse knows when the dressing change is due.

What are the signs of central line infection?

Signs of a central line infection include:

• Fever and/or chills
• Tachycardia
• Pain at the access site
• Warmth, erythema and edema at the access site
• Purulent drainage at the access site
• The catheter may be sluggish or have no blood return, especially in long-term catheters

What happens if your patient acquires a central line infection?

When a central line infection is suspected, the patient will have blood cultures drawn and prescribed medication based on the most likely organism. In some cases, the catheter tip may be cultured as well. Once the organism is identified, antimicrobial therapy will be targeted to that specific organism.

Though there are exceptions, once CLABSI is suspected, it is recommended that non-tunneled catheters be removed as soon as possible. This is basic source control and is the cornerstone of infectious disease treatment.

Exceptions may be made in cases where the infection of a long-term catheter is caused by certain organisms that can be treated with IV antibiotics or in cases where the  patient has limited access sites and is reliant upon central venous access for survival. You may hear this called catheter salvage therapy. 

I hope this overview of central line infections has increased your understanding. If it has, I’d love for you to share it with a nurse colleague or fellow classmate. Want to learn more about IV therapy? Then check out out this article on IV medication administration.

Review this topic again while you’re on the go by tuning in to episode 285 of the Straight A Nursing podcast. Listen from any podcast platform, or straight from the website here.

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