Central Line-Associated Bloodstream Infections (CLABSI)

What is a Central Line-Associated Bloodstream Infection, or CLABSI?

A central line, like the name implies, is a catheter that gains direct entry into the bloodstream with the tip of a line sitting either within the superior vena cava or inferior vena cava, or within one of the great vessels of the neck.

As a result of its central location, this type of catheter can occasionally allow pathogens to gain direct entry into the bloodstream. If this occurs, because of the location of the catheter, patients become unwell very quickly.

This is why prompt assessment, recognition and treatment of central line-associated bloodstream infections (CLABSI) is essential to help ensure favourable patient outcomes are achieved.

Preventing and Controlling Healthcare Associated Infections Standard

In Australia, the Australian Commission on Safety and Quality in Health Care’s (ACSQHC) National Safety and Quality Health Service Standards specifies the prevention and control of healthcare-associated infections (HAI) as one of the eight essential Standards of care for health services.

In accordance with this Standard, the ACSQHC states that certain criteria need to be met in order for the patient to be diagnosed with a CLABSI (ACSQHC 2019), such as the timing of the central line and when it was inserted, a sample of blood cultures taken, and any infection not being attributable to an infection at another site.

Specifically, CLABSI must meet each point of one of the following criteria:

Criterion 1
✔	A patient of any age has a recognised bacterial or fungal pathogen cultured from one or more blood cultures.
✔	The organism cultured from blood is not related to an infection at another site.
Criterion 2
✔	A patient of any age has at least one of the following signs or symptoms: fever (> 38°C), chills or hypotension, or A patient < 1 year of age has at least one of the following signs or symptoms: fever (> 38°C core), hypothermia (< 36°C core), apnoea or bradycardia.
✔	The organism cultured from blood is not related to an infection at another site
✔	The same (matching) potential contaminant organism is cultured from two or more sets of blood cultures drawn on separate occasions within 24 hours.

(ACSQHC 2019)

As you can imagine, the cost of CLABSI in both healthcare dollars and patient morbidity is high. Each CLABSI episode increases the length of the individual’s hospitalisation as well as substantially increasing the cost of the individual’s healthcare (Haddadin et al. 2020). Therefore, it is important to be aware of the causes of CLABSI and how we can prevent them from occurring (ACSQHC 2019).

What Causes a Central Line-Associated Bloodstream Infection?

There are many different ways that contamination can occur of the central line and cause a central line-related infection. These include:

• Contamination on insertion;
• The patient’s skin flora;
• The healthcare professional accessing the central venous access device;
• Central venous access devices (CVAD) hub colonisation;
• Contaminated infusion or components of IV set;
• Haematogenous spread from other sites (e.g. through the bloodstream from another infection); and
• Non-intact dressing.

Patient-related risk factors for developing a CLABSI include:

• Immunosuppression;
• Increased age;
• Poor nutrition;
• Impaired skin integrity;
• Other infection;
• Multiple invasive procedures;
• Antibiotic therapy;
• Certain comorbidities such as diabetes and vascular disease;
• Parenteral nutrition;
• Position of central line can also increase the risk of infection if it is femoral or internal jugular; and
• Lengthy hospitalisation before venous catheterisation.

Other risk factors include:

• Poor patient hygiene;
• Healthcare workers using poor hand hygiene;
• Non-adherence to aseptic technique;
• Type of central line and number of lumens;
• If it was an emergency insertion;
• Non-compliance with central line maintenance, such as not using antiseptics or not completing dressing changes; and
• Prolonged duration of the catheter.

(Guenezan et al. 2018; WHO 2016; Chopra 2013)

Central Line-Associated Bloodstream Infection (CLABSI) Symptoms

Central line related infections can be either localised or systemic.

Symptoms of localised infections include:

• Redness;
• Swelling;
• Discharge at central line exit site.

If it is a suspected localised infection, a swab can also be taken from the central line exit site if exudate is present.

Systemic infection symptoms include:

• Fever;
• Hypotension;
• Tachycardia;
• Respiratory distress;
• Chills/rigors;
• Diaphoresis;
• Altered cognitive state.

(Haddadin et al. 2020; Medline 2018)

If a CLABSI is suspected, a full septic screen of the patient should occur. This will often involve the following investigations:

• A set of blood cultures from each lumen of the CVAD;
• A set of blood cultures from peripheral blood;
• A swab of the central line exit site if there is exudate present;
• Vital signs;
• A full blood count;
• Electrolytes, urea and serum creatinine;
• Liver function;
• Midstream urine specimen;
• Chest x-ray;
• Sputum;
• Other wound swabs.

(Haddadin et al. 2020; ACSQHC 2019)

How Are Central Line-Associated Bloodstream Infections Treated?

Treatment of a CLABSI needs to commence promptly. This can include the use of intravenous antibiotics as well as using supportive measures, such as intravenous fluid administration and oxygen therapy if required, and in conjunction with the ongoing monitoring and assessment of the patient.

The CVAD may also be removed. If it is to be removed, then the catheter tip may be sent to pathology for cultures. Prior to removal, blood cultures may also be taken via the CVAD.

(Haddadin et al. 2020)

Nursing Care and Central Line-Associated Bloodstream Infection Prevention

One of the most important factors of management of a central line is the nursing management of this device and the person. This not only includes assessing the patient for risk factors of potentially developing an infection but also ensuring preventative measures are in place and management of the central line occurs by a no-touch aseptic technique.

The use of maintenance checklists as well as insertion bundles can also be used to standardise central line care and has been found to reduce the incidence of CLABSI from occurring (ANZICS 2020).

The nurse must manage the central line according to their local hospital policy and procedures, however, this management can include the following:

• Hand hygiene;
• Disinfect hubs, needle connectors and injection ports prior to CVAD use and as per protocol;
• Remove nonessential CVADs;
• Chlorhexidine cleansing as per protocol;
• Monitor the CVAD dressing and use of chlorhexidine products and topical antibiotics;
• Antibiotic/anti-infective ‘locks’ in high-risk patients;
• Systemic antibiotic prophylaxis.

(CDC 2017; Chopra et al. 2013)

Healthcare professionals should also educate patients in the management of their central line and how they can help protect themselves against a possible CLABSI. These include:

• Speaking up about any concerns;
• Asking if the central line is absolutely necessary and how long it may be in place;
• Pay attention to the dressing around it (e.g. if it is wet or dirty);
• Tell a healthcare worker if the catheter site is sore or red;
• Avoid touching the tubing as much as possible;
• Do not let visitors touch the tubing.

(CDC 2017)

The healthcare professional must also monitor for any signs or symptoms of a CLABSI, as well as other complications such as air embolism, catheter damage, catheter migration and occlusion.

In the management of central lines and prevention of CLABSI, the role of the healthcare professional is essential.

Additional Resources

• Implementation Guide: Surveillance of Central Line-Associated Bloodstream Infection https://www.safetyandquality.gov.au/sites/default/files/2019-08/....pdf
• ANZICS Central Line Insertion Checklist https://www.anzics.com.au/wp-content/...Insertion-Checklist.pdf

References

• Australia and New Zealand Intensive Care Society 2020, CLABSI, ANZICS, Carlton South, VIC, viewed 24 April 2020, https://www.anzics.com.au/clabsi/.
• Australian Commission on Safety and Quality in Health Care 2019, Implementation Guide: Surveillance of Central Line-Associated Bloodstream Infection, ACSQHC, Sydney, NSW, viewed 24 April 2020, https://www.safetyandquality.gov.au/sites/default/files/2019-08/implementation-guide-for-surveillance-of-central-line-associated-blood-stream-infection-2019-final.pdf.
• Australian Commission on Safety and Quality in Health Care 2017, National Safety and Quality Health Service Standards Second edition, ACSQHC, Sydney, NSW, viewed 24 April 2020, https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf.
• Centers for Disease Control and Prevention (CDC) 2017, Intravascular Catheter-related Infection (BSI), CDC, Atlanta, GA, viewed 24 April 2020, https://www.cdc.gov/infectioncontrol/guidelines/bsi/index.html.
• Chopra, V, Krein, SL, Olmsted, RN, Safdar, N & Saint, S 2013, ‘Chapter 10: Prevention of Central Line-Associated Bloodstream Infections: Brief Update Review’, Making Health Care Safer: An Updated Critical Analysis of the Evidence for Patient Safety Practices, no. 211,viewed 24 April 2020, https://www.ncbi.nlm.nih.gov/books/NBK133364/.
• Guenezan, J, Drugeon, B, Marjanovic, N & Mimoz, O 2018, ‘Treatment of central line-associated bloodstream infections’, Critical Care, vol. 22, no. 303, viewed 24 April 2020, https://ccforum.biomedcentral.com/articles/10.1186/s13054-018-2249-9.
• Haddadin, Y, Annamaraju, P & Regunath, H 2020, ‘Central Line Associated Blood Stream Infections (CLABSI)’, National Center for Biotechnology Information, viewed 24 April 2020, https://www.ncbi.nlm.nih.gov/books/NBK430891/.
• Medline 2018, Central line infections - hospitals, Medline Plus, viewed 24 April 2020, https://medlineplus.gov/ency/patientinstructions/000474.htm.
• World Health Organisation (WHO) 2016, Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level, viewed 24 April 2020, https://www.ncbi.nlm.nih.gov/books/NBK401782/.