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 CLABSIs is essential to help ensure favourable patient outcomes are achieved (Chopra 2013).

In Australia, the Australian Commission on Safety and Quality in Health Care states that certain criteria need to be met in order for the patient to be diagnosed with a CLABSI (ACSQHC 2017). These criteria involve 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. As well as this, the patient must display at least one symptom of fever, chills and/or hypotension, and also the same potential contaminant organism must be cultured from two or more blood cultures drawn on separate occasions (ACSQHC 2017).

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 from 7 to 21 days, as well as substantially increasing the cost of the individual’s healthcare. Therefore, it is important to be aware of the causes of CLABSI and how we can prevent them from occurring (ANZICS 2014; Chopra 2013).

Central line-associated bloodstream infections are one of the most common, preventable healthcare-associated infections (HAIs). Under the Australian National Safety and Quality Health Service Standards, preventing and controlling HAIs are a priority in hospital and healthcare settings.

Central venous catheter (CVCs) types include subclavian vein insertion and internal jugular vein insertion – Central Line-Associated Bloodstream Infections (CLABSI)

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 worker
• CVAD hub colonisation
• Contaminated infusion or components of IV set
• Haematogenous spread from other sites (e.g. through the bloodstream from another infection)
• Non-intact dressing

Patient-related risk factors for developing a CLABSI include:

• Immunosuppression
• 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
• 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
• Prolonged duration of the catheter

(Chopra 2013; Costello et al. 2009)

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 & Regunath 2017)

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 & Regunath 2017)

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 & Regunath 2017)

A central line being inserted – Central Line-Associated Bloodstream Infections (CLABSI)

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 (Schulman et al. 2011).

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, needless connectors and injection ports prior to CVC use
• Remove nonessential CVCs
• Chlorhexidine cleansing
• Monitor the CVC dressing and use of chlorhexidine sponges and topical antibiotics
• Antibiotic/anti-infective ‘locks’ in high-risk patients
• Systemic antibiotic prophylaxis

(CDC 2017; Chopra et al. 2013)

The nurse must also educate the patient in the management of their central line and how they can also 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 nurse must also monitor for any signs or symptoms of a CLABSI, as well as other complications which may occur, such as air embolism, catheter damage, catheter migration and occlusion. Therefore, in the management of central lines and prevention of CLABSI, the role of the nurse is essential.

Want further learning? Watch the lecture ‘Preventing Central Line Associated Blood Stream Infections‘

References

• Australia and New Zealand Intensive Care Society 2014, Central Line Associated Blood Stream Infection (CLABSI) Prevention, ANZICS, Carlton South, VIC, viewed 13 November 2017, http://www.anzics.com.au/Pages/CLABSI.aspx
• Australian Commission on Safety and Quality in Health Care 2017, National definition and calculation of central line associated blood stream infection, ACSQHC, Sydney, NSW, viewed 13 November 2017, https://www.safetyandquality.gov.au/..-of-central-line-associated-blood-stream-infection/
• Centers for Disease Control and Prevention 2016, ‘Central Line-associated Bloodstream infections’, Healthcare-associated Infections, CDC, Atlanta, GA, viewed 13 November 2017, https://www.cdc.gov/hai/bsi/bsi.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 13 November 2017, https://www.ncbi.nlm.nih.gov/books/NBK133364/
• Costello, JM, Graham, DA, Morrow, DF, Potter-Bynoe, G, Sandora, TJ & Laussen, PC 2009, ‘Risk factors for central line-associated bloodstream infection in a pediatric cardiac intensive care unit’, Pediatric Critical Care Medicine, vol. 10, no. 4, pp. 453-459, viewed 13 November 2017, https://www.ncbi.nlm.nih.gov/pubmed/19307818
• Haddadin, Y & Regunath, H 2017, ‘Central line associated blood stream infections’, National Center for Biotechnology Information, viewed 13 November 2017, https://www.ncbi.nlm.nih.gov
• Schulman, J, Stricof, R, Stevens, TP, Horgan, M, Gase, K, Holzman, IR, Koppel, RI, Nafday, S, Gibbs, K, Anger, R, Simmonds, A, Furdon, SA and Sainman, L 2011, ‘Statewide NICU central-line-associated blood stream infection rates decline after bundles and checklists’, Pediatrics, vol. 127, no. 3, viewed 13 November 2017, http://pediatrics.aappublications.org/content/127/3/436.short