INTRODUCTION:

Central Line-Associated Blood Stream Infections (CLABSI) are a major Cause of morbidity and mortality. According to the Centers for Disease Control and Prevention an estimated 80,000 CLABSIs occur in Intensive Care Units(ICUs) alone. A central line is a catheter that is placed into a patient’s large vein, usually in the neck, chest, arms or groin. The central line is often used to draw blood, or to give fluids and medications for critically ill patients more easily. The line can be left in place for several weeks or months if needed.

A central line bloodstream infection (CLABSI) occurs when bacteria or other germs enter the patient’s central line and then enter into their bloodstream. These infections are serious but can often be successfully treated. Health care workers, patients and families can play an active role in CLABSI prevention.

Most of these infections can be prevented with the correct insertion, cleaning, and care practice of a central line¹.

CLABSI (Central Line-Associated Blood Stream Infection)

Definition:

A Central Line-Associated BloodStream Infection (CLABSI) is defined as a laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of central line placement².

Risk factors for CLABSI:

Patient-related risk factors for developing a CLABSI⁵:

· Immunosuppression;

· Increased age;

· Malnutrition;

· Impaired skin integrity;

· Multiple invasive procedures;

· Antibiotic therapy;

· Presence of gastrostomy tube,

· nonoperative cardiovascular disease

· ICU placement of central venous catheter.

· Certain comorbidities such as Diabetes and Hypertension

· 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; and

· Prolonged duration of the catheter.

Pathophysiology:

Fig. 1: Pathogenesis:

Colonization of the endovascular tip of the catheter precedes infection and arises by two main pathways:

The extraluminal and the intraluminal routes (Fig. 1).

Extraluminal:

Pathogens migrate along external surface of catheter from skin entry site. Often occurs within 7 days of insertion

Intraluminal:

Hub contamination, migration along internal surface of catheter. More commonly occurs >7 days, intraluminal colonization

Migration of skin organisms from the insertion site into the cutaneous catheter tract with colonization of the catheter tip is the most common route of infection for short-term Central Venous Catheters (CVCs). For long-term catheters (i.e., catheters staying in place for more than 15 days). The main cause of colonization is manipulation of the venous line with migration of organisms along the internal lumen of the catheter. The adherence properties of microorganisms to host proteins, such as fibronectin, commonly present on catheter tips make this colonization easier. Coagulase-negative staphylo cocci are the most common microorganisms associated with catheter-related bloodstream infections. Other microorganisms commonly involved include Staphylococcus aureus, Candida species, Enterococci and Gram-negative bacilli⁶.

Grading of infection with site selection:

· The subclavian site: Associated with the lowest risk of infection.

· Internal jugular site: Associated with medium risk of infection

· Femoral site: Associated with the highest infection risk, should be used only as a last option with documentation of reason for use and removed within 48 hours. (Agency for Healthcare Research and Quality, 2013)

Clinical manifestations: (Hallmark signs)⁷

· Pain.

· Redness, swelling, or warmth around the central line site.

· Pus or bad smell around the central line site.

· Chills.

· Fever of 100.4 degrees or above.

· Tachycardia

Diagnosis:

· Patients may report pain, swelling, or discharge from the exit site and redness surrounding the exit site or along the subcutaneous track when exit site or tunnel infections are present. For long-term catheters, difficulty in drawing blood or poor flow are considered risk factors and manifestations of CLABSI

· CRBSI (Catheter Related Blood Stream Infection) diagnosis can be made when culture results identify the same organism in at least the culture obtained as a peripheral stick and from a culture of the catheter tip. If the catheter is left in place, the diagnosis can be made if there are two blood samples being drawn (one from the catheter hub and one from a peripheral vein) that meet specific criteria for quantitative blood cultures or differential time to positivity. For Multi-lumen catheters, quantitative cultures may be obtained through multiple lumens; results at least 3 times higher than one of the lumens are suggestive of CRBSI³.

Complications:

Pneumothorax

Tension pneumothorax,

Hematoma,

Cardiac dysrhythmias

thrombophlebitis

Nerve injury

infection

CLABSI care bundles⁴:

1. Central line insertion bundle:

Hand hygiene:

► Wash hands or use an alcohol-based, waterless hand cleaner when caring for central lines: Before and after palpating the catheter insertion site. Before and after inserting, replacing, adjusting or dressing the site. During palpation of the insertion site and after application of antiseptic and only if full asepsis is maintained.

Complete maximal barrier:

► The operator inserting the central venous catheter should adhere to strict aseptic techniques and wear sterile gloves, gown, surgical cap and surgical mask.

Chlorhexidine 2% skin antisepsis:

► Prepare skin with 2% chlorhexidine in 70% alcohol using swabs and a friction scrub for at least 30 seconds s. Do not wipe or blow dry and allow to dry completely before skin puncture: 30 s for a dry site. 2 min for a moist site (especially femoral).

Optimal catheter site selection:

► In adult patients, there is some evidence that the subclavian site has a lower risk of catheter-related blood stream infections. However, there is usually more experience with the internal jugular site. The subclavian and internal jugulars are the preferred sites for infection control purposes.

► Use of sterile, single-use jelly.

► Use sterile, single-use jelly for ultrasound-guided insertions.

2. Central line maintenance bundle:

Hand hygiene:

► Practice hand hygiene at five moments:

Before touching a patient.

Before clean/aseptic procedures.

After body-fluid exposure/risk.

After touching a patient.

After touching patient surroundings.

Aseptic technique for accessing and changing needleless connectors:

► Scrub the access port or hub immediately prior to each use with an appropriate antiseptic.

Standardised tubing change:

► Intravenous medication administration tubing should be changed as per the recommendation in the local organisations policy.

Daily review of catheter necessity:

► Daily review of line necessity during rounds so that the necessity of the lines can be determined and unnecessary lines removed.

CONCLUSION:

Eliminating blood stream infections associated with central line is a national priority. Monitoring adherence to best practices for central-line maintenance is also an important part of CLABSI prevention. Regular cleaning of a patient’s skin to eliminate pathogens is an intuitive CLABSI prevention measure.

REFERENCES:

1. Hallam C, Jackson T, Rajgopal A, Russell B. Establishing catheter-related bloodstream infection surveillance to drive improvement. J Infect Prev. 2018 Jul;19(4):160-166.

2. Aloush SM, Alsaraireh FA. Nurses' compliance with central line associated blood stream infection prevention guidelines. Saudi Med J. 2018 Mar; 39(3):273-279.

3. Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’grady NP, Raad I, Rijnders BJ, Sherertz RJ, Warren DK. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis. 2009; 49:1–45.

4. Gupta P, Thomas M, Patel A, et al. Bundle approach used to achieve zero central line-associated bloodstream infections in an adult coronary intensive care unit. BMJ Open Quality 2021; 10:e001200. doi:10.1136/ bmjoq-2020-001200

5. Guenezan et al. 2018; WHO 2016; Chopra 2013

6. Bell T, O'Grady NP. Prevention of Central Line-Associated Bloodstream Infections. Infect Dis Clin North Am. 2017 Sep; 31(3):551-559.

7. Catheter-related bloodstream infections. EBSCO DynaMed website. Available at: https://www.dynamed.com/condition/catheter-related-bloodstream-infection-crbsi. Accessed September 2, 2021.

8. Shibbi Alexander, CLABSI shibbialexander@mavs.uta.edu/, 2013

Received on 03.12.2021 Modified on 25.04.2022

Asian J. Nursing Education and Research. 2022; 12(3):353-355.

DOI: 10.52711/2349-2996.2022.00074