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Table of Contents
                            Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective
	About the Book
	Staff and Copyright
	Acknowledgments and Technical Advisory Panel
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Appendix A
Appendix B
Document Text Contents
Page 1

Central Line–Associated
Bloodstream Infections

A Global Challenge,
A Global Perspective

Page 2

Preventing Central Line–Associated Bloodstream Infections:
A Global Challenge, A Global Perspective

The use of central venous catheters (CVCs) is an integral part of modern health care

throughout the world, allowing for the administration of intravenous fluids, blood

products, medications, and parenteral nutrition, as well as providing access for

hemodialysis and hemodynamic monitoring. However, their use is associated with the

risk of bloodstream infection caused by microorganisms that colonize the external

surface of the device or the fluid pathway when the device is inserted or manipulated

after insertion. These serious infections, termed central line–associated bloodstream

infections, or CLABSIs, are associated with increased morbidity, mortality, and health

care costs. It is now recognized that CLABSIs are largely preventable when evidence-

based guidelines are followed for the insertion and maintenance of CVCs.

This monograph includes information about the following:

• The types of central venous catheters and risk factors for and pathogenesis of


• The evidence-based guidelines, position papers, patient safety initiatives, and

published literature on CLABSI and its prevention

• CLABSI prevention strategies, techniques and technologies, and barriers to best


• CLABSI surveillance, benchmarking, and public reporting

• The economic aspects of CLABSIs and their prevention, including the current

approaches to developing a business case for infection prevention resources

This monograph was authored by The Joint Commission, Joint Commission

Resources, and Joint Commission International. They partnered with infection preven-

tion leaders from the following organizations:

• Association for Professionals in Infection Control and Epidemiology

• Association for Vascular Access

• Infectious Diseases Society of America

• International Nosocomial Infection Control Consortium

• National Institutes of Health

• Society for Healthcare Epidemiology of America

Additionally, several international and US infection prevention leaders lent their expertise

to the writing of this publication and were also instrumental in the development of the

monograph. International representatives were from Argentina, Australia, Egypt,

Saudi Arabia, Switzerland, and Thailand.

This monograph was supported in part by a research grant from Baxter Healthcare


Page 76

are a tool to support the implementation of a multifaceted
intervention aimed at improving patient care.112,113

Vascular Access Teams
Studies have shown that the use of specialized vascular
access teams (or IV teams), consisting of trained nurses or
technicians who use strict aseptic technique during catheter
insertion and follow-up care, can reduce the risk of
phlebitis, bloodstream infections, and costs.14,18,65 Marschall
et al. note, however, that few studies have been performed
regarding the specific impact of such teams on CLABSI

Marschall et al.18 and Pratt et al.19 categorize the use of vas-
cular access teams as a CLABSI improvement strategy that is
an unresolved issue regarding reducing CVC infection risk,
due to the paucity of studies specific to CVC insertion.
However, regarding peripheral venous catheter infection pre-
vention or combined peripheral venous and CVC infection
prevention, studies of IV teams have repeatedly demon-
strated reduced cost and risk of infection.54 Having a team
may be difficult to achieve in settings with a low nurse-to-
patient ratio. However, even if an organization does not
have a vascular access team, the evidence does support for-
mal education of physicians and nurses, as well as adherence
to CVC insertion and maintenance care best practices, to
reduce CLABSI rates.17,68

Safe Practices for Parenteral Fluid and
Medication Administration and Vial Access
Aseptic technique, which is important in the insertion
and care of CVCs, also plays a broader role in an organi-
zation’s overall approach to safe handling of intravenous
fluids. All fluids (that is, infusates, medications, parenteral
nutrition, and flushes) must be prepared and administered
aseptically to avoid introducing microorganisms into the
intravenous system. Outbreaks have occurred following
improper preparation or administration of such flu-
ids.114–116 In 2008, the United States Pharmacopeia (USP)
revised General Chapter 797: Pharmaceutical
Compounding—Sterile Preparations, which applies to
pharmacy settings and to all individuals who prepare
compounded sterile preparations (CSPs) in all settings in
which they are administered.117 Commonly known simply
as USP 797, this chapter covers standards for preparing
and labeling sterile preparations, as well as time frames for
discarding these preparations. To maintain the sterility of
compounded sterile preparations, pharmacies compound
sterile preparations in an International Organization for

Standardization (ISO) Class 5 environment. A Class 5
environment is a “clean room” that has stringent ventila-
tion and air quality specifications, as well as laminar air-
flow hoods and strict requirements for personal protective
equipment worn by health care personnel and for surface
sanitation. However, “immediate use” CSPs (for example,
those that involve the measuring, diluting, dissolving, or
mixing of nonnutrient sterile preparations using sterile
devices) that are prepared outside the ISO 5 environment
without these special facilities is permitted for certain ster-
ile products; “immediate use” requires beginning the
administration of these preparations within one hour. The
rationale for the requirement that immediate-use CSPs be
administered within that time frame takes into considera-
tion the potential for contamination of intravenous solu-
tions, vials, and syringes from both direct contact and
airborne sources. If contamination does occur, microor-
ganisms begin to replicate within one to four hours, with
rapidly accelerating growth thereafter.117 It is important,
therefore, that only health care personnel who are deemed
competent perform these procedures and that adherence
to proper procedures and aseptic technique be periodically

Although outbreaks associated with contaminated infusate
are rare, as with all aseptic practices, proper hand hygiene
must always be performed before handling solutions and
medications.14 Other basic infection prevention practices
that should also be performed include the following118,119:
■ Medications should be stored and prepared in a desig-

nated clean medication area away from areas where
potentially contaminated items are placed (for example,
locations with equipment such as syringes, needles, IV
tubing, blood collection tubes, needle holders, or other
soiled equipment or materials that have been used in a
procedure). In general, any item that could have come in
contact with blood or body fluids should not be in the
medication preparation area.

■ Ideally, IV solutions should be admixed in a controlled
environment in a pharmacy, using a laminar airflow
hood and aseptic technique.13,120,121

■ Syringes and needles/cannulas should be stored in their
original packages until ready to use, to maintain sterility.120

■ To prevent introducing potential contaminants into the
patient’s CVC line, IV ports and the rubber septum on
vials should be disinfected by wiping with friction, using
an approved antiseptic swab prior to piercing it (for
example, chlorhexidine, 70% isopropyl alcohol,
ethyl/ethanol alcohol, iodophors).


Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, A Global Perspective

Page 77

Chapter 3: CLABSI Prevention Strategies, Techniques, and Technologies

■ Parenteral medications should be accessed in an aseptic
manner, using a new sterile syringe and sterile needle
to draw up medications. Care should be taken to pre-
vent contact between the injection materials and the
nonsterile environment.

■ A medication vial should be entered with a new sterile
access and sterile syringe.120 There has been at least one
outbreak attributed to health care personnel using a
common needle and syringe to access multiple multidose
vials for the purpose of combining their contents into a
single syringe.114 If one vial becomes contaminated, con-
tamination can spread to the other vials, increasing the
potential for infection transmission. Syringe reuse in this
fashion may also have been a factor in additional out-

■ A needle or other device should never be left inserted
into a medication vial septum for multiple uses. This
provides a direct route for microorganisms to enter the
vial and contaminate the fluid.

■ Intravenous solution containers (for example, bottles
or bags) should never be used as a common source of
solution for more than one patient for any reason,
even if using a spiking device that has a one-way
valve.120 (Note: The only exception to this is in phar-
macies using laminar airflow hoods and meeting asso-
ciated air quality, ventilation, and sanitation
requirements to maintain sterility in the preparation of
solutions and medications.118,120)

■ Single-dose vials should be used for each patient.
■ The use of multidose vials should be limited; if they

must be used, each should be used for one patient only
(labeled with the patient’s name and date).

■ All opened IV solutions, vials, and prepared or
opened syringes involved in a patient emergency
should be discarded.120

■ Any solutions, medications, or vials should be discarded
in any of the following situations:
● Sterility is compromised or in question.
● The expiration date has passed, even if the vial con-

tains antimicrobial preservatives.
● Any discoloration, particulate matter, or turbidity is


The tools and techniques described in the foregoing sections
are examples of best practices. However, there are some
practices, as shown in Sidebar 3-4 on page 62, that should
be avoided because they have not been found effective or,
worse, have been found to increase risk of harm to the

Special Considerations
The following sections discuss the special considerations of
parental nutrition and of CVC use in ICU versus non-ICU

Parenteral Nutrition
Parenteral nutrition (PN) provides the minimal critical
nutrients to reduce the risk of malnutrition in patients
unable to obtain adequate nutrition by the oral or enteral
route.124,125 Candidates for PN include patients with Crohn’s
disease, radiation enteritis, and intestinal obstruction, as well
as critically ill and trauma patients.125,126 Due to the often
acidic and hypertonic properties of the solution, most PN
solutions require administration through a CVC.127–129

However, peripherally administered PN may be used for
low-osmolarity mixtures.128

The risk of administering PN is different from that of other
intravascular therapy modalities due to the following128:
■ Underlying disease in the patient can increase the risks

of acquiring HAIs.
■ Remote infections are often present that can result in

hematogenous seeding of the CVC.
■ CVCs for PN are often in place longer than most CVCs.

PN is widely recognized as an independent risk factor for
CLABSI,130–135 so health care personnel should replace PN
with enteral feeding at the earliest opportunity to reduce
CLABSI risk.135–138 Due to differences in study design, defi-
nitions of infections, and varying populations, the incidence
of CLABSI has been reported to be as low as 1.3% and as
high as 39% in patients receiving PN.125,126,132 Contamination
of PN is seldom the cause of CLABSI when there is strict
adherence to aseptic compounding technique. PN solutions
can foster microbial growth, with Candida being the
microorganism most frequently reported to proliferate in
PN.125,139 The component of PN most likely to foster fungal
or bacterial proliferation is the lipid emulsion compo-
nent.125,139 One group of researchers, however, did not find
lipid emulsions administered with premixed PN to be a sig-
nificant factor in the development of infection, when com-
pared to omitting lipids from PN therapy.140

PN can be provided as either standardized or individualized
solutions compounded in a health care facility or by an out-
sourced pharmacy. Commercially available premixed ready-
to-use formulations in multichamber bags are also
available.128 The use of multichamber bags instead of com-
pounded PN has been associated with lower risks of


Page 151


Veterans Affairs, US Department of
CVC insertion bundle and surveillance system, 57
CVC maintenance bundle, 57
VA Inpatient Evaluation Center (IPEC)–led CLABSI initiative,

Veterans Health Administration, 27
Victorian Hospital Acquired Surveillance System (VICNISS), 88
Vietnam, CLABSI prevalence and incidence rates in, 116, 117
Virginia public reporting of HAIs, 114
VRE (vancomycin-resistant enterococci), 55


National Institute for Health and Clinical Excellence (NICE),

Royal College of Nursing (RCN), 20, 21

Central Line Insertion Practices (CLIP), 94
CLABSI information from NHSN, v
CLABSIs, estimating costs of, 105–106
electronic surveillance systems, tool for evaluation of, 91

HHS Action Plan to Prevent Healthcare-Associated Infections,

Hospital Compare website (CMS), 96
Institute for Healthcare Improvement, 24
International Nosocomial Infection Control Consortium

(INICC), 12
safety culture resources, 75–76

World Bank. See Developing countries
World Health Organization (WHO)

Bacteriemia Zero project, x, 26
CLABSI prevalence and incidence rates, 104, 105
CLABSI prevention initiatives, x, 33
“Clean Care Is Safer Care,” 15–16, 32
Global Patient Safety Challenges, 15–16
HAI prevalence and incidence rates, vii, viii, ix, 104
hand hygiene guidelines, 42
“My 5 Moments for Hand Hygiene,” 32, 42, 43
“Safe Surgery Saves Lives,” 15–16
WHO Guidelines on Hand Hygiene in Health Care, 15–16

Zero-tolerance approach to adverse events, x, 24, 30


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Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, A Global Perspective

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