Innovations in Quality Improvement of Intravascular Catheter-Related Bloodstream Infections

  • Rajendra Karnatak
  • Mark E. Rupp
  • Kelly CawcuttEmail author
New Technologies and Advances in Infections Prevention (A Marra, Section Editor)
Part of the following topical collections:
  1. Topical Collection on New Technologies and Advances in Infection Prevention


Purpose of review

Significant reductions in catheter-related bloodstream infections (CRBSI) have occurred in the United States. Reductions in CRBSIs are attributed to the widespread implementation of the practice-based measures and innovations in the diagnosis, treatment, and prevention of CRBSI.

Recent findings

Diagnosis of CRBSI historically required removal of the central venous catheter (CVC) for catheter tip culture. Removing the CVC for CRBSI diagnosis predisposes many patients to potential life-threatening complications. Advances in diagnostic techniques such as culturing catheter hubs, catheter entry site cultures, applying differential time to positivity, molecular diagnostics, biomarkers, and innovative approaches like biosensors on the CVC lumen may provide an alternative to CVC removal. Removal of the CVC is common for the treatment of CRBSI; however, antimicrobial lock therapy is increasingly used as a CVC salvage method. Implementation of newer technology such as antimicrobial coated catheters, chlorhexidine-impregnated dressings, and antiseptic port protectors are crucial for the prevention of CRBSIs. Increasing evidence also support newer sutureless CVC securement devices prevent CRBSIs.


CRBSI remains a significant clinical problem despite advances made in the diagnosis, management, and prevention. Molecular techniques are increasingly being used for pathogen identification in CRBSI, but the optimal diagnostic test remains debatable. Increasing experience is being gained with antimicrobial lock therapy for CRBSI treatment with catheter salvage. Use and adherence to practice-based measures and technological innovations has significantly reduced CRBSIs. Continued efforts are required to develop a cost-effective and targeted approach for CRBSI prevention.


Catheter-related bloodstream infection Central line–associated bloodstream infection Central venous catheter Bacteremia Healthcare-associated infection Antimicrobial lock therapy 


Compliance with ethical standards

Conflicts of interest

1. Rajendra Karnatak: Dr. Karnatak declares no conflicts of interests.

2. Mark E Rupp: Dr. Rupp reports personal fees from 3M, personal fees from Citius, personal fees from Teleflex.

3. Kelly Cawcutt: Dr. Cawcutt declares paid for lecture on vascular access and attendance at an advisory board meeting for BD.

Human and animal rights informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Centers for Disease Control and Prevention. Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central Line Associated Bloodstream Infection). Available at Accessed 8 Nov 2018.
  2. 2.
    •• Mermel LA, Allon M, Bouza E, et al. 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):1–45 IDSA 2009 clinical practice guidelines.CrossRefGoogle Scholar
  3. 3.
    Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, et al. Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173(22):2039–46.CrossRefGoogle Scholar
  4. 4.
    Dudeck MA, Edwards JR, Allen-Bridson K, Gross C, Malpiedi PJ, Peterson KD, et al. National healthcare safety network report, data summary for 2013, device-associated module. Am J Infect Control. 2015;43(3):206–21.CrossRefGoogle Scholar
  5. 5.
    European Centre for Disease Prevention and Control. Healthcare-associated infections acquired in intensive care units—annual epidemiological report for 2015. Stockholm (Sweden): European Centre for Disease Prevention and Control; 2017. Available at: Accessed 23 Jan 2018.
  6. 6.
    Rosenthal VD. Central line-associated bloodstream infections in limited resource countries: a review of the literature. Clin Infect Dis. 2009;49(12):1899–907.CrossRefGoogle Scholar
  7. 7.
    Ziegler MJ, Pellegrini DC, Safdar N. Attributable mortality of central line associated bloodstream infection: systematic review and meta-analysis. Infection. 2015;43(1):29–36.CrossRefGoogle Scholar
  8. 8.
    Stevens V, Geiger K, Concannon C, Nelson RE, Brown J, Dumyati G. Inpatient costs, mortality and 30-day re-admission in patients with central-line-associated bloodstream infections. Clin Microbiol Infect. 2014;20:O318–24. Scholar
  9. 9.
    •• Patrick, et al. Mortality risk factors among non-ICU patients with nosocomial vascular catheter-related bloodstream infections: a prospective cohort study SALIBA. J Hosp Infect. 2017. This study evaluated risk factors for nosocomial CRBSIs and demonstrated Staphylococcus aureus and Candida infections were independent risk factors for increased mortality in CRBSIs.
  10. 10.
    Centers for Disease Control and Prevention (CDC). National and state healthcare associated infections progress report. Available at: Accessed 14 Oct 2018.
  11. 11.
    Slobbe L, El Barzouhi A, Boersma E, et al. Comparison of the roll plate method to the sonication method to diagnose catheter colonization and bacteremia in patients with long-term tunnelled catheters: a randomized prospective study. J Clin Microbiol. 2009;47(4):885–8.CrossRefGoogle Scholar
  12. 12.
    Erb S, Frei R, Schregenberger K, Dangel M, Nogarth DWidmer AF. Sonication for diagnosis of catheter-related infection is not better than traditional roll plate culture: a prospective cohort study with 975 central venous catheters. Clin Infect Dis. 2014;59:541–4.CrossRefGoogle Scholar
  13. 13.
    Bouza E, Alvarado N, Alcalá L, et al. A prospective, randomized, and comparative study of 3 different methods for the diagnosis of intravascular catheter colonization. Clin Infect Dis. 2005;40:1096–100.CrossRefGoogle Scholar
  14. 14.
    Peterson LR, Smith BA. Nonutility of catheter tip cultures for the diagnosis of central line-associated bloodstream infection. Clin Infect Dis. 2015;60:492–3.CrossRefGoogle Scholar
  15. 15.
    Lepainteur M, Desroches M, Bourrel AS, Aberrane S, Fihman V, L’Hériteau F, et al. Role of the central venous catheter in bloodstream infections caused by coagulase-negative staphylococci in very preterm neonates. Pediatr Infect Dis J. 2013;32:622–8.CrossRefGoogle Scholar
  16. 16.
    • Safdar N, Fine JP, Maki DG. Meta-analysis: methods for diagnosing intravascular device-related bloodstream infection. Ann Intern Med. 2005;142:451–66 Meta-analysis to compare diagnostic methods for CRBSIs.CrossRefGoogle Scholar
  17. 17.
    Planes AM, Calleja R, Bernet A, Campins-Martí M, Almirante B, Pumarola T, et al. Evaluation of the usefulness of a quantitative blood culture in the diagnosis of catheter-related bloodstream infection: comparative analysis of two periods (2002 and 2012). Enferm Infecc Microbiol Clin. 2015;34:484–9. Scholar
  18. 18.
    Guembe M, Rodríguez-Créixems M, Sánchez Carrillo C, Pérez Parra A, Martín-Rabadán P, Bouza E. How many lumens should be cultured in the conservative diagnosis of catheter-related bloodstream infections? Clin Infect Dis. 2010;50(12):1575–9 Scholar
  19. 19.
    Herrera-Guerra AS, Garza-González E, Martínez-Resendez MF, Llaca-Díaz JM, Camacho-Ortiz A. Individual versus pooled multiple-lumen blood cultures for the diagnosis of intravascular catheter-related infections. Am J Infect Control. 2015;43:715–8.CrossRefGoogle Scholar
  20. 20.
    Bouza E, Alvarado N, Alcalá L, Pérez MJ, Rincón C, Muñoz P. A randomized and prospective study of 3 procedures for the diagnosis of catheter-related bloodstream infection without catheter withdrawal. Clin Infect Dis. 2007;44:820–6.CrossRefGoogle Scholar
  21. 21.
    Catton JA, Dobbins BM, Kite P, Wood JM, Eastwood K, Sugden S, et al. In situ diagnosis of intravascular catheter-related bloodstream infection: a comparison of quantitative culture, differential time to positivity, and endoluminal brushing. Crit Care Med. 2005;33:787–91.CrossRefGoogle Scholar
  22. 22.
    Raad I, Hanna HA, Alakech B, Chatzinikolaou I, Johnson MM, Tarrand J. Differential time to positivity: a useful method for diagnosing catheter-related bloodstream infections. Ann Intern Med. 2004;140:18–25.CrossRefGoogle Scholar
  23. 23.
    Park K-H, Lee MS, Lee S-O, Choi SH, Sung H, Kim MN, et al. Diagnostic usefulness of differential time to positivity for catheter-related Candidemia. Forbes BA, ed. J Clin Microbiol. 2014;52(7):2566–72. Scholar
  24. 24.
    Bouza E, Alcalá L, Muñoz P, Martín-Rabadán P, Guembe M, Rodríguez-Créixems M, et al. Can microbiologists help to assess catheter involvement in candidaemic patients before removal? Clin Microbiol Infect. 2013;19:E129–35. Scholar
  25. 25.
    Mermel LA, Maki DG. Detection of bacteremia in adults: consequences of culturing an inadequate volume of blood. Ann Intern Med. 1993;119:270–2. Scholar
  26. 26.
    Antillon M, Saad NJ, Baker S, Pollard AJ, Pitzer VE. The relationship between blood sample volume and diagnostic sensitivity of blood culture for typhoid and paratyphoid fever: a systematic review and meta-analysis. J Infect Dis. 2018;218:jiy471–S267. Scholar
  27. 27.
    •• Jones RL, Sayles HR, Fey PD, et al. Effect of clinical variables on the volume of blood collected for blood cultures in an adult patient population. Infect Control Hosp Epidemiol. 2017;38(12):1493–7. Results from this study showed blood volume obtained from the CVC was on average 2.53 ml higher than peripheral blood cultures indicating need for further validation of DTP to diagnose CRBSIs.Google Scholar
  28. 28.
    Bouza E, Rojas L, Guembe M, Marín M, Anaya F, Luño J, et al. Predictive value of superficial cultures to anticipate tunneled hemodialysis catheter-related bloodstream infection. Diagn Microbiol Infect Dis. 2014;78:316–9.CrossRefGoogle Scholar
  29. 29.
    Paredes J, Alonso-Arce M, Schmidt C, et al. Smart central venous port for early detection of bacterial biofilm related infections. Biomed Microdevices. 2014;16(3):365–74.PubMedGoogle Scholar
  30. 30.
    •• Zhang L, Rickard CM. Non-culture based diagnostics for intravascular catheter related bloodstream infections. Expert Rev Mol Diagn. 2017;17(2):181–8 This is an excellent review of molecular diagnostic tests and biomarkers for the diagnosis of CRBSIs.CrossRefGoogle Scholar
  31. 31.
    •• Timbrook TT, Morton JB, McConeghy KW, Caffrey AR, Mylonakis E, LaPlante KL. The effect of molecular rapid diagnostic testing on clinical outcomes in bloodstream infections: a systematic review and meta-analysis. Clin Infect Dis. 2017;64(1):15–23 This meta-analysis found significant improvement in time to effective therapy and mortality with the use of molecular rapid diagnostics in BSIs. Molecular diagnostic tests combined with antimicrobial stewardship support should be utilized in BSIs, including CRBSI to optimize outcomes via early administration of targeted antimicrobial therapy.CrossRefGoogle Scholar
  32. 32.
    Dark P, Wilson C, Blackwood B, McAuley DF, Perkins GD, McMullan R, et al. Accuracy of LightCycler® SeptiFast for the detection and identification of pathogens in the blood of patients with suspected sepsis: a systematic review protocol. BMJ Open. 2012;17:e000392. Scholar
  33. 33.
    Altun O, Almuhayawi M, Ullberg M, Ozenci V. Clinical evaluation of the FilmArray blood culture identification panel in identification of bacteria and yeasts from positive blood culture bottles. J Clin Microbiol. 2013;51(12):4130–6.CrossRefGoogle Scholar
  34. 34.
    Stevenson M, Pandor A, Martyn-St James M, Rafia R, Uttley L, Stevens J, et al. Sepsis: the LightCycler SeptiFast Test MGRADE®, SepsiTest and IRIDICA BAC BSI assay for rapidly identifying bloodstream bacteria and fungi—a systematic review and economic evaluation. Health Technol Assess. 2016;20(46):1–246.CrossRefGoogle Scholar
  35. 35.
    Guembe M, Marín M, Martín-Rabadán P, Echenagusia A, Camúnez F, Rodríguez-Rosales G, et al. Use of universal 16S rRNA gene PCR as a diagnostic tool for venous access port-related bloodstream infections. J Clin Microbiol. 2013;51:799–804.CrossRefGoogle Scholar
  36. 36.
    Ozsurekci Y, Oktay Arikan K, Bayhan C, et al. Can procalcitonin be a diagnostic marker for catheter-related blood stream infection in children? J Pediatr. 2016;92(4):414–20.CrossRefGoogle Scholar
  37. 37.
    El Haddad H, Chaftari A-M, Hachem R, Chaftari P, Raad II. Biomarkers of sepsis and bloodstream infections: the role of procalcitonin and proadrenomedullin with emphasis in patients with cancer. Clin Infect Dis. 2018;67(6):971–7.CrossRefGoogle Scholar
  38. 38.
    •• Thoendel M, Jeraldo PR, Greenwood-Quaintance KE, et al. Comparison of microbial DNA enrichment tools for metagenomic whole genome sequencing. J Microbiol Methods. 2016;127:141–5. This study used metagenomic whole genome sequencing with microbial DNA enrichment for the identification of microorganisms from resected arthroplasty specimens. Similar techniques can be utilized for the suspected CRBSIs.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Bouza E, Eworo A, Fernández Cruz A, Reigadas E, RodríguezCréixems M, Munoz P. Catheter-related bloodstream infections caused by gram-negative bacteria. J Hosp Infect. 2013;85:316–20.CrossRefGoogle Scholar
  40. 40.
    Marcos M, Soriano A, Inurrieta A, Martínez JA, Romero A, Cobos N, et al. Changing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of gram-negative pathogens. J Antimicrob Chemother. 2011;66:2119–25.CrossRefGoogle Scholar
  41. 41.
    •• Chaftari A, Hachem R, Jiang Y, Shah P, Hussain A, Hamal Z, et al. Changing epidemiology of catheter-related bloodstream infections in cancer patients. Infect Control Hosp Epidemiol. 2018;39(6):727–9. Significant increase in gram-negative CRBSIs were noted between two-time cohorts. Current guidelines do not recommend routine use of empiric gram-negative antibiotics for suspected CRBSI. Risk factors for gram-negative CRBSI and changing epidemiology of CRBSIs should be considered when treating empirically, especially in critically ill patients.CrossRefPubMedGoogle Scholar
  42. 42.
    Rijnders BJ, Peetermans WE, Verwaest C, Wilmer A, Van Wijngaerden E. Watchful waiting versus immediate catheter removal in ICU patients with suspected catheter-related infection: a randomized trial. Intensive Care Med. 2004;30:1073–80.CrossRefGoogle Scholar
  43. 43.
    Lorente L, Martín MM, Vidal P, Rebollo S, Ostabal MI, Solé-Violán J, et al. Should central venous catheter be systematically removed in patients with suspected catheter related infection? Crit Care. 2014;18:564.CrossRefGoogle Scholar
  44. 44.
    Cook D, Randolph A, Kernerman P, Cupido C, King D, Soukup C, et al. Central venous catheter replacement strategies: a systematic review of the literature. Crit Care Med. 1997;25:1417–24.CrossRefGoogle Scholar
  45. 45.
    Garnacho-Montero J, Aldabó-Pallás T, Palomar-Martínez M, Vallés J, Almirante B, Garcés R, et al. Risk factors and prognosis of catheter-related bloodstream infection in critically ill patients: a multicenter study. Intensive Care Med. 2008;34:2185–93.CrossRefGoogle Scholar
  46. 46.
    Casey J, Davies J, Balshaw-Greer A, et al. Inserting tunnelled hemodialysis catheters using elective guidewire exchange from nontunnelled catheters: is there a greater risk of infection when compared with new-site replacement? Hemodial Int. 2008;12(1):52–4.CrossRefGoogle Scholar
  47. 47.
    Justo JA, Bookstaver PB. Antibiotic lock therapy: review of technique and logistical challenges. Infect Drug Resist. 2014;7:343–63. Scholar
  48. 48.
    Rupp ME, Lisco SJ, Lipsett PA, Perl TM, Keating K, Civetta JM, et al. Effect of a second-generation venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter–related infections: a randomized, controlled trial. Ann Intern Med. 2005;143:570–80. Scholar
  49. 49.
    Baddour LM, Wilson WR, Bayer AS, Fowler VG Jr, Tleyjeh IM, Rybak MJ, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015;132:1435–86. Scholar
  50. 50.
    Georgopapadakou N. Antibiotic resistance in biofilms [chapter: 21]. In: Pace JL, Rupp ME, Finch RG, editors. Biofilms, infection, and antimicrobial therapy. Boca Raton (FL): Taylor & Francis; 2006. p. 401–5.Google Scholar
  51. 51.
    Lewis K, Spoering A, Kaldalu N, et al. Persisters: specialized cells responsible for biofilm tolerance to antimicrobial agents [chapter: 12]. In: Pace JL, Rupp ME, Finch RG, editors. Biofilms, infection, and antimicrobial therapy. Boca Raton (FL): Taylor & Francis; 2006. p. 241–53.Google Scholar
  52. 52.
    Banin E, Brady KM, Greenberg EP. Chelator-induced dispersal and killing of Pseudomonas aeruginosa cells in a biofilm. Appl Environ Microbiol. 2006;72(3):2064–9.CrossRefGoogle Scholar
  53. 53.
    Raad I, Fang X, Keutgen XM, Jiang Y, Sherertz R, Hachem R. The role of chelators in preventing biofilm formation and catheter-related bloodstream infections. Curr Opin Infect Dis. 2008;21(4):385–92.CrossRefGoogle Scholar
  54. 54.
    Fernandez-Hidalgo N, Almirante B, Calleja R, Ruiz I, Planes AM, Rodriguez D, et al. Antibiotic-lock therapy for long-term intravascular catheter-related bacteraemia: results of an open, non-comparative study. J Antimicrob Chemother. 2006;57(6):1172–80. Scholar
  55. 55.
    •• Raad I, Chaftari A-M, Zakhour R, et al. Successful salvage of central venous catheters in patients with catheter-related or central line-associated bloodstream infections by using a catheter lock solution consisting of minocycline, EDTA, and 25% ethanol. Antimicrob Agents Chemother. 2016;60(6):3426–32. Single-center, pilot study evaluated minocycline–EDTA–ethanol (M-EDTA-EtOH) lock solution for CVC salvage in CRBSIs. This pilot study suggested catheter salvage may be possible even with most virulent organisms such as Staphylococcus aureus in uncomplicated CRBSIs.CrossRefPubMedPubMedCentralGoogle Scholar
  56. 56.
    Vassallo M, Dunais B, Roger PM. Antimicrobial lock therapy in central-line associated bloodstream infections: a systematic review. Infection. 2015;43:389–98.CrossRefGoogle Scholar
  57. 57.
    •• Rosenblatt J, Reitzel RA, Vargas-Cruz N, Chaftari A-M, Hachem R, Raad II. Comparative efficacies of antimicrobial catheter lock solutions for fungal biofilm eradication in an in vitro model of catheter-related fungemia. Ghannoum MA, ed. J Fungi. 2017;3(1):7. Three antimicrobial solutions were evaluated in an in vitro study to eradicate fungal biofilms. Only one antimicrobial lock solution nitroglycerin–citrate–ethanol (NiCE) completely eradicated all fungal biofilms.CrossRefGoogle Scholar
  58. 58.
    •• Imbert C, Rammaert B. What could be the role of antifungal lock-solutions? From bench to bedside. Pathogens. 2018;7(1):6. This is a comprehensive review of antifungal lock solutions with amphotericin B, echinocandins, and azoles. Although antifungal agents showed good activity in eradicating fungal biofilms in vitro, clinical studies are lacking.CrossRefPubMedCentralGoogle Scholar
  59. 59.
    Wu H, Moser C, Wang HZ, Høiby N, Song ZJ. Strategies for combating bacterial biofilm infections. Int J Oral Sci. 2014;7(1):1–7. Published 2014 Dec 12. Scholar
  60. 60.
    Umscheid CA, Mitchell MD, Doshi JA, Agarwal R, Williams K, Brennan PJ. Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol. 2011;32(2):101–14.CrossRefGoogle Scholar
  61. 61.
    •• O'Grady NP, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e 162–93 Guidelines for the prevention CLABSIs.CrossRefGoogle Scholar
  62. 62.
    •• Herc E, Patel P, Washer L, Conlon A, Flanders S, Chopra V. A model to predict central-line–associated bloodstream infection among patients with peripherally inserted central catheters: the MPC score. Infect Control Hosp Epidemiol. 2017;38(10):1155–66. This was an innovative approach to predict high-risk patients for CLABSI.CrossRefPubMedGoogle Scholar
  63. 63.
    Kostoula A, et al. Cumulative evidence of randomized controlled and observational studies on catheter-related infection risk of central venous catheter insertion site in ICU patients: a pairwise and network meta-analysis. Crit Care Med. 2017;45(4):e437–48.CrossRefGoogle Scholar
  64. 64.
    Parienti JJ, Mongardon N, Mégarbane B, Mira JP, Kalfon P, Gros A, et al. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373(13):1220–9.CrossRefGoogle Scholar
  65. 65.
    Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–32.CrossRefGoogle Scholar
  66. 66.
    Chapman AK, Aucott SW, Milstone AM. Safety of chlorhexidine gluconate used for skin antisepsis in the preterm infant. J Perinatol. 2012;32(1):4–9.CrossRefGoogle Scholar
  67. 67.
    •• Sathiyamurthy S, Banerjee J, Godambe SV. Antiseptic use in the neonatal intensive care unit—a dilemma in clinical practice: an evidence-based review. World J Clin Pediatr. 2016;5(2):159–71 Extensive review of safety and efficacy of antiseptic agents in neonates.CrossRefGoogle Scholar
  68. 68.
    Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev. 2015;(1).Google Scholar
  69. 69.
    Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32(10):2014–20.CrossRefGoogle Scholar
  70. 70.
    Institute for Healthcare Improvement How-to guide: prevent central line-associated bloodstream infections. Cambridge (MA); 2012. Available from: Accessed 20 Oct 2018.
  71. 71.
    Furuya E, Dick A, Herzig C, Pogorzelska-Maziarz M, Larson E, Stone P. Central line–associated bloodstream infection reduction and bundle compliance in intensive care units: a National Study. Infect Control Hosp Epidemiol. 2016;37(7):805–10. Scholar
  72. 72.
    Gawande A. The checklist manifesto: how to get things right. New York: Henry Holt and Co; 2009.Google Scholar
  73. 73.
    Exline MC, Ali NA, Zikri N, Mangino JE, Torrence K, Vermillion B, et al. Beyond the bundle—journey of a tertiary care medical intensive care unit to zero central line-associated bloodstream infections. Crit Care. 2013;17(2):R41.CrossRefGoogle Scholar
  74. 74.
    James Davis et al. Central-line-associated bloodstream infection: comprehensive, data-driven prevention. Pennsylvania Patient Safety Advisory, Vol. 8, No. 3—September 2011. Available at: Accessed Oct 2018
  75. 75.
    Gorksi L, Hadaway L, Hagle M, et al. J Infus Nurs 2016;30(1).Google Scholar
  76. 76.
    Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, et al. Strategies to prevent central line associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol. 2014;35(Suppl 2):S89–107.PubMedGoogle Scholar
  77. 77.
    •• Drews FA, Bakdash JZ, Gleed JR. Improving central line maintenance to reduce central line-associated bloodstream infections. Am J Infect Control. 2017;45(11):1224–30. ISSN 0196–6553, This study used a CVC maintenance kit including a procedural guide (how to perform central line maintenance) and indicated improved adherence to the central line maintenance best practices with the use of maintenance kit.CrossRefPubMedGoogle Scholar
  78. 78.
    Simmons S, Bryson C, Porter S. Crit Care Nurs Q. United States: 2011. "Scrub the hub": cleaning duration and reduction in bacterial load on central venous catheters; p. 31–5.Google Scholar
  79. 79.
    Rupp ME, Yu S, Huerta T, Cavalieri RJ, Alter R, Fey PD, et al. Adequate disinfection of a split-septum needleless intravascular connector with a 5-second alcohol scrub. Infect Control Hosp Epidemiol. 2012;33(7):661–5.CrossRefGoogle Scholar
  80. 80.
    Rupp ME, Sholtz LA, Jourdan DR, Marion ND, Tyner LK, Fey PD, et al. Outbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve. Clin Infect Dis. 2007;44(11):1408–14.CrossRefGoogle Scholar
  81. 81.••
    Pallotto C, Fiorio M, De Angelis V, Ripoli A, Franciosini E, Girolamo LQ, et al. Daily bathing with 4% chlorhexidine gluconate in intensive care settings: a randomized controlled trial. Clin Microbiol Infect. 2018. Randomized controlled trial evaluated effect of daily chlorhexidine bathing on hospital acquired infections. Results noted significant reduction in BSI + CRBSIs.Google Scholar
  82. 82.
    •• Kim HY, Lee WK, Na S, et al. The effects of chlorhexidine gluconate bathing on health care-associated infection in intensive care units: a meta-analysis. J Crit Care. 2016;32:126–37 Meta-analysis showed daily chlorhexidine bathing was associated with reduced risks for CRBSIs and infections with MRSA and VRE.CrossRefGoogle Scholar
  83. 83.
    •• Frost SA, Alogso MC, Metcalfe L, et al. Chlorhexidine bathing and health care associated infections among adult intensive care patients: a systematic review and meta-analysis. Crit Care. 2016;20(1):379 Meta-analysis indicated daily chlorhexidine bathing reduces the risks for CLABSI by 56%.CrossRefGoogle Scholar
  84. 84.
    •• Kampf G. Acquired resistance to chlorhexidine—is it time to establish an antiseptic stewardship’ initiative? J Hosp Infect. 2016;94(3):213–27 This in vitro study examined potential for CHG resistance and cross resistance with other antimicrobials. The resistance to chlorhexidine with specific organisms may be responsible for the outbreaks of hospital-acquired infections. Cross-resistance with other antimicrobials could not be established.CrossRefGoogle Scholar
  85. 85.
    Arora N, Patel K, Engell CA, LaRosa JA. The effect of interdisciplinary team rounds on urinary catheter and central venous catheter days and rates of infection. Am J Med Qual. 2014;29:329–34.CrossRefGoogle Scholar
  86. 86.
    •• Morata L, Ogilvie C, Yon J, Johnson A. Decreasing peripherally inserted central catheter use with ultrasound-guided peripheral intravenous lines: a quality improvement project in the acute care setting. J Nurs Adm. 2017;47:338–44 In this quality improvement project, training of nursing personnel for ultrasound-guided peripheral IV placement decreased PICC (peripherally inserted central catheter) utilization by 46.7%.CrossRefGoogle Scholar
  87. 87.
    •• Swaminathan L, Flanders S, Rogers M, et al. Improving PICC use and outcomes in hospitalised patients: an interrupted time series study using MAGIC criteria. BMJ Qual Saf. 2018;27:271–8 In this study, using a Michigan Appropriateness Guide for Intravenous Catheters (MAGIC) criteria substantially decreased inappropriate PICC use.CrossRefGoogle Scholar
  88. 88.
    Chandramohan S, Navalkele B, Mushtaq A, Krishna A, Kacir J, Chopra T. Impact of a multidisciplinary infection prevention initiative on central line and urinary catheter utilization in a long-term acute care hospital. Open Forum Infect Dis. 2018;5(7):ofy156. Scholar
  89. 89.••
    Xiong Z, Chen H. Interventions to reduce unnecessary central venous catheter use to prevent central-line–associated bloodstream infections in adults: a systematic review. Infect Control Hosp Epidemiol. n.d.;39:1–7. Meta-analysis showed significant reduction in CLABSIs with the interventions to decrease unnecessary CVC use. Total 13 studies analyzed in this meta-analysis and results were consistent across the studies.
  90. 90.
    •• Harron K, et al. Generalisability and cost-impact of antibiotic-impregnated central venous catheters for reducing risk of bloodstream infection in paediatric intensive care units in England. PLoS One. 2016;11(3):e0151348 In a pediatric ICU, switching from the standard CVC to the antimicrobial-impregnated CVC averted a significant number of CRBSIs. The cost of purchasing the antimicrobial-impregnated CVCs was less than the cost of treating CLABSIs.CrossRefGoogle Scholar
  91. 91.
    •• Gilbert RE, et al. Impregnated central venous catheters for prevention of bloodstream infection in children (the CATCH trial): a randomised controlled trial. Lancet. 2016;387(10029):1732–42 In this randomized controlled trial in pediatric ICUs, patients were randomized to receive an antimicrobial-impregnated CVC, heparin-impregnated CVC, or standard CVC. The antimicrobial-impregnated catheter decreased CLABSIs. Antimicrobial-coated CVC versus standard CVC with a number needed to treat was 47.CrossRefGoogle Scholar
  92. 92.
    •• Lai NM, et al. Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database Syst Rev. 2016;3:Cd007878 This systematic review noted significant difference in CVC colonization with the use of antimicrobial-coated CVC. However, significant benefits were only seen in ICU patients.PubMedGoogle Scholar
  93. 93.
    •• Chong HY, Lai NM, Apisarnthanarak A, Chaiyakunapruk N. Comparative efficacy of antimicrobial central venous catheters in reducing catheter-related bloodstream infections in adults: abridged Cochrane systematic review and network meta-analysis. Clin Infect Dis. 2017;64(suppl_2):S131–40 This meta-analysis reviewed the comparative efficacy of different antimicrobial agents in reducing CRBSIs and noted minocycline/rifampin-coated CVCs were the most effective in reducing CRBSIs.CrossRefGoogle Scholar
  94. 94.
    Ramos ER, Reitzel R, Jiang Y, Hachem RY, Chaftari AM, Chemaly RF, et al. Clinical effectiveness and risk of emerging resistance associated with prolonged use of antibiotic-impregnated catheters: more than 0.5 million catheter days and 7 years of clinical experience. Crit Care Med. 2011;39(2):245–51.CrossRefGoogle Scholar
  95. 95.
    Timsit JF, Mimoz O, Mourvillier B, Souweine B, Garrouste-Orgeas M, Alfandari S, et al. Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med. 2012;186(12):1272–8.CrossRefGoogle Scholar
  96. 96.
    Ullman AJ, et al. Dressings and securement devices for central venous catheters (CVC). Cochrane Database Syst Rev. 2015;(9):Cd010367.Google Scholar
  97. 97.
    Safdar N, O'Horo JC, Ghufran A, et al. Chlorhexidine-impregnated dressing for prevention of catheter-related bloodstream infection: a meta-analysis. Crit Care Med. 2014;42(7):1703–13.CrossRefGoogle Scholar
  98. 98.
    Sweet MA, Cumpston A, Briggs F, Craig M, Hamadani M. Impact of alcohol-impregnated port protectors and needleless neutral pressure connectors on central line-associated bloodstream infections and contamination of blood cultures in an inpatient oncology unit. Am J Infect Control. 2012;40(10):931–4.CrossRefGoogle Scholar
  99. 99.
    Kamboj M, Blair R, Bell N, Son C, Huang YT, Dowling M, et al. Use of disinfection cap to reduce central-line–associated bloodstream infection and blood culture contamination among hematology–oncology patients. Infect Control Hosp Epidemiol. 2015;36(12):1401–8. Scholar
  100. 100.
    Casey AL, Karpanen TJ, Nightingale P, Cook M, Elliott TSJ. Microbiological comparison of a silver-coated and a non-coated needleless intravascular connector in clinical use. J Hosp Infect. 2012;80(4):299–303.CrossRefGoogle Scholar
  101. 101.
    Jacob JT, Chernetsky Tejedor S, Dent Reyes M, Lu X, Easley KA, Aurand WL, et al. Comparison of a silver-coated needleless connector and a standard needleless connector for the prevention of central line-associated bloodstream infections. Infect Control Hosp Epidemiol. 2015;36(3):294–301.CrossRefGoogle Scholar
  102. 102.
    •• Ruth AR, Rosenblatt J, Ginsberg CH, Murray K, Chaftari AM, Hachem R, et al. Optimized Nitroglycerin-Citrate-Ethanol (NiCE), non-antibiotic, antimicrobial, catheter lock solution for prevention of central line associated blood stream infections (CLABSI)—an in vitro assessment of antimicrobial efficacy. Antimicrob Agents Chemother. 2016;60:AAC.00254-16. In vitro study demonstrated antimicrobial lock solution with nitroglycerine + Citrate + Ethanol (NiCE) completely eradicated biofilms of MRSA, VISA, VRE, MDR Pseudomonas aeruginosa, MDR Klebsiella pneumoniae, MDR Enterobacter cloacae, and Candida glabrata isolates.CrossRefGoogle Scholar
  103. 103.••
    Rijnders B, DiSciullo G, Csiky B, Rutkowski B, Appelt K, Cheronis J, et al. Locking hemodialysis catheters with trimethoprim–ethanol–Ca–EDTA to prevent bloodstream infections. A randomized, evaluator blinded clinical trial. Clin Infect Dis. 2018:ciy840. In this randomized controlled trial, hemodialysis patients with a CVC noted 4.56-fold decrease in CLABSIs with the use of trimethoprim–ethanol–Ca–EDTA lock solution in between dialysis.
  104. 104.
    Zacharioudakis IM, Zervou FN, Arvanitis M, Ziakas PD, Mermel LA, Mylonakis E. Antimicrobial lock solutions as a method to prevent central line-associated bloodstream infections: a meta-analysis of randomized controlled trials. Clin Infect Dis. 2014;59(12):1741–9.CrossRefGoogle Scholar
  105. 105.
    Maiefski M, Rupp ME, Hermsen ED. Ethanol lock technique: review of the literature. Infect Control Hosp Epidemiol. 2009;30(11):1096–108.CrossRefGoogle Scholar
  106. 106.
    Oliveira C, Nasr A, Brindle M, Wales PW. Ethanol locks to prevent catheter-related bloodstream infections in parenteral nutrition: a meta-analysis. Pediatrics. 2012;129(2):318–29.CrossRefGoogle Scholar
  107. 107.
    Chan RJ, Northfield S, Larsen E, et al. Central venous Access device SeCurement and Dressing Effectiveness for peripherally inserted central catheters in adult acute hospital patients (CASCADE): a pilot randomised controlled trial. Trials. 2017;18:458.
  108. 108.
    Macmillan T, Pennington M, Summers JA, et al. Appl Health Econ Health Policy. 2018.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Rajendra Karnatak
    • 1
  • Mark E. Rupp
    • 1
  • Kelly Cawcutt
    • 1
    Email author
  1. 1.Division of Infectious DiseasesUniversity of Nebraska Medical CenterOmahaUSA

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