Education, Training, and Staffing (CDC, 2011; Marschall et al., 2014)

• Educate healthcare personnel on indications for central lines, proper procedures for insertion and maintenance, and appropriate infection prevention measures.
• Periodically assess staff knowledge and compliance to guidelines of care.
• Allow only trained personnel to insert and care for peripheral and central intravascular catheters and ensure these clinicians undergo a credentialing process to confirm competency.
• Ensure proper nursing staff levels in intensive care units (ICUs), a minimum ratio of 1 nurse to 2 patients.
• Provide a checklist to clinicians to ensure adherence to aseptic insertion practices.
• Reeducate personnel at regular intervals on central line insertion, handling and maintenance, and policies, procedures, supplies, or equipment changes.
• Empower staff to stop non-emergent CVC insertion if aseptic technique is not maintained.
• Ensure efficient access to supplies for central line insertion and maintenance.
• Use hospital-specific or collaborative performance initiatives to impove compliance with recommended evidence-based practices.
• Perform surveillance for CLABSI and measure unit-specific incidence (CLABSI per 1,000 catheter-days).

Diagnosis (Band, 2018)

• If infection is suspected, notify the licensed independent practitioner (LIP) immediately.
  • Symptoms may include fever, hemodynamic instability, altered mental status, catheter dysfunction, and clinical signs of sepsis that start immediately after catheter infusion.
• If infection is suspected, draw two sets of blood cultures: one from the CVC and one from a peripheral vein prior to antibiotic administration.
  • If blood cannot be drawn from a peripheral vein, blood may be drawn from different lumens of multi-lumen catheters (≥ 2 blood samples should be drawn from lumens at different times).
  • Blood cultures positive for Staphylococcus Aureus, coagulase-negative staphylococci, or Candida species in the absence of other sources of infection should increase the suspicion of catheter-related infection.
  • Catheter cultures should be performed when a catheter is removed for suspected infection.
• Laboratory confirmation of a catheter-related bloodstream infection requires one of the following criteria (Band, 2018):
  • Culture of the same organism from both the catheter tip and at least one percutaneous blood culture.
  • Culture of the same organism from at least two blood samples (one from the catheter hub and the other from a peripheral vein or second lumen).

Treatment (Band, 2018)

• Once the infection is confirmed, the healthcare provider must determine if the catheter will be removed, salvaged, or exchanged.
  • Catheter should be removed in the following circumstances:
    • Severe sepsis
    • Hemodynamic instability
    • Endocarditis or evidence of metastatic infection
    • Erythema or exudate due to thrombophlebitis
    • Persistent bacteremia after 72 hours of antimicrobial therapy
  • Benefit of catheter removal must be weighed against the difficulty in obtaining alternative venous access.
  • Long-term catheters (indwelling ≥ 14 days) infected with S. aureus, P. aeruginosa, fungi, or mycobacteria, as well as organisms that are difficult to treat (Bacillus spp, Micrococcus spp, or cutibacteria) should be removed.
  • Long-term catheters with uncomplicated infection due to pathogens other than those listed above, may be salvaged.
  • Catheters may be exchanged over a guidewire if the risk for mechanical complications or bleeding during catheter reinsertion is high.
• If the catheter cannot be removed, an adjunctive antibiotic lock therapy combined with systemic therapy may be used in infections due to coagulase-negative staphylococci. Antibiotic lock therapy should not be used for extraluminal infections or for infections due to S. aureus, P. aeruginosa, resistant gram-negative bacilli, or Candida.

Empiric Antibiotic Treatment (Band, 2018)

• When selecting antibiotic, consider severity of illness, risk factors for infection, and likely pathogens associated with the specific intravascular device.
• Coagulase-negative staphylococci are the most common cause of catheter-related infections and most respond to vancomycin but are resistant to methicillin.
• Use daptomycin in institutions with high rates of infection due to methicillin-resistant S. aureus.
• With S. aureus bacteremia, perform transesophageal echocardiogram (TEE) to rule out infective endocarditis (unless fever and bacteremia resolve within 72 hours after catheter removal and patient has no underlying cardiac conditions).
• In uncomplicated infection with negative blood cultures following catheter removal, duration of therapy is 10 to 14 days.
• In persistent bacteremia > 72 hours following catheter removal, duration of treatment is at least 4 to 6 weeks (coagulase-negative staphylococcal infection does not require prolonged therapy). Following device removal, administer antibiotic therapy for at least 2 to 3 days prior to new device replacement.
• Monitor patients closely following therapy for relapses or signs of metastatic infection.
  • Repeat blood cultures after treatment is started to assess for resolving infection.
  • Positive blood cultures and/or persistent symptoms 72 hours after catheter removal with antibiotic therapy should prompt evaluation for other complications such as thrombophlebitis, endocarditis, and metastatic infection.