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

• 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 improve compliance with recommended evidence-based practices.
• Perform surveillance for CLABSI and measure unit-specific incidence (CLABSI per 1,000 catheter-days).

Diagnosis (Calderwood, 2019)  

• If infection is suspected, notify the healthcare provider 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 S.  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 (Calderwood, 2019)

• 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.

• When selecting an 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 a 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.

Reporting Guideline Instructions (CDC, 2020)

• Group B streptococcus: Group B streptococcus identified from blood, with a date of event (DOE) during the first 6 days of life, will not be reported as a CLABSI. A bloodstream infection (BSI) repeat infection timeframe (RIT) is set and any associated device days should be included in counts for denominator summary data.
• Do not report a BSI that has a DOE that occurs within a BSI RIT. However, add additional organisms identified that are eligible for BSI events to the initial BSI event.
• Only primary BSIs create a 14-day BSI RIT.
  • Example: Patient has a positive blood specimen identifying S. aureus on hospital day 6, which is not secondary to another site-specific source of infection. A subsequent positive blood specimen is collected on hospital day 12 that identifies Pseudomonas aeruginosa. Because this occurs in the BSI RIT, no new BSI event is identified or reported, and Pseudomonas is added to the initial BSI event.
• Secondary BSIs do not create a 14-day BSI RIT.
  • Example: A symptomatic urinary tract infection (SUTI) with Enterococcus faecalis is identified and E. faecalis is also collected from a blood specimen on hospital day 11 within the SUTI secondary BSI attribution period. This BSI is secondary to the SUTI. Only a SUTI RIT is set, not a BSI RIT. On hospital day 15 (also within the SUTI RIT and secondary BSI attribution period), a blood culture which grows S. aureus is collected. Because the blood growing S. aureus does not have at least one pathogen that matches the urine culture used to meet the SUTI criterion, the BSI cannot be attributed as secondary to the SUTI. There is no BSI RIT in effect, therefore the BSI will need to be investigated as a new BSI event and either assigned as a secondary BSI to another primary site of infection or determined to be a primary BSI. Note: The secondary BSI attribution period of a primary source of infection is not a “catch all” for subsequent BSIs.
• There is no expectation that positive blood specimens collected during the present on admission (POA) timeframe be investigated. If identified, they are not reported to the National Healthcare Safety Network (NHSN). However, if a subsequent positive blood specimen is collected within 14 days of a positive blood specimen collected during the POA timeframe, it is imperative that a determination be made for the original blood specimen to make the correct determination about the subsequent blood specimen.
• Purulent phlebitis confirmed with a positive semi quantitative culture of a catheter tip, but with either a negative or no blood culture is considered a cardiovascular system- arterial or venous infection (CVS-VASC), not an LCBI, skin and soft tissue-skin (SST-SKIN), or a skin and soft tissue- soft tissue (SST-ST) infection.