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Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update Jonas Marschall Washington University School of Medicine in St. Louis

Leonard A. Mermel Brown University

Mohamed Fakih Wayne State University

Lynn Hadaway Lynn Hadaway Associates, Inc.

Alexander Kallen Center for Disease Control and Prevention, Atlanta

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Recommended Citation Marschall, Jonas; Mermel, Leonard A.; Fakih, Mohamed; Hadaway, Lynn; Kallen, Alexander; O’Grady, Naomi P.; Pettis, Ann Marie; Rupp, Mark E.; Sandora, Thomas; Maragakis, Lisa L.; and Yokoe, Deborah S., ,”Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update.” Infection Control and Hospital Epidemiology.35,7. 753-771. (2014). https://digitalcommons.wustl.edu/open_access_pubs/3453



Authors Jonas Marschall, Leonard A. Mermel, Mohamed Fakih, Lynn Hadaway, Alexander Kallen, Naomi P. O’Grady, Ann Marie Pettis, Mark E. Rupp, Thomas Sandora, Lisa L. Maragakis, and Deborah S. Yokoe

This open access publication is available at Digital Commons@Becker: https://digitalcommons.wustl.edu/open_access_pubs/3453



Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update Author(s): Jonas Marschall, MD; Leonard A. Mermel, DO, ScM; Mohamad Fakih, MD, MPH; Lynn Hadaway, MEd, RN, BC, CRNI; Alexander Kallen, MD, MPH; Naomi P. O’Grady, MD; Ann Marie Pettis, RN, BSN, CIC; Mark E. Rupp, MD; Thomas Sandora, MD, MPH; Lisa L. Maragakis, MD, MPH; Deborah S. Yokoe, MD, MPH Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 7 (July 2014), pp. 753-771 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/676533 . Accessed: 08/11/2014 13:40

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infection control and hospital epidemiology july 2014, vol. 35, no. 7

s h e a / i d s a p r a c t i c e r e c o m m e n d a t i o n

Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals:

2014 Update

Jonas Marschall, MD;1,2,a Leonard A. Mermel, DO, ScM;3,a Mohamad Fakih, MD, MPH;4

Lynn Hadaway, MEd, RN, BC, CRNI;5 Alexander Kallen, MD, MPH;6 Naomi P. O’Grady, MD;7

Ann Marie Pettis, RN, BSN, CIC;8 Mark E. Rupp, MD;9 Thomas Sandora, MD, MPH;10

Lisa L. Maragakis, MD, MPH;11 Deborah S. Yokoe, MD, MPH12

Affiliations: 1. Washington University School of Medicine, St. Louis, Missouri; 2. Bern University Hospital and University of Bern, Bern, Switzerland; 3. Warren Alpert Medical School of Brown University and Rhode Island Hospital, Providence, Rhode Island; 4. St. John Hospital and Medical Center and Wayne State University School of Medicine, Detroit, Michigan; 5. Lynn Hadaway Associates, Inc., Milner, Georgia; 6. Centers for Disease Control and Prevention, Atlanta, Georgia; 7. National Institutes of Health, Bethesda, Maryland; 8. University of Rochester Medical Center, Rochester, New York; 9. University of Nebraska Medical Center, Omaha, Nebraska; 10. Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts; 11. Johns Hopkins University School of Medicine, Baltimore, Maryland; 12. Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; a. These authors contributed equally to this article.

Received March 12, 2014; accepted March 13, 2014; electronically published June 9, 2014. Infect Control Hosp Epidemiol 2014;35(7):753-771 � 2014 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2014/3507-0001$15.00. DOI: 10.1086/676533


Previously published guidelines are available that provide comprehensive recommendations for detecting and prevent- ing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a con- cise format designed to assist acute care hospitals in imple- menting and prioritizing their central line–associated blood- stream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals,”1 published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content ex- pertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.2

section 1: rationale and statements of concern

I. Patients at risk for CLABSIs in acute care facilities A. Intensive care unit (ICU) population: the risk of CLABSI

in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters, the use of spe- cific types of catheters that are almost exclusively inserted

in ICU patients and associated with substantial risk (eg, pulmonary artery catheters with catheter introducers), and the fact that catheters are frequently placed in emer- gency circumstances, repeatedly accessed each day, and often needed for extended periods of time.3,4

B. Non-ICU population: although the primary focus of attention over the last 2 decades has been the ICU set- ting, the majority of CLABSIs occur in hospital units outside the ICU or in outpatients.5-10

C. Infection prevention and control efforts should include other vulnerable populations, such as patients receiving hemodialysis through catheters,11 intraoperative pa- tients,12 and oncology patients.

D. Besides central venous catheters (CVCs), peripheral ar- terial catheters also carry a risk of infection.3

II. Outcomes associated with hospital-acquired CLABSI A. Increased length of hospital stay.13-17

B. Increased cost (the non-inflation-adjusted attributable cost of CLABSIs has been found to vary from $3,700 to $39,000 per episode14,17-19).

III. Independent risk factors for CLABSI (in at least 2 pub- lished studies)20-25

A. Factors associated with increased risk. 1. Prolonged hospitalization before catheterization 2. Prolonged duration of catheterization 3. Heavy microbial colonization at the insertion site 4. Heavy microbial colonization of the catheter hub 5. Internal jugular catheterization 6. Femoral catheterization in adults

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754 infection control and hospital epidemiology july 2014, vol. 35, no. 7

7. Neutropenia 8. Prematurity (ie, early gestational age) 9. Reduced nurse-to-patient ratio in the ICU26,27

10. Total parenteral nutrition 11. Substandard catheter care (eg, excessive manipula-

tion of the catheter) 12. Transfusion of blood products (in children)

B. Factors associated with reduced risk. 1. Female sex 2. Antibiotic administration22,28

3. Minocycline-rifampin-impregnated catheters29,30

section 2: background—strategies to detect clabsi

I. Surveillance protocol and definition of CLABSIs A. Use consistent surveillance methods and definitions to

allow comparison to benchmark data. B. Refer to the National Healthcare Safety Network (NHSN)

Manual: Patient Safety Component Protocol for infor- mation on the appropriate surveillance methodology, in- cluding information about blood specimen collection, and for surveillance definitions of CLABSIs. The relevant sections of the manual are “Identifying Healthcare- Associated Infections (HAI) in NHSN,” “Device-Asso- ciated Module: Methodology,” and “Device-Associated Module: Central Line–Associated Bloodstream Infection (CLABSI) Event.”31

1. Recent data suggest that interrater reliability using NHSN definitions is lower than expected.32-34 This may also affect the reliability of public reporting. Addition- ally, the NHSN surveillance definition for CLABSI is different from the clinical definition for catheter- related bloodstream infection.35

section 3: background—strategies to prevent clabsi

I. Existing guidelines and recommendations A. Several governmental, public health, and professional

organizations have published evidence-based guidelines and/or implementation aids regarding the prevention of CLABSI, including the following:

1. The Healthcare Infection Control Practices Advisory Committee (HICPAC), Centers for Disease Control and Prevention36,37

2. The Institute for Healthcare Improvement38

3. The Agency for Healthcare Research and Quality39

4. The American Pediatric Surgical Association Out- comes and Clinical Trials Committee40

5. The Joint Commission41

6. APIC42

7. The Infusion Nurses Society43

B. The recommendations in this document focus on CVCs unless noted otherwise. These recommendations

1. Are not stratified on the basis of catheter type (eg, tunneled, implanted, cuffed, noncuffed catheter, and dialysis catheter) and

2. May not be applicable for prevention of bloodstream infections with other intravascular devices.

II. Infrastructure requirements include the following: A. An adequately staffed infection prevention and control

program responsible for identifying patients who meet the surveillance definition for CLABSI.

B. Information technology to collect and calculate cathe- ter-days as a denominator when computing rates of CLABSI and patient-days to allow calculation of CVC utilization. Catheter-days from information systems should be validated against a manual method, with a margin of error no greater than �5%.

C. Resources to provide appropriate education and training.

D. Adequate laboratory support for timely processing of specimens and reporting of results.

section 4: recommended strategies for clabsi prevention

Recommendations are categorized as either (1) basic practices that should be adopted by all acute care hospitals or (2) special approaches that can be considered for use in lo- cations and/or populations within hospitals when CLABSIs are not controlled by use of basic practices. Basic practices include recommendations where the potential to impact CLABSI risk clearly outweighs the potential for undesirable effects. Special approaches include recommendations where the intervention is likely to reduce CLABSI risk but where there is concern about the risks for undesirable outcomes, where the quality of evidence is low, or where evidence supports the impact of the intervention in select settings (eg, during outbreaks) or for select patient populations. Hospitals can prioritize their efforts by initially focusing on implementing the prevention approaches listed as basic practices. If CLABSI surveillance or other risk assessments suggest that there are ongoing opportunities for improve- ment, hospitals should then consider adopting some or all of the prevention approaches listed as special approaches. These can be implemented in specific locations or patient populations or can be implemented hospital-wide, depend- ing on outcome data, risk assessment, and/or local require- ments. Each infection prevention recommendation is given a quality-of-evidence grade (see Table 1).

Note that some of the following measures have been com- bined into a “prevention bundle” that focuses on catheter insertion (eg, measures B.2, B.3, B.6, B.7, and C.3).44-46 Nu- merous studies have documented that use of such bundles is effective, sustainable, and cost-effective in both adults and children.47-50 Bundles are most likely to be successful if im- plemented in a previously established patient safety culture, and their success depends on adherence to individual mea-

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strategies to prevent clabsi: 2014 update 755

table 1. Grading of the Quality of Evidence

Grade Definition

I. High Highly confident that the true effect lies close to that of the estimated size and direction of the effect. Evidence is rated as high quality when there is a wide range of studies with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.

II. Moderate The true effect is likely to be close to the estimated size and direction of the effect, but there is a possibility that it is substantially different. Evidence is rated as moderate quality when there are only a few studies and some have limitations but not major flaws, there is some variation between studies, or the confidence interval of the summary estimate is wide.

III. Low The true effect may be substantially different from the estimated size and direction of the effect. Evidence is rated as low quality when supporting studies have major flaws, there is important variation between studies, the confidence interval of the summary estimate is very wide, or there are no rigorous studies, only expert consensus.

note. Based on Grades of Recommendation, Assessment, Development, and Evaluation (GRADE)257 and the Canadian Task Force on Preventive Health Care.258

sures.51 However, recent data suggest that not all components of bundles may be necessary to achieve an effect on CLABSI rates.52 After catheter insertion, maintenance bundles have been proposed to ensure optimal catheter care.53 More data are needed to determine which components of the mainte- nance bundle are essential in reducing risk.54,55

I. Basic practices for preventing and monitoring CLABSI: recommended for all acute care hospitals A. Before insertion

1. Provide easy access to an evidence-based list of in- dications for CVC use to minimize unnecessary CVC placement (quality of evidence: III).

2. Require education of healthcare personnel involved in insertion, care, and maintenance of CVCs about CLABSI prevention (quality of evidence: II).56-60

a. Include the indications for catheter use, appropri- ate insertion and maintenance, the risk of CLABSI, and general infection prevention strategies.

b. Ensure that all healthcare personnel involved in catheter insertion and maintenance complete an educational program regarding basic practices to prevent CLABSI before performing these duties.61,62

Periodic retraining with a competency assessment may be of benefit.63

c. Ensure that any healthcare professional who inserts a CVC undergoes a credentialing process (as es- tablished by the individual healthcare institution) to ensure their competency before independently inserting a CVC.

d. Reeducate when an institution changes compo- nents of the infusion system that requires a change in practice (eg, when an institution’s change of the needleless connector requires a change in nursing practice).

e. Consider using simulation training for proper cath- eter insertion technique.64-66

3. Bathe ICU patients over 2 months of age with a chlor-

hexidine preparation on a daily basis (quality of evi- dence: I).67-70

a. In long-term acute care hospitals, daily chlorhex- idine bathing may also be considered as a preven- tive measure.71

b. The role of chlorhexidine bathing in non-ICU pa- tients remains to be determined.72

c. The optimal choice of antiseptic agents is unre- solved for children under 2 months of age. How- ever, chlorhexidine is widely used in children under 2 months of age.73 A US survey found that in the majority of neonatal ICUs (NICUs) chlorhexidine products are used for catheter insertion in this age group.74 For chlorhexidine gluconate (CHG)–based topical antiseptic products, the Food and Drug Ad- ministration recommends “use with care in pre- mature infants or infants under 2 months of age; these products may cause irritation or chemical burns.” The American Pediatric Surgical Associa- tion recommends CHG use but states that “care should be taken in using chlorhexidine in neonates and premature infants because of increased risk of skin irritation and risk of systemic absorption.”40

Concerns in children under 2 months have been noted elsewhere.75 Cutaneous reactions to CHG have also been reported in extremely-low-birth- weight neonates under 48 hours of age;76 however, in a small pilot trial of neonates under 1,000 g and at least 7 days of age, severe contact dermatitis did not occur, although CHG was cutaneously ab- sorbed.77 These findings have not been replicated in a recent trial in neonates weighing more than or equal to 1,500 g.78,79 Some institutions have used chlorhexidine-containing sponge dressings for CVCs79 and chlorhexidine for cleaning CVC in- sertion sites in children in this age group with min- imal risk of such reactions.40 Providers must care-

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756 infection control and hospital epidemiology july 2014, vol. 35, no. 7

fully weigh the potential benefit in preventing CLABSI in children under 2 months and the risks of CHG, recognizing that term and preterm infants may have different risks. Alternative agents, such as povidone-iodine or alcohol, can be used in this age group.80

B. At insertion 1. Have a process in place to ensure adherence to in-

fection prevention practices at the time of CVC in- sertion in ICU and non-ICU settings, such as a check- list (quality of evidence: II).45,81,82

a. Ensure and document adherence to aseptic technique. i. Checklists have been suggested to ensure op-

timal insertion practices. If used, the docu- mentation should be done by someone other than the inserter.

ii. Observation of CVC insertion by a nurse, phy- sician, or other healthcare personnel who has received appropriate education (see above) to ensure that aseptic technique is maintained.

iii. Such healthcare personnel should be empow- ered to stop the procedure if breaches in aseptic technique are observed.

2. Perform hand hygiene prior to catheter insertion or manipulation (quality of evidence: II).83-87

a. Use an alcohol-based waterless product or anti- septic soap and water. i. Use of gloves does not obviate hand hygiene.

3. Avoid using the femoral vein for central venous access in obese adult patients when the catheter is placed under planned and controlled conditions (quality of evidence: I).28,88-90

a. Additional factors may influence the risk of CLABSI in patients with femoral vein catheters.91,92

b. Femoral vein catheterization can be done without general anesthesia in children and has not been associated with an increased risk of infection in this population.93

c. Controversy exists regarding infectious and non- infectious complications associated with different short-term CVC access sites.89,94 The risk and ben- efit of different insertion sites must be considered on an individual basis with regard to infectious and noninfectious complications (eg, patients with jug- ular access may have a higher infection risk if they have a concurrent tracheostomy95).

d. Do not use peripherally inserted CVCs (PICCs) as a strategy to reduce the risk of CLABSI. i. The risk of infection with PICCs in ICU patients

approaches that of CVCs placed in the subcla- vian or internal jugular veins.96,97

ii. The majority of CLABSIs due to PICCs occur in non-ICU settings.98 The PICC-associated CLABSI risk may be different outside the ICU.

4. Use an all-inclusive catheter cart or kit (quality of evidence: II).45

a. A catheter cart or kit that contains all necessary components for aseptic catheter insertion has to be available and easily accessible in all units where CVCs are inserted.

5. Use ultrasound guidance for internal jugular catheter insertion (quality of evidence: II).99

a. Ultrasound-guided internal jugular vein catheter- ization reduces the risk of CLABSI and of non- infectious complications of CVC placement.100

6. Use maximum sterile barrier precautions during CVC insertion (quality of evidence: II).101-107

a. Use maximal sterile barrier precautions. i. A mask, cap, sterile gown, and sterile gloves are

to be worn by all healthcare personnel involved in the catheter insertion procedure.

ii. The patient is to be covered with a large (“full- body”) sterile drape during catheter insertion.

b. These measures must also be followed when ex- changing a catheter over a guidewire.

c. A prospective randomized study in surgical patients showed no additional benefit for maximal sterile barrier precautions;105 nevertheless, most available evidence suggests risk reduction with this inter- vention.

7. Use an alcoholic chlorhexidine antiseptic for skin preparation (quality of evidence: I).108-111

a. Before catheter insertion, apply an alcoholic chlor- hexidine solution containing more than 0.5% CHG to the insertion site.112

i. The antiseptic solution must be allowed to dry before making the skin puncture.

C. After insertion 1. Ensure appropriate nurse-to-patient ratio and limit

the use of float nurses in ICUs (quality of evidence: I).26,27,113,114

a. Observational studies suggest that there should be a nurse-to-patient ratio of at least 1 to 2 in ICUs where nurses are managing patients with CVCs and that the number of float nurses working in the ICU environment should be minimized.

2. Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (quality of evidence: II).115-119

a. Before accessing catheter hubs, needleless con- nectors, or injection ports, vigorously apply me- chanical friction with an alcoholic chlorhexidine preparation, 70% alcohol, or povidone-iodine. Al- coholic chlorhexidine may have additional residual activity compared with alcohol for this purpose.120

b. Apply mechanical friction for no less than 5 seconds to reduce contamination.121,122 It is unclear whether this duration of disinfection can be generalized to needleless connectors not tested in these studies.

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strategies to prevent clabsi: 2014 update 757

c. Monitor compliance with hub/connector/port dis- infection since approximately half of such catheter components are colonized under conditions of standard practice.117,121

3. Remove nonessential catheters (quality of evidence: II).123,124

a. Assess the need for continued intravascular access on a daily basis during multidisciplinary rounds. Remove catheters not required for patient care.

b. Audits to determine whether CVCs are routinely removed after their intended use may be help- ful.125,126 Both simple and multifaceted interventions are effective at reducing unnecessary CVC use.127,128

4. For nontunneled CVCs in adults and children, change transparent dressings and perform site care with a chlorhexidine-based antiseptic every 5–7 days or im- mediately if the dressing is soiled, loose, or damp; change gauze dressings every 2 days or earlier if the dressing is soiled, loose, or damp (quality of evidence: II).129-131

a. Less-frequent dressing changes may be used for selected NICU patients to reduce the risk of cath- eter dislodgement.

b. If there is drainage from the catheter exit site, use gauze dressings instead of transparent dressings until drainage resolves.

5. Replace administration sets not used for blood, blood products, or lipids at intervals not longer than 96 hours (quality of evidence: II).132,133

a. The optimal replacement intervals of intermittently used administration sets are currently unresolved.

6. Use antimicrobial ointments for hemodialysis cath- eter-insertion sites (quality of evidence: I).134-140

a. Polysporin “triple” (where available) or povidone- iodine ointment should be applied to hemodialysis catheter insertion if compatible with the catheter material. i. Certain manufacturers have indicated that the

glycol constituents of ointments should not be used on their polyurethane catheters.

b. Mupirocin ointment should not be applied to the catheter-insertion site due to the risks of facilitating mupirocin resistance and the potential damage to polyurethane catheters.

7. Perform surveillance for CLABSI in ICU and non- ICU settings (quality of evidence: I).6,7,141,142

a. Measure the unit-specific incidence of CLABSI (CLABSIs per 1,000 catheter-days) and report the data on a regular basis to the units, physician and nursing leadership, and hospital administrators overseeing the units.

b. Compare CLABSI incidence with historical data for individual units and with national rates (ie, NHSN143).

c. Audit surveillance as necessary to minimize vari-

ation in interobserver reliability.32,33

d. Surveillance for CLABSI outside the ICU setting requires additional resources.144 Electronic surveil- lance is an option in these settings.145

II. Special approaches for preventing CLABSI A number of special approaches are currently available

for use. Perform a CLABSI risk assessment before con- sidering implementing any of these approaches, and take potential adverse events and cost into consideration. Al- though it is reasonable to evaluate the utility of technol- ogy-based interventions when CLABSI rates are above the institutional or unit-based threshold, this is also an op- portunity to review practices and consider behavioral changes that may be instituted to reduce CLABSI risk. These special approaches are recommended for use in locations and/or populations within the hospital with un- acceptably high CLABSI rates despite implementation of the basic CLABSI prevention strategies listed above. These measures may not be indicated if institutional goals have been consistently achieved.

1. Use antiseptic- or antimicrobial-impregnated CVCs in adult patients (quality of evidence: I).29,30,146-152

a. The risk of CLABSI is reduced with some currently marketed antiseptic-impregnated (eg, chlorhexidine– silver sulfadiazine) catheters and antimicrobial- impregnated (eg, minocycline-rifampin) catheters. Use such catheters in the following instances. i. Hospital units or patient populations have a

CLABSI rate above institutional goals despite compliance with basic CLABSI prevention prac- tices. Some evidence suggests that use of anti- microbial CVCs may have no additional benefit in patient care units that have already established a low incidence of catheter infections.153

ii. Patients have limited venous access and a history of recurrent CLABSI.

iii. Patients are at heightened risk of severe sequelae from a CLABSI (eg, patients with recently im- planted intravascular devices, such as a prosthetic heart valve or aortic graft).

b. Monitor patients for untoward effects, such as anaphylaxis.154

2. Use chlorhexidine-containing dressings for CVCs in patients over 2 months of age (quality of evidence: I).80,155-160

a. It is unclear whether there is additional benefit to using a chlorhexidine-containing dressing if daily chlorhexidine bathing is already established and vice versa.

3. Use an antiseptic-containing hub/connector cap/port protector to cover connectors (quality of evidence: I).161-165

4. Use silver zeolite–impregnated umbilical catheters in preterm infants (in countries where it is approved for use in children; quality of evidence: II).166

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758 infection control and hospital epidemiology july 2014, vol. 35, no. 7

a. Observational studies suggest that other antimicro- bial-impregnated catheters appear to be safe and hold promise in pediatric ICU patients.167-169

5. Use antimicrobial locks for CVCs (quality of evidence: I).170-175

a. Antibiotic locks are created by filling the lumen of the catheter with a supratherapeutic concentration of an antimicrobial solution and leaving the solution in place until the catheter hub is reaccessed. Such an approach can reduce the risk of CLABSI. Because of concerns regarding the potential for the emergence of resistance in exposed organisms, use antimicrobial locks as a preventative strategy for the following: i. Patients with long-term hemodialysis catheters.176

ii. Patients with limited venous access and a history of recurrent CLABSI.

iii. Patients who are at heightened risk of severe se- quelae from a CLABSI (eg, patients with recently implanted intravascular devices, such as a pros- thetic heart valve or aortic graft).

b. To minimize systemic toxicity, aspirate rather than flush the antimicrobial lock solution after the dwell time has elapsed.177-180 For additional guidance, see the IDSA’s “Clinical Practice Guidelines for the Di- agnosis and Management of Intravascular Catheter- Related Infection.”35

6. Use recombinant tissue plasminogen activating factor once weekly after hemodialysis in patients undergoing hemodialysis through a CVC (quality of evidence: II).181

III. Approaches that should not be considered a routine part of CLABSI prevention

1. Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (quality of evidence: I).182-186

a. Systemic antimicrobial prophylaxis is not recom- mended.

2. Do not routinely replace central venous or arterial cath- eters (quality of evidence: I).187-189

a. Routine catheter replacement is not recommended. IV. Unresolved issues

1. Routine use of needleless connectors as a CLABSI pre- vention strategy before an assessment of risks, benefits, and education regarding proper use.190-194

a. Multiple devices are currently available, but the op- timal design for preventing infections is unresolved. The original purpose of needleless connectors was to prevent needlestick injuries during intermittent use. No data regarding their use with continuous infusions are available.

2. Intravenous therapy teams for reducing CLABSI rates.77,195

a. Studies have shown that an intravenous therapy team responsible for insertion and maintenance of periph- eral intravenous catheters reduces the risk of blood- stream infections.196 However, few studies have been

performed regarding the impact of intravenous ther- apy teams on CLABSI rates.

3. Surveillance of other types of catheters (eg, peripheral arterial or venous catheters).3,4

a. Peripheral arterial catheters and peripheral venous catheters are not included in most surveillance sys- tems, although they are associated with risk of blood- stream infection independent of CVCs.197,198 Future surveillance systems may need to include bloodstream infections associated with these types of catheters.

4. Estimating catheter-days for determining incidence density of CLABSI. a. Surveillance can be facilitated in settings with a lim-

ited workforce by estimating the number of catheter- days.199-201

5. Use of silver-coated catheter connectors are associated with reduced intraluminal contamination in ex vivo catheters.202

a. There is a paucity of clinical evidence regarding the risk reduction with their routine use or use of other antimicrobial catheter connectors.

6. Standard, nonantimicrobial transparent dressings and CLABSI risk. a. A recent meta-analysis reported an association be-

tween CLABSI and transparent dressing use. How- ever, the source studies for the meta-analysis report- ing this association were of low quality.203

7. Impact of the use of chlorhexidine-based products on bacterial resistance to chlorhexidine. a. Widespread use of chlorhexidine-based products (eg,

use of chlorhexidine bathing, antisepsis, and dress- ings) may promote reduced chlorhexidine suscepti- bility in bacterial strains.204 However, testing for chlorhexidine susceptibility is not standardized. The clinical impact of reduced chlorhexidine susceptibility in gram-negative bacteria is unknown.

section 5: performance measures

I. Internal reporting These performance measures are intended to support

internal hospital quality improvement efforts205,206 and do not necessarily address external reporting needs. The pro- cess and outcome measures suggested here are derived from published guidelines, other relevant literature, and the opinion of the authors. Report process and outcome measures to senior hospital leadership, nursing leadership, and clinicians who care for patients at risk for CLABSI. A. Process measures

1. Compliance with CVC insertion guidelines as doc- umented on an insertion checklist. a. Assess compliance with the checklist in all hospital

settings where CVCs are inserted (eg, ICUs, emer- gency departments, operating rooms, radiology, and general nursing units) and assign a healthcare

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strategies to prevent clabsi: 2014 update 759

personnel familiar with catheter care to this task. i. For an example of a central catheter checklist,

see http://www.ihi.org/knowledge/Pages/Tools /CentralLineInsertionChecklist.aspx.

b. Measure the percentage of CVC insertion proce- dures in which compliance with appropriate hand hygiene, use of maximal sterile barrier precautions, and use of chlorhexidine-based cutaneous antisep- sis of the insertion site is documented: i. Numerator: number of CVC insertions that

have documented the use of all 3 interventions (hand hygiene, maximal barrier precautions, and chlorhexidine-based cutaneous antiseptic use) performed at the time of CVC insertion.

ii. Denominator: number of all CVC insertions. iii. Multiply by 100 so that the measure is expressed

as a percentage. 2. Compliance with documentation of daily assessment

regarding the need for continuing CVC access. a. Measure the percentage of patients with a CVC

where there is documentation of daily assessment: i. Numerator: number of patients with a CVC

who have documentation of daily assessment. ii. Denominator: number of patients with a CVC.

iii. Multiply by 100 so that the measure is expressed as a percentage.

3. Compliance with cleaning of catheter hubs and in- jection ports before they are accessed (or compliance with use of antiseptic-containing port protectors). a. Assess compliance through observations of prac-

tice: i. Numerator: number of times that a catheter

hub or port (or port protector) is observed to be cleaned before being accessed.

ii. Denominator: number of times a catheter hub or port (or port protector) is observed to be accessed.

iii. Multiply by 100 so that the measure is expressed as a percentage.

B. Outcome measures 1. CLABSI rate.

a. Use NHSN definitions. i. Numerator: number of CLABSIs in each unit

assessed (using NHSN definitions). ii. Denominator: total number of catheter-days in

each unit assessed (using NHSN definitions). iii. Multiply by 1,000 so that the measure is ex-

pressed as the number of CLABSIs per 1,000 catheter-days.

iv. Risk adjustment: stratify CLABSI rates by type of patient care unit.207-209

(a) Report comparisons based on historical data and NHSN data, if available.143

II. External reporting There are many challenges in providing useful infor-

mation to consumers and other stakeholders while pre- venting unintended consequences of public reporting of HAIs.210,211 Recommendations for public reporting of HAIs have been provided by HICPAC,212 the Healthcare- Associated Infection Working Group of the Joint Public Policy Committee,213 and the National Quality Forum.214

A. State and federal requirements 1. Hospitals in states that have mandatory reporting re-

quirements for CLABSI must collect and report the data required by the state.

2. For information on state and federal requirements, contact your state or local health department.

B. External quality initiatives 1. Hospitals that participate in external quality initia-

tives or state programs must collect and report the data required by the initiative or program.

2. Problems with interrater reliability may affect com- parisons between different institutions.

section 6: examples of implementation strategies

Accountability is an essential principle for preventing HAIs. It provides the necessary translational link between science and implementation. Without clear accountability, scientifi- cally based implementation strategies will be used in an in- consistent and fragmented way, decreasing their effectiveness in preventing HAIs. Accountability begins with the chief ex- ecutive officer and other senior leaders who provide the im- perative for HAI prevention, thereby making HAI prevention an organizational priority. Senior leadership is accountable for providing adequate resources needed for effective imple- mentation of an HAI prevention program. These resources include necessary personnel (clinical and nonclinical), edu- cation, and equipment (Table 2).

Insertion of CVCs is one of the most common procedures performed at the patient’s bedside. The insertion procedure represents only one aspect of the risk for CLABSI, with the risk extending to all aspects of nursing care and maintenance during the CVC dwell time. CLABSI prevention strategies have expanded as new studies are published. Additionally, experience with implementing these strategies is increasing. This discussion will focus on strategies for engagement, ed- ucation, execution, and evaluation of CLABSI prevention ef- forts. Published literature and expert opinion form the basis for the following recommendations.

I. Engage The first step toward successful reduction of CLABSIs

is to engage both frontline and senior leadership cham- pions in the process and outcome improvement plan.215

A. Develop a multidisciplinary team that sets goals, defines the steps in the implementation process, and monitors

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760 infection control and hospital epidemiology july 2014, vol. 35, no. 7

table 2. Fundamental Elements of Accountability for Healthcare-Associated Infection Prevention

Senior management is responsible for ensuring that the healthcare system supports an infection prevention and control (IPC) pro- gram that effectively prevents healthcare-associated infections (HAIs) and the transmission of epidemiologically important pathogens

Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the IPC program and adequate staffing of other departments that play a key role in HAI prevention (eg, environmental services)

Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are ade- quately trained and competent to perform their job responsibilities

Direct healthcare providers (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as environmental service and equipment processing personnel) are responsible for ensuring that appropriate IPC practices are used at all times (including hand hygiene, standard and isolation precautions, and cleaning and disinfection of equipment and the environment)

Senior and unit leaders are responsible for holding personnel accountable for their actions IPC leadership is responsible for ensuring that an active program to identify HAIs is implemented, that HAI data are analyzed and

regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidence-based practices are incorporated into the program

Senior and unit leaders are accountable for ensuring that appropriate training and educational programs to prevent HAIs are devel- oped and provided to personnel, patients, and families

Personnel from the IPC program, the laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program

progress in achieving the goals. Regular team meetings should be held.216

B. Focus on a culture of safety, which includes teamwork, technical processes, and promotion of accountability for prevention of CLABSI.

C. Make the problem real to all of those involved to in- crease buy-in. One strategy to accomplish this is to identify a patient in the unit who has suffered harm as a result of developing a CLABSI217 and then share that story with the team.

D. Identify and involve local champions. Engage infusion nurses or vascular access specialists as team members. Include formal (eg, medical or nursing directors, charge nurses) and informal (eg, frontline) leaders.218 Local champions increase the chance for success by engaging and educating peers, thereby increasing buy-in and own- ership by all involved.215 These champions can influence the development of strategies that are a good match with the unit culture. Frequent communication between champions and frontline staff is imperative if concerns are to be resolved and improvement sustained.215

E. Share the outcome data regularly with each unit. Data can be represented as the monthly CLABSI rate and/or the number of days since last infection.217 Consider re- porting CLABSI rates as the standardized infection ratio (SIR). Displaying a trend line is also useful.

F. Utilize peer networks. Voluntary peer networking be- tween hospitals can promote and ensure compliance with evidence-based practices. It also facilitates collab- oration, performance evaluation, and accountability. All can benefit from best practices being shared, and brain- storming can be done to solve shared problems.219

II. Educate A. Change in human behavior is the goal of educational

programs about CVC insertion, care, and maintenance.

Various educational methods and strategies have been studied to reduce CLABSI. In general, these educational interventions showed improvements in CLABSI rates; however, more study is needed to clearly understand the most effective teaching strategies, content taught, length of presentation, and frequency for repeating the program.220,221 Both extraluminal and intraluminal av- enues for CVC infection should be addressed in the educational plan.

B. Educational programs for all healthcare personnel in- volved with the insertion and care of all types of CVCs should address knowledge, critical thinking, behavior and psychomotor skills, and attitudes and beliefs. Iden- tifying and analyzing gaps in these areas leads to the selection of measureable learning objectives, course content, and corresponding appropriate teaching strat- egies. The value of infection prevention should be em- phasized through all education efforts.221,222

C. Adult learners employ multiple ways to learn; therefore, multiple teaching strategies should be used. This in- cludes self-directed study guides, instructor-led courses, and small- and large-group discussions. The planning group for the educational offering should have repre- sentatives from multiple professions, including physi- cians, nurse managers, staff nurses, infusion nurse spe- cialists, and infection preventionists.223-225 The learner should be actively involved with the teaching methods, as lecture alone has been shown to be less effective with retention of information and changes in behavior.226,227

Delivery methods should be chosen on the basis of the learners’ needs and availability, along with the technical capabilities of the facility. This includes printed learning packages; audiovisual formats, such as slide presenta- tions and videos; skills labs; journal clubs and nursing grand rounds; and computer-, Internet-, or DVD-based

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strategies to prevent clabsi: 2014 update 761

packages of learning materials.58,224,228-231 Multiple deliv- ery methods tailored to specific problems or issues and given intermittently over time produce greater reduc- tion in CLABSI than a single structured offering or lecture.61,232

D. Other educational job aides should be readily accessible in the clinical setting for quick reminders and rein- forcement of the appropriate procedures. This includes but is not limited to facility policies and procedures, posters, fact sheets, small pocket cards, e-mail messages, and messages via computer screen savers.233,234

E. To enhance patient safety, learning CVC insertion tech- niques requires a structured educational program fo- cusing on knowledge acquisition and performance of insertions in a simulated environment, followed by su- pervised performance on patients.43,235-237 A meta-anal- ysis of 20 studies using simulation for CVC insertion showed benefits in learner performance, knowledge, and confidence.66 Simulation for CVC insertion in- cludes use of anatomical models and computer-based virtual reality.238 Other approaches have tried to sim- ulate the “feel” of tissue puncture.239

F. All healthcare professionals should have documented competency with CVC insertion, care, and maintenance before being allowed to practice without direct super- vision. A standardized competency assessment checklist should be used to assess and document competency of each individual performing CVC insertion and proce- dures related to care and maintenance (eg, dressing changes). Competency assessment checklists should be evaluated for interrater reliability and validity. The pro- fessional performing competency assessment of the learner should be competent with the procedure being assessed.220,240

G. Changes of products, devices, or technology used in the insertion and care of CVCs require adequate device training for all healthcare personnel expected to use the product(s). This training follows a period of device evaluation and its impact on CLABSI. Most device manufacturers employ personnel with clinical experi- ence to provide product training, and this resource should not be overlooked.

H. Healthcare professionals using CVCs for infusion should have documented competency with all proce- dures, including but not limited to catheter stabiliza- tion, catheter dressing changes, intravenous adminis- tration set management, disinfection of needleless connectors, accessing implanted ports, and flushing and locking the CVC.43 This would involve demon- stration of procedures in a simulation lab or in the clinical setting while being observed by a qualified professional.241,242

I. Assessment of educational programs includes the learner’s satisfaction with the program, changes in knowledge, and changes in work performance. Written

tests are the most common form of measurement; how- ever, this is limited to knowledge acquisition only and may produce anxiety in many adult learners. Other forms of assessment include contributions to group dis- cussions and observation of performance using simu- lation. Measurement of healthcare professionals’ current level of knowledge about CVC insertion and care can provide valuable information for designing educational programs.243,244

J. Prior to an educational program, there should be plan- ning for transfer of the learning from the classroom to the clinical setting. This includes patient care assign- ments to allow for application of new knowledge and practice of new skills, support and encouragement from leaders and managers, and the ability to follow up on issues or concerns that arise from clinical performance.

K. Education of the patient and/or family, as appropriate, is required for all CVC care procedures (eg, hand hy- giene, dressing changes, intravenous administration set management, and flushing and locking), especially when transfer to an alternative setting (eg, home care, ambulatory setting) is planned.43,242

L. Education of facility administrators is necessary to en- sure adequate funding and implementation of CLABSI prevention.242 Additionally, the goal of zero tolerance for CLABSI may be set by the chief officers of an in- stitution;245 however, whether this goal can be reached depends on a number of factors.

III. Execute A. Consider the use of quality improvement methodolo-

gies, such as Lean Six Sigma, Comprehensive Unit- Based Safety Program, Team STEPPS, Plan-Do-Study- Act, and the like, to structure prevention efforts. Various performance improvement tools can be used, such as dashboards and score cards, to share data with stakeholders.

B. Standardize care processes. This can be done through implementation of guidelines, bundles, and protocols that address both insertion and maintenance of central lines. Consider conducting structured daily multidis- ciplinary rounds. During rounds, discuss whether the patient still requires the central line, patient goals for the day, and potential barriers or safety issues.217 Em- power staff to report process defects or barriers to im- plementation encountered to appropriate leadership. This can facilitate rapid intervention and process im- provement. Assign accountability for adherence to spe- cific departments or functions.

C. Create redundancy. Build redundancy or independent checks into the care delivery process to increase staff compliance. This can be done by incorporating visual cues as reminders for proper procedures. Implement a line insertion and line maintenance checklist both in- side and outside ICUs. Consider the use of screen-saver messages, posters, banners, fact sheets, preprinted order

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762 infection control and hospital epidemiology july 2014, vol. 35, no. 7

sets, pocket cards, and the like to educate and serve as reminders for staff.217,218

D. Consider participating in a CLABSI reduction collab- orative. Collaboratives provide an organization with the opportunity to discover and share best practices and utilize comparative outcome data.

IV. Evaluate A. Multidisciplinary teams should be used to form quality

improvement collaboratives to set goals and identify the key factors to be measured. This team should have representatives from administration, all professions, and clinical nursing units.246,247 These teams may rep- resent one hospital or many different hospitals.54,248,249

B. Evaluation involves both process and outcome mea- surement.246 Differences between age groups should also be considered (eg, neonates, pediatrics, and adults).54,249,250

C. Process measurement includes but is not limited to compliance with insertion bundles, CVC utilization by insertion site or type (eg, femoral catheters vs other CVC sites; PICCs vs centrally inserted lines), the con- dition of CVC dressing and timely dressing changes, and integrity and appropriate management of needle- less connectors, other add-on devices, and intravenous administration sets.43,251,252 Device utilization is defined as the number of catheter-days divided by the number of patient-days.245

D. Establish baseline compliance with evidence-based practices for line maintenance, such as the presence of clean and intact dressings.

E. Outcome measurement is the incidence rate of CLABSI and other infections associated with all types of vascular access devices (eg, exit-site infection, suppurative throm- bophlebitis). Consider reporting CLABSI rates as SIR.

F. Process and outcome data should be linked to initial and ongoing competency assessment. Initial compe- tency should be assessed at employment, after orien- tation, and with the introduction of new equipment or technology. Ongoing competency assessment is deter- mined by process and outcome data with the facility deciding the frequency for repeated competency assessment.43

G. Measurement of education outcomes is needed on sev- eral levels. The learner’s satisfaction with the program is assessed by completion of the evaluation form im- mediately following completion of the program. This form also includes the learner’s self-assessment of achieving the learning objectives. The next level is mea- suring the change in learner’s knowledge, most often accomplished by comparison of scores on written pre- and posttests. The third level is to measure the actual change in behavior in clinical practice following the completion of the program. Using only the first and second levels of measurement will not ensure that a change in clinical behavior will occur.

Numerous factors affect CLABSI surveillance, in- cluding CVC type, CLABSI definition, blood culturing practices and written policies, laboratory practices, and staff attitudes and beliefs. Standardization of these fac- tors facilitates benchmarking within and between or- ganizations. Additionally, variations in these determi- nants could impact publicly reported CLABSI rates and influence reimbursement for hospital-acquired con- ditions.32,247

H. Surveillance for CLABSI outside the ICU is becoming more prevalent, especially with increasing use of elec- tronic methods for data collection.253,254

I. Feedback to all healthcare staff is critical for the success of any evaluation program. Unit-based recognition of achievement of low CLABSI rates or the length of time between CLABSI events is a useful method to encourage staff involvement. The goals for improvement should be clearly and frequently articulated. Audit compliance with completion of insertion checklists and share this data with the staff. Other forms of feedback include periodic (eg, monthly, quarterly) communication (eg, e-mail messages, written reports) of process measure- ment data: posters, reports, or other forms of com- munication with graphs showing cumulative compliance with process measures.245,250,255,256


Disclaimer. A.K.—The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Potential conflicts of interest. J.M. reports receiving a speaker honorarium from Gilead Sciences Switzerland. L.A.M. reports serving as an advisor/con- sultant for ICU Medical, Fresenius Medical Care, Bard Access Systems, Mar- vao Medical Devices, CareFusion, 3M Healthcare, Catheter Connections, Semprus Biosciences, and Sharklet Technologies. L.H. reports serving as an advisor/consultant for B Braun Medical, BD Medical, Excelsior Medical, Ivera Medical, Access Scientific, 3M, and Baxter Healthcare. A.M.P. reports re- ceiving speaking fees from Bard and serving as a speaker and author for Covidien. M.E.R reports serving as an advisor/consultant for 3M, Ariste, Semprus, and Sharklet Technologies and receiving honoraria from Baxter and CareFusion. All other authors report no relevant conflicts of interest.

Address correspondence to Leonard A. Mermel, DO, ScM, Division of Infectious Diseases, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 (lmermel@lifespan.org).


1. Marschall J, Mermel LA, Classen D, et al. Strategies to prevent central line–associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29(suppl 1):S22– S30.

2. Yokoe DS, Anderson DJ, Berenholtz SM, et al. Introduction to “A Compendium of Strategies to Prevent Healthcare-Associ- ated Infections in Acute Care Hospitals: 2014 Updates.” Infect Control Hosp Epidemiol 2014;35(5):455–459.

3. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



strategies to prevent clabsi: 2014 update 763

infection in adults with different intravascular devices: a sys- tematic review of 200 published prospective studies. Mayo Clin Proc 2006;81(9):1159–1171.

4. Esteve F, Pujol M, Limon E, et al. Bloodstream infection related to catheter connections: a prospective trial of two connection systems. J Hosp Infect 2007;67(1):30–34.

5. Climo M, Diekema D, Warren DK, et al. Prevalence of the use of central venous access devices within and outside of the in- tensive care unit: results of a survey among hospitals in the Prevention Epicenter Program of the Centers for Disease Con- trol and Prevention. Infect Control Hosp Epidemiol 2003;24(12): 942–945.

6. Vonberg RP, Behnke M, Geffers C, et al. Device-associated infection rates for non–intensive care unit patients. Infect Con- trol Hosp Epidemiol 2006;27(4):357–361.

7. Marschall J, Leone C, Jones M, Nihill D, Fraser VJ, Warren DK. Catheter-associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study. Infect Control Hosp Epidemiol 2007;28(8):905–909.

8. Vital signs: central line–associated blood stream infections— United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep 2011;60(8):243–248.

9. Kallen AJ, Patel PR, O’Grady NP. Preventing catheter-related bloodstream infections outside the intensive care unit: ex- panding prevention to new settings. Clin Infect Dis 2010;51(3): 335–341.

10. Zingg W, Sandoz L, Inan C, et al. Hospital-wide survey of the use of central venous catheters. J Hosp Infect 2011;77(4):304– 308.

11. Xue H, Ix JH, Wang W, et al. Hemodialysis access usage pat- terns in the incident dialysis year and associated catheter- related complications. Am J Kidney Dis 2013;61(1):123–130.

12. Loftus RW, Brown JR, Koff MD, et al. Multiple reservoirs con- tribute to intraoperative bacterial transmission. Anesth Analg 2012;114(6):1236–1248.

13. Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream in- fection in critically ill patients: excess length of stay, extra costs, and attributable mortality. JAMA 1994;271(20):1598–1601.

14. Digiovine B, Chenoweth C, Watts C, Higgins M. The attrib- utable mortality and costs of primary nosocomial bloodstream infections in the intensive care unit. Am J Respir Crit Care Med 1999;160(3):976–181.

15. Renaud B, Brun-Buisson C. Outcomes of primary and catheter- related bacteremia: a cohort and case-control study in critically ill patients. Am J Respir Crit Care Med 2001;163(7):1584–1590.

16. Dimick JB, Pelz RK, Consunji R, Swoboda SM, Hendrix CW, Lipsett PA. Increased resource use associated with catheter- related bloodstream infection in the surgical intensive care unit. Arch Surg 2001;136(2):229–234.

17. Warren DK, Quadir WW, Hollenbeak CS, Elward AM, Cox MJ, Fraser VJ. Attributable cost of catheter-associated blood- stream infections among intensive care patients in a nonteach- ing hospital. Crit Care Med 2006;34(8):2084–2089.

18. Mermel LA. Prevention of intravascular catheter-related infec- tions. Ann Intern Med 2000;132(5):391–402.

19. Elward AM, Hollenbeak CS, Warren DK, Fraser VJ. Attrib- utable cost of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics 2005;115(4): 868–872.

20. Mermel LA. Infections caused by intravascular devices. In:

Pfeiffer JA, ed. APIC Text of Infection Control and Epidemiology. 2nd ed. St. Louis: Mosby, 2000:30–38.

21. Almuneef MA, Memish ZA, Balkhy HH, Hijazi O, Cunning- ham G, Francis C. Rate, risk factors and outcomes of catheter- related bloodstream infection in a paediatric intensive care unit in Saudi Arabia. J Hosp Infect 2006;62(2):207–213.

22. Alonso-Echanove J, Edwards JR, Richards MJ, et al. Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units. Infect Control Hosp Epidemiol 2003;24(12):916–925.

23. Lorente L, Henry C, Martin MM, Jimenez A, Mora ML. Central venous catheter–related infection in a prospective and obser- vational study of 2,595 catheters. Crit Care 2005;9(6):R631– R635.

24. Rey C, Alvarez F, De-La-Rua V, et al. Intervention to reduce catheter-related bloodstream infections in a pediatric intensive care unit. Intensive Care Med 2011;37(4):678–685.

25. Lorente L, Jimenez A, Naranjo C, et al. Higher incidence of catheter-related bacteremia in jugular site with tracheostomy than in femoral site. Infect Control Hosp Epidemiol 2010;31(3): 311–313.

26. Fridkin SK, Pear SM, Williamson TH, Galgiani JN, Jarvis WR. The role of understaffing in central venous catheter–associated bloodstream infections. Infect Control Hosp Epidemiol 1996; 17(3):150–158.

27. Cimiotti JP, Haas J, Saiman L, Larson EL. Impact of staffing on bloodstream infections in the neonatal intensive care unit. Arch Pediatr Adolesc Med 2006;160(8):832–836.

28. Merrer J, De Jonghe B, Golliot F, et al. Complications of fem- oral and subclavian venous catheterization in critically ill pa- tients: a randomized controlled trial. JAMA 2001;286(6):700– 707.

29. Raad I, Darouiche R, Dupuis J, et al; Texas Medical Center Catheter Study Group. Central venous catheters coated with minocycline and rifampin for the prevention of catheter-related colonization and bloodstream infections: a randomized, double-blind trial. Ann Intern Med 1997;127(4):267–274.

30. Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term sil- icone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial. J Clin Oncol 2004;22(15):3163–3171.

31. National Healthcare Safety Network, Centers for Disease Control and Prevention. The National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocol. July 2013. http:// www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf. Accessed September 28, 2013.

32. Niedner MF. The harder you look, the more you find: catheter- associated bloodstream infection surveillance variability. Am J Infect Control 2010;38(8):585–595.

33. Lin MY, Hota B, Khan YM, et al. Quality of traditional sur- veillance for public reporting of nosocomial bloodstream in- fection rates. JAMA 2010;304(18):2035–2041.

34. Tomlinson D, Mermel LA, Ethier MC, Matlow A, Gillmeister B, Sung L. Defining bloodstream infections related to central venous catheters in patients with cancer: a systematic review. Clin Infect Dis 2011;53(7):697–710.

35. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



764 infection control and hospital epidemiology july 2014, vol. 35, no. 7

related infection: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49(1):1–45.

36. O’Grady NP, Alexander M, Dellinger EP, et al; Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. MMWR Recomm Rep 2002;51(RR-10):1–29.

37. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin In- fect Dis 2011;52(9):e162–e193.

38. Institute for Healthcare Improvement. http://www.ihi.org. March 11, 2014.

39. Saint S. Prevention of intravascular catheter-associated infections. In: Making Health Care Safer. Agency for Healthcare Research and Quality, 2001. http://www.ahrq.gov/clinic/ptsafety/, chap- ter 16. March 11, 2014.

40. Huang EY, Chen C, Abdullah F, et al. Strategies for the pre- vention of central venous catheter infections: an American Pe- diatric Surgical Association Outcomes and Clinical Trials Com- mittee systematic review. J Pediatr Surg 2011;46(10):2000–2011.

41. The Joint Commission. Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, A Global Perspective. Oakbrook Terrace, IL: The Joint Commission, 2012. http:// www.jointcommission.org/assets/1/18/CLABSI_Monograph .pdf. March 11, 2014.

42. Association for Professionals in Infection Control and Epide- miology (APIC). Guide to the Elimination of Catheter-Related Bloodstream Infections. Chicago: APIC, 2009.

43. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs 2011;S34.

44. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355(26):2725–2732.

45. Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32(10):2014–2020.

46. Reduction in central line–associated bloodstream infections among patients in intensive care units—Pennsylvania, April 2001–March 2005. MMWR Morb Mortal Wkly Rep 2005; 54(40):1013–1016.

47. Kim JS, Holtom P, Vigen C. Reduction of catheter-related bloodstream infections through the use of a central venous line bundle: epidemiologic and economic consequences. Am J Infect Control 2011;39(8):640–646.

48. Halton KA, Cook D, Paterson DL, Safdar N, Graves N. Cost- effectiveness of a central venous catheter care bundle. PLoS ONE 2010;5(9):e12815.

49. Helder O, van den Hoogen A, de Boer C, van Goudoever J, Verboon-Maciolek M, Kornelisse R. Effectiveness of non-phar- macological interventions for the prevention of bloodstream infections in infants admitted to a neonatal intensive care unit: a systematic review. Int J Nurs Stud 2013;50(6):819–831.

50. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reductions in catheter related bloodstream infections in Mich- igan intensive care units: observational study. BMJ 2010;340: c309.

51. Pronovost PJ, Berenholtz SM, Goeschel CA, et al. Creating high reliability in health care organizations. Health Serv Res 2006; 41(4 pt 2):1599–1617.

52. Furuya EY, Dick A, Perencevich EN, Pogorzelska M, Goldmann D, Stone PW. Central line bundle implementation in US in-

tensive care units and impact on bloodstream infections. PLoS ONE 2011;6(1):e15452.

53. Guerin K, Wagner J, Rains K, Bessesen M. Reduction in central line–associated bloodstream infections by implementation of a postinsertion care bundle. Am J Infect Control 2010;38(6): 430–433.

54. Miller MR, Griswold M, Harris JM 2nd, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 2010;125(2):206–213.

55. Miller MR, Niedner MF, Huskins WC, et al. Reducing PICU central line–associated bloodstream infections: 3-year results. Pediatrics 2011;128(5):e1077–e1083.

56. Sherertz RJ, Ely EW, Westbrook DM, et al. Education of phy- sicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132(8):641–648.

57. Eggimann P, Harbarth S, Constantin MN, Touveneau S, Chev- rolet JC, Pittet D. Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in in- tensive care. Lancet 2000;355(9218):1864–1868.

58. Coopersmith CM, Rebmann TL, Zack JE, et al. Effect of an education program on decreasing catheter-related bloodstream infections in the surgical intensive care unit. Crit Care Med 2002;30(1):59–64.

59. Warren DK, Zack JE, Cox MJ, Cohen MM, Fraser VJ. An educational intervention to prevent catheter-associated blood- stream infections in a nonteaching, community medical center. Crit Care Med 2003;31(7):1959–1963.

60. Warren DK, Zack JE, Mayfield JL, et al. The effect of an ed- ucation program on the incidence of central venous catheter– associated bloodstream infection in a medical ICU. Chest 2004; 126(5):1612–1618.

61. Lobo RD, Levin AS, Oliveira MS, et al. Evaluation of inter- ventions to reduce catheter-associated bloodstream infection: continuous tailored education versus one basic lecture. Am J Infect Control 2010;38(6):440–448.

62. Cherry MG, Brown JM, Neal T, Ben Shaw N. What features of educational interventions lead to competence in aseptic in- sertion and maintenance of CV catheters in acute care? BEME Guide 15. Med Teach 2010;32(3):198–218.

63. Joint Commission on Accreditation of Healthcare Organiza- tions. Assessing Hospital Staff Competence. Oakbrook Terrace, IL: Joint Commission Resources, 2007.

64. Barsuk JH, Cohen ER, Feinglass J, McGaghie WC, Wayne DB. Use of simulation-based education to reduce catheter-related bloodstream infections. Arch Intern Med 2009;169(15):1420– 1423.

65. Khouli H, Jahnes K, Shapiro J, et al. Performance of medical residents in sterile techniques during central vein catheteri- zation: randomized trial of efficacy of simulation-based train- ing. Chest 2011;139(1):80–87.

66. Ma IW, Brindle ME, Ronksley PE, Lorenzetti DL, Sauve RS, Ghali WA. Use of simulation-based education to improve out- comes of central venous catheterization: a systematic review and meta-analysis. Acad Med 2011;86(9):1137–1147.

67. Bleasdale SC, Trick WE, Gonzalez IM, Lyles RD, Hayden MK, Weinstein RA. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007;167(19):2073–2079.

68. O’Horo JC, Silva GL, Munoz-Price LS, Safdar N. The efficacy of daily bathing with chlorhexidine for reducing healthcare-

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



strategies to prevent clabsi: 2014 update 765

associated bloodstream infections: a meta-analysis. Infect Con- trol Hosp Epidemiol 2012;33(3):257–267.

69. Montecalvo MA, McKenna D, Yarrish R, et al. Chlorhexidine bathing to reduce central venous catheter–associated blood- stream infection: impact and sustainability. Am J Med 2012; 125(5):505–511.

70. Milstone AM, Elward A, Song X, et al. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a mul- ticentre, cluster-randomised, crossover trial. Lancet 2013; 381(9872):1099–1106.

71. Munoz-Price LS, Hota B, Stemer A, Weinstein RA. Prevention of bloodstream infections by use of daily chlorhexidine baths for patients at a long-term acute care hospital. Infect Control Hosp Epidemiol 2009;30(11):1031–1035.

72. Medina A, Serratt T, Pelter M, Brancamp T. Decreasing central line–associated bloodstream infections in the non-ICU pop- ulation. J Nurs Care Qual 2014;29(2):133–140.

73. Tamma PD, Aucott SW, Milstone AM. Chlorhexidine use in the neonatal intensive care unit: results from a national survey. Infect Control Hosp Epidemiol 2010;31(8):846–849.

74. Bryant KA, Zerr DM, Huskins WC, Milstone AM. The past, present, and future of healthcare-associated infection preven- tion in pediatrics: catheter-associated bloodstream infections. Infect Control Hosp Epidemiol 2010;31(suppl 1):S27–S31.

75. Chapman AK, Aucott SW, Milstone AM. Safety of chlorhex- idine gluconate used for skin antisepsis in the preterm infant. J Perinatol 2012;32(1):4–9.

76. Andersen C, Hart J, Vemgal P, Harrison C. Prospective eval- uation of a multi-factorial prevention strategy on the impact of nosocomial infection in very-low-birthweight infants. J Hosp Infect 2005;61(2):162–167.

77. Taylor T, Massaro A, Williams L, et al. Effect of a dedicated percutaneously inserted central catheter team on neonatal cath- eter-related bloodstream infection. Adv Neonatal Care 2011; 11(2):122–128.

78. Garland JS, Alex CP, Uhing MR, Peterside IE, Rentz A, Harris MC. Pilot trial to compare tolerance of chlorhexidine gluconate to povidone-iodine antisepsis for central venous catheter place- ment in neonates. J Perinatol 2009;29(12):808–813.

79. Curry S, Honeycutt M, Goins G, Gilliam C. Catheter-associated bloodstream infections in the NICU: getting to zero. Neonatal Netw 2009;28(3):151–155.

80. Garland JS, Alex CP, Mueller CD, et al. A randomized trial comparing povidone-iodine to a chlorhexidine gluconate- impregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics 2001;107(6):1431–1436.

81. Tsuchida T, Makimoto K, Toki M, Sakai K, Onaka E, Otani Y. The effectiveness of a nurse-initiated intervention to reduce catheter-associated bloodstream infections in an urban acute hospital: an intervention study with before and after compar- ison. Int J Nurs Stud 2007;44(8):1324–1333.

82. Gozu A, Clay C, Younus F. Hospital-wide reduction in central line–associated bloodstream infections: a tale of two small com- munity hospitals. Infect Control Hosp Epidemiol 2011;32(6): 619–622.

83. Occupational Health and Safety Administration, US Depart- ment of Labor. http://www.osha.gov. March 11, 2014.

84. Yilmaz G, Koksal I, Aydin K, Caylan R, Sucu N, Aksoy F. Risk factors of catheter-related bloodstream infections in parenteral

nutrition catheterization. JPEN J Parenter Enteral Nutr 2007; 31(4):284–287.

85. Boyce JM, Pittet D; Society for Healthcare Epidemiology of America, Association for Professionals in Infection Control, Infectious Diseases Society of America. Guideline for hand hy- giene in health-care settings: recommendations of the Health- care Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recomm Rep 2002;51(RR-16):1–45.

86. Rosenthal VD, Guzman S, Safdar N. Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. Am J Infect Control 2005;33(7):392–397.

87. Capretti MG, Sandri F, Tridapalli E, Galletti S, Petracci E, Fal- della G. Impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants. Am J Infect Control 2008;36(6):430–435.

88. Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of in- fection due to central venous catheters: effect of site of place- ment and catheter type. Infect Control Hosp Epidemiol 1998; 19(11):842–845.

89. Parienti JJ, du Cheyron D, Timsit JF, et al. Meta-analysis of subclavian insertion and nontunneled central venous catheter– associated infection risk reduction in critically ill adults. Crit Care Med 2012;40(5):1627–1634.

90. Ge X, Cavallazzi R, Li C, Pan SM, Wang YW, Wang FL. Central venous access sites for the prevention of venous thrombosis, stenosis and infection. Cochrane Database Syst Rev 2012;(3): CD004084.

91. Parienti JJ, Thirion M, Megarbane B, et al. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized con- trolled trial. JAMA 2008;299(20):2413–2422.

92. Timsit JF, Bouadma L, Mimoz O, et al. Jugular versus femoral short-term catheterization and risk of infection in intensive care unit patients: causal analysis of two randomized trials. Am J Respir Crit Care Med 2013;188(10):1232–1239.

93. de Jonge RC, Polderman KH, Gemke RJ. Central venous cath- eter use in the pediatric patient: mechanical and infectious complications. Pediatr Crit Care Med 2005;6(3):329–339.

94. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as com- pared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 2012;40(8):2479–2485.

95. Lorente L, Jimenez A, Roca I, Martin MM, Mora ML. Influence of tracheostomy on the incidence of catheter-related blood- stream infection in the catheterization of jugular vein by pos- terior access. Eur J Clin Microbiol Infect Dis 2011;30(9):1049– 1051.

96. Safdar N, Maki DG. Risk of catheter-related bloodstream in- fection with peripherally inserted central venous catheters used in hospitalized patients. Chest 2005;128(2):489–495.

97. Chopra V, Anand S, Krein SL, Chenoweth C, Saint S. Blood- stream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med 2012; 125(8):733–741.

98. Ajenjo MC, Morley JC, Russo AJ, et al. Peripherally inserted central venous catheter–associated bloodstream infections in

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



766 infection control and hospital epidemiology july 2014, vol. 35, no. 7

hospitalized adult patients. Infect Control Hosp Epidemiol 2011; 32(2):125–130.

99. Karakitsos D, Labropoulos N, De Groot E, et al. Real-time ultrasound-guided catheterisation of the internal jugular vein: a prospective comparison with the landmark technique in crit- ical care patients. Crit Care 2006;10(6):R162.

100. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327(7411):361.

101. Mermel LA, McCormick RD, Springman SR, Maki DG. The pathogenesis and epidemiology of catheter-related infection with pulmonary artery Swan-Ganz catheters: a prospective study utilizing molecular subtyping. Am J Med 1991;91(3B): 197S–205S.

102. Raad II, Hohn DC, Gilbreath BJ, et al. Prevention of central venous catheter–related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epi- demiol 1994;15(4 pt 1):231–238.

103. Hu KK, Lipsky BA, Veenstra DL, Saint S. Using maximal sterile barriers to prevent central venous catheter–related infection: a systematic evidence-based review. Am J Infect Control 2004; 32(3):142–146.

104. Young EM, Commiskey ML, Wilson SJ. Translating evidence into practice to prevent central venous catheter–associated bloodstream infections: a systems-based intervention. Am J In- fect Control 2006;34(8):503–506.

105. Ishikawa Y, Kiyama T, Haga Y, et al. Maximal sterile barrier precautions do not reduce catheter-related bloodstream infec- tions in general surgery units: a multi-institutional randomized controlled trial. Ann Surg 2010;251(4):620–623.

106. Burrell AR, McLaws ML, Murgo M, Calabria E, Pantle AC, Herkes R. Aseptic insertion of central venous lines to reduce bacteraemia. Med J Aust 2011;194(11):583–587.

107. Lee DH, Jung KY, Choi YH. Use of maximal sterile barrier precautions and/or antimicrobial-coated catheters to reduce the risk of central venous catheter–related bloodstream infec- tion. Infect Control Hosp Epidemiol 2008;29(10):947–950.

108. Maki DG, Ringer M, Alvarado CJ. Prospective randomised trial of povidone-iodine, alcohol, and chlorhexidine for prevention of infection associated with central venous and arterial cath- eters. Lancet 1991;338(8763):339–343.

109. Garland JS, Buck RK, Maloney P, et al. Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the pre- vention of peripheral intravenous catheter colonization in neo- nates: a prospective trial. Pediatr Infect Dis J 1995;14(6):510– 516.

110. Humar A, Ostromecki A, Direnfeld J, et al. Prospective ran- domized trial of 10% povidone-iodine versus 0.5% tincture of chlorhexidine as cutaneous antisepsis for prevention of central venous catheter infection. Clin Infect Dis 2000;31(4):1001– 1007.

111. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlor- hexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med 2002; 136(11):792–801.

112. Maiwald M, Chan ES. The forgotten role of alcohol: a system- atic review and meta-analysis of the clinical efficacy and per- ceived role of chlorhexidine in skin antisepsis. PLoS ONE 2012; 7(9):e44277.

113. Robert J, Fridkin SK, Blumberg HM, et al. The influence of

the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit. Infect Control Hosp Epidemiol 2000;21(1):12–17.

114. Stone PW, Mooney-Kane C, Larson EL, et al. Nurse working conditions and patient safety outcomes. Med Care 2007;45(6): 571–578.

115. Salzman MB, Isenberg HD, Rubin LG. Use of disinfectants to reduce microbial contamination of hubs of vascular catheters. J Clin Microbiol 1993;31(3):475–479.

116. Luebke MA, Arduino MJ, Duda DL, et al. Comparison of the microbial barrier properties of a needleless and a conventional needle-based intravenous access system. Am J Infect Control 1998;26(4):437–441.

117. Casey AL, Worthington T, Lambert PA, Quinn D, Faroqui MH, Elliott TS. A randomized, prospective clinical trial to assess the potential infection risk associated with the PosiFlow needleless connector. J Hosp Infect 2003;54(4):288–293.

118. Munoz-Price LS, Dezfulian C, Wyckoff M, et al. Effectiveness of stepwise interventions targeted to decrease central catheter– associated bloodstream infections. Crit Care Med 2012;40(5): 1464–1469.

119. Soothill JS, Bravery K, Ho A, Macqueen S, Collins J, Lock P. A fall in bloodstream infections followed a change to 2% chlor- hexidine in 70% isopropanol for catheter connection antisepsis: a pediatric single center before/after study on a hemopoietic stem cell transplant ward. Am J Infect Control 2009;37(8):626– 630.

120. Hong H, Morrow DF, Sandora TJ, Priebe GP. Disinfection of needleless connectors with chlorhexidine-alcohol provides long-lasting residual disinfectant activity. Am J Infect Control 2013;41(8):e77–e79.

121. Rupp ME, Yu S, Huerta T, et al. Adequate disinfection of a split-septum needleless intravascular connector with a 5- second alcohol scrub. Infect Control Hosp Epidemiol 2012;33(7): 661–665.

122. Simmons S, Bryson C, Porter S. “Scrub the hub”: cleaning duration and reduction in bacterial load on central venous catheters. Crit Care Nurs Q 2011;34(1):31–35.

123. Lederle FA, Parenti CM, Berskow LC, Ellingson KJ. The idle intravenous catheter. Ann Intern Med 1992;116(9):737–738.

124. Parenti CM, Lederle FA, Impola CL, Peterson LR. Reduction of unnecessary intravenous catheter use: internal medicine house staff participate in a successful quality improvement pro- ject. Arch Intern Med 1994;154(16):1829–1832.

125. Rotz S, Sopirala MM. Assessment beyond central line bundle: audits for line necessity in infected central lines in a surgical intensive care unit. Am J Infect Control 2012;40(1):88–89.

126. Cload B, Day AG, Ilan R. Evaluation of unnecessary central venous catheters in critically ill patients: a prospective obser- vational study. Can J Anaesth 2010;57(9):830–835.

127. Seguin P, Laviolle B, Isslame S, Coue A, Malledant Y. Effec- tiveness of simple daily sensitization of physicians to the du- ration of central venous and urinary tract catheterization. In- tensive Care Med 2010;36(7):1202–1206.

128. Faruqi A, Medefindt J, Dutta G, Philip SA, Tompkins D, Carey J. Effect of a multidisciplinary intervention on central line uti- lization in an acute care hospital. Am J Infect Control 2012; 40(6):e211–e215.

129. Maki DG, Stolz SS, Wheeler S, Mermel LA. A prospective, randomized trial of gauze and two polyurethane dressings for

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



strategies to prevent clabsi: 2014 update 767

site care of pulmonary artery catheters: implications for cath- eter management. Crit Care Med 1994;22(11):1729–1737.

130. Rasero L, Degl’Innocenti M, Mocali M. Comparison of two different time interval protocols for central venous catheter dressing in bone marrow transplant patients: results of a ran- domized, multicenter study. Haematologica 2000;85:275–279.

131. Timsit JF, Bouadma L, Ruckly S, et al. Dressing disruption is a major risk factor for catheter-related infections. Crit Care Med 2012;40(6):1707–1714.

132. Gillies D, O’Riordan L, Wallen M, Morrison A, Rankin K, Nagy S. Optimal timing for intravenous administration set replace- ment. Cochrane Database Syst Rev 2005;(4):CD003588.

133. Ullman AJ, Cooke ML, Gillies D, et al. Optimal timing for intravascular administration set replacement. Cochrane Data- base Syst Rev 2013;(9):CD003588.

134. Levin A, Mason AJ, Jindal KK, Fong IW, Goldstein MB. Pre- vention of hemodialysis subclavian vein catheter infections by topical povidone-iodine. Kidney Int 1991;40(5):934–938.

135. Zakrzewska-Bode A, Muytjens HL, Liem KD, Hoogkamp- Korstanje JA. Mupirocin resistance in coagulase-negative staphylococci, after topical prophylaxis for the reduction of colonization of central venous catheters. J Hosp Infect 1995; 31(3):189–193.

136. Riu S, Ruiz CG, Martinez-Vea A, Peralta C, Oliver JA. Spon- taneous rupture of polyurethane peritoneal catheter: a possible deleterious effect of mupirocin ointment. Nephrol Dial Trans- plant 1998;13(7):1870–1871.

137. Lok CE, Stanley KE, Hux JE, Richardson R, Tobe SW, Conly J. Hemodialysis infection prevention with polysporin ointment. J Am Soc Nephrol 2003;14(1):169–179.

138. Fong IW. Prevention of haemodialysis and peritoneal dialysis catheter related infection by topical povidone-iodine. Postgrad Med J 1993;69(suppl 3):S15–S17.

139. Battistella M, Bhola C, Lok CE. Long-term follow-up of the Hemodialysis Infection Prevention with Polysporin Ointment (HIPPO) Study: a quality improvement report. Am J Kidney Dis 2011;57(3):432–441.

140. James MT, Conley J, Tonelli M, Manns BJ, MacRae J, Hem- melgarn BR. Meta-analysis: antibiotics for prophylaxis against hemodialysis catheter-related infections. Ann Intern Med 2008; 148(8):596–605.

141. Gastmeier P, Geffers C, Brandt C, et al. Effectiveness of a na- tionwide nosocomial infection surveillance system for reducing nosocomial infections. J Hosp Infect 2006;64(1):16–22.

142. Zingg W, Sax H, Inan C, et al. Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected. J Hosp Infect 2009;73(1):41–46.

143. National Healthcare Safety Network, Department of Health and Human Services, Centers for Disease Control and Prevention. Surveillance for central line–associated bloodstream infections (CLABSI). http://www.cdc.gov/nhsn/acute-care-hospital/clabsi /index.html. March 11, 2014.

144. Edwards JR, Peterson KD, Andrus ML, et al. National Health- care Safety Network (NHSN) Report, data summary for 2006, issued June 2007. Am J Infect Control 2007;35(5):290–301.

145. Woeltje KF, McMullen KM, Butler AM, Goris AJ, Doherty JA. Electronic surveillance for healthcare-associated central line– associated bloodstream infections outside the intensive care unit. Infect Control Hosp Epidemiol 2011;32(11):1086–1090.

146. Maki DG, Stolz SM, Wheeler S, Mermel LA. Prevention of

central venous catheter–related bloodstream infection by use of an antiseptic-impregnated catheter: a randomized, con- trolled trial. Ann Intern Med 1997;127(4):257–266.

147. Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy of antiseptic-impregnated central venous catheters in prevent- ing catheter-related bloodstream infection: a meta-analysis. JAMA 1999;281(3):261–267.

148. Darouiche RO, Raad II, Heard SO, et al; Catheter Study Group. A comparison of two antimicrobial-impregnated central ve- nous catheters. N Engl J Med 1999;340(1):1–8.

149. Hanna HA, Raad II, Hackett B, et al. Antibiotic-impregnated catheters associated with significant decrease in nosocomial and multidrug-resistant bacteremias in critically ill patients. Chest 2003;124(3):1030–1038.

150. McConnell SA, Gubbins PO, Anaissie EJ. Do antimicrobial- impregnated central venous catheters prevent catheter-related bloodstream infection? Clin Infect Dis 2003;37(1):65–72.

151. Rupp ME, Lisco SJ, Lipsett PA, et al. Effect of a second-gen- eration venous catheter impregnated with chlorhexidine and silver sulfadiazine on central catheter–related infections: a ran- domized, controlled trial. Ann Intern Med 2005;143(8):570– 580.

152. Wang H, Huang T, Jing J, et al. Effectiveness of different central venous catheters for catheter-related infections: a network meta-analysis. J Hosp Infect 2010;76(1):1–11.

153. Cherry-Bukowiec JR, Denchev K, Dickinson S, et al. Prevention of catheter-related blood stream infection: back to basics? Surg Infect (Larchmt) 2011;12(1):27–32.

154. Guleri A, Kumar A, Morgan RJ, Hartley M, Roberts DH. Anaphylaxis to chlorhexidine-coated central venous catheters: a case series and review of the literature. Surg Infect (Larchmt) 2012;13(3):171–174.

155. Levy I, Katz J, Solter E, et al. Chlorhexidine-impregnated dress- ing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study. Pediatr Infect Dis J 2005;24(8):676–679.

156. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and in- fection: a meta-analysis. J Antimicrob Chemother 2006;58(2): 281–287.

157. Timsit JF, Schwebel C, Bouadma L, et al. Chlorhexidine- impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults: a randomized controlled trial. JAMA 2009;301(12):1231–1241.

158. Ruschulte H, Franke M, Gastmeier P, et al. Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Ann Hematol 2009;88(3):267–272.

159. Camins BC, Richmond AM, Dyer KL, et al. A crossover in- tervention trial evaluating the efficacy of a chlorhexidine- impregnated sponge in reducing catheter-related bloodstream infections among patients undergoing hemodialysis. Infect Control Hosp Epidemiol 2010;31(11):1118–1123.

160. Timsit JF, Mimoz O, Mourvillier B, et al. Randomized con- trolled trial of chlorhexidine dressing and highly adhesive dress- ing for preventing catheter-related infections in critically ill adults. Am J Respir Crit Care Med 2012;186(12):1272–1278.

161. Menyhay SZ, Maki DG. Preventing central venous catheter– associated bloodstream infections: development of an antisep-

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



768 infection control and hospital epidemiology july 2014, vol. 35, no. 7

tic barrier cap for needleless connectors. Am J Infect Control 2008;36(10):S174e1–S174e5.

162. Oto J, Imanaka H, Konno M, Nakataki E, Nishimura M. A prospective clinical trial on prevention of catheter contami- nation using the hub protection cap for needleless injection device. Am J Infect Control 2011;39(4):309–313.

163. 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 blood- stream infections and contamination of blood cultures in an inpatient oncology unit. Am J Infect Control 2012;40(10):931– 934.

164. Wright MO, Tropp J, Schora DM, et al. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. Am J Infect Control 2013;41(1):33–38.

165. Loftus RW, Brindeiro BS, Kispert DP, et al. Reduction in in- traoperative bacterial contamination of peripheral intravenous tubing through the use of a passive catheter care system. Anesth Analg 2012;115(6):1315–1323.

166. Bertini G, Elia S, Ceciarini F, Dani C. Reduction of catheter- related bloodstream infections in preterm infants by the use of catheters with the AgION antimicrobial system. Early Hum Dev 2013;89(1):21–25.

167. Chelliah A, Heydon KH, Zaoutis TE, et al. Observational trial of antibiotic-coated central venous catheters in critically ill pediatric patients. Pediatr Infect Dis J 2007;26(9):816–820.

168. Bhutta A, Gilliam C, Honeycutt M, et al. Reduction of blood- stream infections associated with catheters in paediatric inten- sive care unit: stepwise approach. BMJ 2007;334(7589):362– 365.

169. Weber JM, Sheridan RL, Fagan S, Ryan CM, Pasternack MS, Tompkins RG. Incidence of catheter-associated bloodstream infection after introduction of minocycline and rifampin an- timicrobial-coated catheters in a pediatric burn population. J Burn Care Res 2012;33(4):539–543.

170. Carratala J, Niubo J, Fernandez-Sevilla A, et al. Randomized, double-blind trial of an antibiotic-lock technique for preven- tion of gram-positive central venous catheter–related infection in neutropenic patients with cancer. Antimicrob Agents Che- mother 1999;43(9):2200–2204.

171. Henrickson KJ, Axtell RA, Hoover SM, et al. Prevention of central venous catheter–related infections and thrombotic events in immunocompromised children by the use of van- comycin/ciprofloxacin/heparin flush solution: a randomized, multicenter, double-blind trial. J Clin Oncol 2000;18(6):1269– 1278.

172. Safdar N, Maki DG. Use of vancomycin-containing lock or flush solutions for prevention of bloodstream infection asso- ciated with central venous access devices: a meta-analysis of prospective, randomized trials. Clin Infect Dis 2006;43(4):474– 484.

173. Labriola L, Crott R, Jadoul M. Preventing haemodialysis cath- eter-related bacteraemia with an antimicrobial lock solution: a meta-analysis of prospective randomized trials. Nephrol Dial Transplant 2008;23(5):1666–1672.

174. Snaterse M, Ruger W, Scholte Op Reimer WJ, Lucas C. An- tibiotic-based catheter lock solutions for prevention of cath- eter-related bloodstream infection: a systematic review of ran- domised controlled trials. J Hosp Infect 2010;75(1):1–11.

175. 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):318–329.

176. Yahav D, Rozen-Zvi B, Gafter-Gvili A, Leibovici L, Gafter U, Paul M. Antimicrobial lock solutions for the prevention of infections associated with intravascular catheters in patients undergoing hemodialysis: systematic review and meta-analysis of randomized, controlled trials. Clin Infect Dis 2008;47(1):83– 93.

177. Opilla MT, Kirby DF, Edmond MB. Use of ethanol lock therapy to reduce the incidence of catheter-related bloodstream infec- tions in home parenteral nutrition patients. JPEN J Parenter Enteral Nutr 2007;31(4):302–305.

178. Slobbe L, Doorduijn JK, Lugtenburg PJ, et al. Prevention of catheter-related bacteremia with a daily ethanol lock in patients with tunnelled catheters: a randomized, placebo-controlled trial. PLoS ONE 2010;5(5):e10840.

179. Cober MP, Kovacevich DS, Teitelbaum DH. Ethanol-lock ther- apy for the prevention of central venous access device infections in pediatric patients with intestinal failure. JPEN J Parenter Enteral Nutr 2011;35(1):67–73.

180. Heng AE, Abdelkader MH, Diaconita M, et al. Impact of short term use of interdialytic 60% ethanol lock solution on tunneled silicone catheter dysfunction. Clin Nephrol 2011;75(6):534–541.

181. Hemmelgarn BR, Moist LM, Lok CE, et al. Prevention of di- alysis catheter malfunction with recombinant tissue plasmin- ogen activator. N Engl J Med 2011;364(4):303–312.

182. McKee R, Dunsmuir R, Whitby M, Garden OJ. Does antibiotic prophylaxis at the time of catheter insertion reduce the inci- dence of catheter-related sepsis in intravenous nutrition? J Hosp Infect 1985;6(4):419–425.

183. Ranson MR, Oppenheim BA, Jackson A, Kamthan AG, Scarffe JH. Double-blind placebo controlled study of vancomycin pro- phylaxis for central venous catheter insertion in cancer patients. J Hosp Infect 1990;15(1):95–102.

184. Sandoe JA, Kumar B, Stoddart B, et al. Effect of extended perioperative antibiotic prophylaxis on intravascular catheter colonization and infection in cardiothoracic surgery patients. J Antimicrob Chemother 2003;52(5):877–879.

185. van de Wetering MD, van Woensel JB, Kremer LC, Caron HN. Prophylactic antibiotics for preventing early gram-positive cen- tral venous catheter infections in oncology patients: a Cochrane systematic review. Cancer Treat Rev 2005;31(3):186–196.

186. Karanlik H, Kurul S, Saip P, et al. The role of antibiotic pro- phylaxis in totally implantable venous access device placement: results of a single-center prospective randomized trial. Am J Surg 2011;202(1):10–15.

187. Eyer S, Brummitt C, Crossley K, Siegel R, Cerra F. Catheter- related sepsis: prospective, randomized study of three methods of long-term catheter maintenance. Crit Care Med 1990;18(10): 1073–1079.

188. Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992;327(15):1062–1068.

189. Cook D, Randolph A, Kernerman P, et al. Central venous cath- eter replacement strategies: a systematic review of the literature. Crit Care Med 1997;25(8):1417–1424.

190. Maragakis LL, Bradley KL, Song X, et al. Increased catheter- related bloodstream infection rates after the introduction of a new mechanical valve intravenous access port. Infect Control Hosp Epidemiol 2006;27(1):67–70.

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



strategies to prevent clabsi: 2014 update 769

191. Field K, McFarlane C, Cheng AC, et al. Incidence of catheter- related bloodstream infection among patients with a needleless, mechanical valve–based intravenous connector in an Austra- lian hematology-oncology unit. Infect Control Hosp Epidemiol 2007;28(5):610–613.

192. Salgado CD, Chinnes L, Paczesny TH, Cantey JR. Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hospital. Infect Control Hosp Epidemiol 2007;28(6):684– 688.

193. Rupp ME, Sholtz LA, Jourdan DR, et al. Outbreak of blood- stream infection temporally associated with the use of an in- travascular needleless valve. Clin Infect Dis 2007;44(11):1408– 1414.

194. Jarvis WR, Murphy C, Hall KK, et al. Health care–associated bloodstream infections associated with negative- or positive- pressure or displacement mechanical valve needleless con- nectors. Clin Infect Dis 2009;49(12):1821–1827.

195. Miller JM, Goetz AM, Squier C, Muder RR. Reduction in nos- ocomial intravenous device-related bacteremias after institu- tion of an intravenous therapy team. J Intraven Nurs 1996; 19(2):103–106.

196. Soifer NE, Borzak S, Edlin BR, Weinstein RA. Prevention of peripheral venous catheter complications with an intravenous therapy team: a randomized controlled trial. Arch Intern Med 1998;158(5):473–477.

197. Koh DB, Gowardman JR, Rickard CM, Robertson IK, Brown A. Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous cath- eters. Crit Care Med 2008;36(2):397–402.

198. Lucet JC, Bouadma L, Zahar JR, et al. Infectious risk associated with arterial catheters compared with central venous catheters. Crit Care Med 2010;38(4):1030–1035.

199. Tokars JI, Klevens RM, Edwards JR, Horan TC. Measurement of the impact of risk adjustment for central line–days on in- terpretation of central line–associated bloodstream infection rates. Infect Control Hosp Epidemiol 2007;28(9):1025–1029.

200. Klevens RM, Tokars JI, Edwards J, Horan T. Sampling for collection of central line–day denominators in surveillance of healthcare-associated bloodstream infections. Infect Control Hosp Epidemiol 2006;27(4):338–342.

201. Thompson ND, Edwards JR, Bamberg W, et al. Evaluating the accuracy of sampling to estimate central line–days: simplifi- cation of the National Healthcare Safety Network surveillance methods. Infect Control Hosp Epidemiol 2013;34(3):221–228.

202. Casey AL, Karpanen TJ, Nightingale P, Cook M, Elliott TS. Microbiological comparison of a silver-coated and a non- coated needleless intravascular connector in clinical use. J Hosp Infect 2012;80(4):299–303.

203. Webster J, Gillies D, O’Riordan E, Sherriff KL, Rickard CM. Gauze and tape and transparent polyurethane dressings for central venous catheters. Cochrane Database Syst Rev 2011;(11): CD003827.

204. Batra R, Cooper BS, Whiteley C, Patel AK, Wyncoll D, Edge- worth JD. Efficacy and limitation of a chlorhexidine-based de- colonization strategy in preventing transmission of methicillin- resistant Staphylococcus aureus in an intensive care unit. Clin Infect Dis 2010;50(2):210–217.

205. Bizzarro MJ, Sabo B, Noonan M, Bonfiglio MP, Northrup V, Diefenbach K. A quality improvement initiative to reduce cen-

tral line–associated bloodstream infections in a neonatal in- tensive care unit. Infect Control Hosp Epidemiol 2010;31(3):241– 248.

206. Sawyer M, Weeks K, Goeschel CA, et al. Using evidence, rig- orous measurement, and collaboration to eliminate central catheter–associated bloodstream infections. Crit Care Med 2010;38(suppl 8):S292–S298.

207. Widmer AF, Nettleman M, Flint K, Wenzel RP. The clinical impact of culturing central venous catheters: a prospective study. Arch Intern Med 1992;152(6):1299–1302.

208. Raad II, Baba M, Bodey GP. Diagnosis of catheter-related in- fections: the role of surveillance and targeted quantitative skin cultures. Clin Infect Dis 1995;20(3):593–597.

209. Pittet D, Wenzel RP. Nosocomial bloodstream infections: sec- ular trends in rates, mortality, and contribution to total hospital deaths. Arch Intern Med 1995;155(11):1177–1184.

210. Wong ES, Rupp ME, Mermel L, et al. Public disclosure of healthcare-associated infections: the role of the Society for Healthcare Epidemiology of America. Infect Control Hosp Ep- idemiol 2005;26(2):210–212.

211. Aswani MS, Reagan J, Jin L, Pronovost PJ, Goeschel C. Vari- ation in public reporting of central line–associated bloodstream infections by state. Am J Med Qual 2011;26(5):387–395.

212. Talbot TR, Bratzler DW, Carrico RM, et al. Public reporting of health care–associated surveillance data: recommendations from the Healthcare Infection Control Practices Advisory Committee. Ann Intern Med 2013;159(9):631–635.

213. Healthcare-Associated Infection Working Group of the Joint Public Policy Committee. Essentials of Public Reporting of Health- care-Associated Infections: A Tool Kit. 2007. http://www.shea -online.org/Assets/files/Essentials_of_Public_Reporting_Tool _Kit.pdf. March 11, 2014.

214. National Quality Forum (NQF). National Voluntary Consensus Standards for the Reporting of Healthcare-Associated Infection Data. Washington, DC: NQF, 2008. http://www.qualityforum .org/Publications/2008/03/National_Voluntary_Consensus _Standards_for_the_Reporting_of_Healthcare-Associated _Infection_Data.aspx. March 11, 2014.

215. Weaver SJ, Lubomksi LH, Wilson RF, Pfoh ER, Martinez KA, Dy SM. Promoting a culture of safety as a patient safety strat- egy: a systematic review. Ann Intern Med 2013;158(5 pt 2):369– 374.

216. Hatler CW, Mast D, Corderella J, et al. Using evidence and process improvement strategies to enhance healthcare out- comes for the critically ill: a pilot project. Am J Crit Care 2006; 15(6):549–555.

217. On the CUSP: Stop BSI CLABSI Toolkit. http://www .onthecuspstophai.org/on-the-cuspstop-bsi/toolkits-and -resources/.

218. Tools for Reducing Line Associated Blood Stream Infections. http://www.ahrq.gov/professionals/education/curriculum -tools/clabsitools/index.html.

219. Silow-Carrol S, Edwards JN. Eliminating Central Line Infections and Spreading Success at High-Performing Hospitals. New York: Commonwealth Fund, 2011.

220. Huang GC, Newman LR, Schwartzstein RM, et al. Procedural competence in internal medicine residents: validity of a central venous catheter insertion assessment instrument. Acad Med 2009;84(8):1127–1134.

221. Safdar N, Abad C. Educational interventions for prevention of

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



770 infection control and hospital epidemiology july 2014, vol. 35, no. 7

healthcare-associated infection: a systematic review. Crit Care Med 2008;36(3):933–940.

222. Smith JS, Kirksey KM, Becker H, Brown A. Autonomy and self-efficacy as influencing factors in nurses’ behavioral inten- tion to disinfect needleless intravenous systems. J Infus Nurs 2011;34(3):193–200.

223. Faruqi A, Medefindt J, Dutta G, Philip SA, Tompkins D, Carey J. Effect of a multidisciplinary intervention on central line uti- lization in an acute care hospital. Am J Infect Control 2012; 40(6):e211–e215.

224. Warren D, Zack J, Mayfield J, et al. The effect of an education program on the incidence of central venous catheter–associated bloodstream infection in a medical ICU. Chest 2004;126(5): 1612–1618.

225. Warren DK, Yokoe DS, Climo MW, et al. Preventing catheter- associated bloodstream infections: a survey of policies for in- sertion and care of central venous catheters from hospitals in the Prevention Epicenter Program. Infect Control Hosp Epi- demiol 2006;27(1):8–13.

226. Chittick P, Sherertz RJ. Recognition and prevention of noso- comial vascular device and related bloodstream infections in the intensive care unit. Crit Care Med 2010;38(suppl 8):S363– S372.

227. Moureau N, Lamperti M, Kelly LJ, et al. Evidence-based con- sensus on the insertion of central venous access devices: def- inition of minimal requirements for training. Br J Anaesth 2013; 110(3):347–356.

228. Warren DK, Cosgrove SE, Diekema DJ, et al. A multicenter intervention to prevent catheter-associated bloodstream infec- tions. Infect Control Hosp Epidemiol 2006;27(7):662–669.

229. Sannoh S, Clones B, Munoz J, Montecalvo M, Parvez B. A multimodal approach to central venous catheter hub care can decrease catheter-related bloodstream infection. Am J Infect Control 2010;38(6):424–429.

230. Banks CM, Gilmartin H, Fink RM. Education methods for maintaining nursing competency in low-volume, high-risk procedures in the rural setting: bridging the theory to practice gap. J Nurses Staff Dev 2010;26(3):E1–E7.

231. Comer A, Harris AD, Shardell MP, et al. Web-based training improves knowledge about central line bloodstream infections. Infect Control Hosp Epidemiol 2011;32(12):1219–1222.

232. Guembe M, Pérez-Parra A, Gómez E, et al. Impact on knowl- edge and practice of an intervention to control catheter infec- tion in the ICU. Eur J Clin Microbiol Infect Dis 2012;31(10): 2799–2808.

233. Zack J. Zeroing in on zero tolerance for central line–associated bacteremia. Am J Infect Control 2008;36(10):S176.e1.

234. Aboelela SW, Stone PW, Larson EL. Effectiveness of bundled behavioural interventions to control healthcare-associated in- fections: a systematic review of the literature. J Hosp Infect 2007; 66(2):101–108.

235. Sherertz R, Ely E, Westbrook D, et al. Education of physicians- in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132(8):641–648.

236. Walz JM, Memtsoudis SG, Heard SO. Analytic reviews: pre- vention of central venous catheter bloodstream infections. J Intensive Care Med 2010;25(3):131–138.

237. Rodriguez-Paz JM, Kennedy M, Salas E, et al. Beyond “see one, do one, teach one”: toward a different training paradigm. Qual Saf Health Care 2009;18(1):63–68.

238. Ahya SN, Barsuk JH, Cohen ER, Tuazon J, McGaghie WC, Wayne DB. Clinical performance and skill retention after sim- ulation-based education for nephrology fellows. Semin Dial 2012;25(4):470–473.

239. Ault MJ, Rosen BT, Ault B. The use of tissue models for vascular access training: phase I of the procedural patient safety initia- tive. J Gen Intern Med 2006;21(5):514–517.

240. Evans LV, Dodge KL. Simulation and patient safety: evaluative checklists for central venous catheter insertion. Qual Saf Health Care 2010;19(suppl 3):i42–i46.

241. Ahlin C, Klang-Söderkvist B, Brundin S, Hellström B, Pet- tersson K, Johansson E. Implementation of a written protocol for management of central venous access devices: a theoretical and practical education, including bedside examinations. J Infus Nurs 2006;29(5):253–259.

242. Segreti J, Garcia-Houchins S, Gorski L, et al. Consensus con- ference on prevention of central line–associated bloodstream infections: 2009. J Infus Nurs 2011;34(2):126–133.

243. Labeau S, Vereecke A, Vandijck DM, Claes B, Blot SI. Critical care nurses’ knowledge of evidence-based guidelines for pre- venting infections associated with central venous catheters: an evaluation questionnaire. Am J Crit Care 2008;17(1):65–71.

244. Labeau SO, Vandijck DM, Rello J, et al. Centers for Disease Control and Prevention guidelines for preventing central ve- nous catheter–related infection: results of a knowledge test among 3405 European intensive care nurses. Crit Care Med 2009;37(1):320–323.

245. Marra AR, Cal RG, Durao MS, et al. Impact of a program to prevent central line–associated bloodstream infection in the zero tolerance era. Am J Infect Control 2010;38(6):434–439.

246. Wheeler DS, Giaccone MJ, Hutchinson N, et al. A hospital- wide quality-improvement collaborative to reduce catheter- associated bloodstream infections. Pediatrics 2011;128(4):e995– e1004.

247. Harting BP, Talbot TR, Dellit TH, et al. University Health- System Consortium quality performance benchmarking study of the insertion and care of central venous catheters. Infect Control Hosp Epidemiol 2008;29(5):440–442.

248. Jeffries HE, Mason W, Brewer M, et al. Prevention of central venous catheter–associated bloodstream infections in pediatric intensive care units: a performance improvement collaborative. Infect Control Hosp Epidemiol 2009;30(7):645–651.

249. Stevens TP, Schulman J. Evidence-based approach to prevent- ing central line–associated bloodstream infection in the NICU. Acta Paediatr Suppl 2012;101(464):11–16.

250. Powers RJ, Wirtschafter DW. Decreasing central line associated bloodstream infection in neonatal intensive care. Clin Perinatol 2010;37(1):247–272.

251. Rupp ME, Cassling K, Faber H, et al. Hospital-wide assessment of compliance with central venous catheter dressing recom- mendations. Am J Infect Control 2013;41(1):89–91.

252. O’Grady N, Alexander M, Burns L, Dellinger E. Guideline for the Prevention of Intravascular Catheter-Related Infections, 2011. Atlanta: Centers for Disease Control and Prevention, 2011. http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html. Ac- cessed April 1, 2011.

253. Son CH, Daniels TL, Eagan J, et al. Central line–associated bloodstream infection surveillance outside the intensive care unit: a multicenter survey. Infect Control Hosp Epidemiol 2012; 33(9):869–874.

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions



strategies to prevent clabsi: 2014 update 771

254. Woeltje KF, McMullen KM, Butler AM, Goris AJ, Doherty JA. Electronic surveillance for healthcare-associated central line– associated bloodstream infections outside the intensive care unit. Infect Control Hosp Epidemiol 2011;32(11):1086–1090.

255. Berhe M, Edmond MB, Bearman G. Measurement and feed- back of infection control process measures in the intensive care unit: impact on compliance. Am J Infect Control 2006;34(8): 537–539.

256. Assanasen S, Edmond M, Bearman G. Impact of 2 different

levels of performance feedback on compliance with infection control process measures in 2 intensive care units. Am J Infect Control 2008;36(6):407–413.

257. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of rec- ommendations. BMJ 2008;336(7650):924–926.

258. GRADE. Canadian Task Force on Preventive Health Care web- site. http://canadiantaskforce.ca/methods/grade/. Accessed De- cember 31, 2013.

This content downloaded from on Sat, 8 Nov 2014 13:40:56 PM All use subject to JSTOR Terms and Conditions


  • Washington University School of Medicine
  • Digital Commons@Becker
    • 2014
  • Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update
    • Jonas Marschall
    • Leonard A. Mermel
    • Mohamed Fakih
    • Lynn Hadaway
    • Alexander Kallen
      • See next page for additional authors
      • Recommended Citation
      • Authors
  • Strategies to Prevent Central Line–Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

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