Application of the
• Estimated 250,000
cases occur annually
• Mortality rate of 12%
to 25% for each
• Marginal cost to
hospital can be as
high as $25,000 per
Surveillance for Hospital-
• Surveillance is employed in
• Comparison of hospital-
acquired infections rates is
made possible through
various national surveillance
networks that allow
surveillance findings to be
used for quality
• Largest database in US:
National Healthcare Safety
• Four major risk factors are
associated with increased catheter-
related infection rates:
– Cutaneous colonization of the
– Moisture under the dressing
– Prolonged catheter time
– Technique of care and placement of
the central line
Selected to Reduce CLA-BSIs
1. Central line-associated bloodstream
2. Hand hygiene
3. Maximal sterile barriers
4. Chlorhexidine for skin asepsis
5. Avoid femoral lines
6. Avoid/remove unnecessary lines
• Cornerstone of any infection
• Many studies have shown
that improvement in hand
decreases a variety of
• Insufficient or ineffective hand
significantly to a greater
bacterial burden and
subsequent spread of
microorganisms within the
• Use of waterless alcohol-
base hand rub
– Most effective and efficient
method for hand antisepsis
against bacterial pathogens
• When hands are visibly
soiled, they should be
washed with soap and
Efficacy of Hand Hygiene
Preparations in Killing
Good Better Best
Plain Soap Antimicrobial Alcohol-based
prompts to remind
hygiene resulted in
Swoboda SM, Earsing K, Strauss K, et al. Electronic
monitoring and voice prompts improve hand hygiene and
decreased nosocomial infections in an intermediate care
unit. Crit Care Med. 2004;32:358–363.
Maximal Sterile Barriers
• Maximal sterile barriers
improve sterile technique
during catheter insertion
• The person inserting the
central line wears a head
cap, face mask, sterile body
gown, and sterile gloves, and
uses a full size drape to
cover the patient from head
Maximal Sterile Barriers
• One study found a 6-fold
higher rate of catheter-
related septicemia when
minimal sterile barriers
(sterile gloves and small
drape) were used instead
of maximal sterile barriers
Raad II, Hohn H, Gilbreath J, et al. Prevention of central venous
catheter-related infections by using maximal sterile barrier precautions
during insertion. Infect Control Hosp Epidemiol. 1994;15:231–238.
Chlorhexidine for Skin
• Studies have compared chlorhexidine
gluconate (CHG) versus povidone iodine
as a skin antiseptic for catheter insertion
and routine insertion site care
– Recent meta-analysis, the use of CHG rather
than povidone iodine was found to reduce
the risk of CLA-BSIs by approximately 50%
in hospitalized patients who required short
Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine
compared with povidone-iodine solution for vascular catheter-site care: a
meta-analysis. Ann Intern Med. 2002;136:792–801.
Benefits of CHG
• 2% CHG in tincture of isopropyl alcohol
has rapid bactericidal activity and is
effective within 30 seconds after
application versus 2-minute period for
• CHG provides persistent bactericidal
activity on the skin and maintains its
activity in the presence of other organic
• Minimal systemic absorption
How to Use CHG
• Back and forth, up and down motion
• Motion promotes penetration of the
cleanser within multiple layers of the
• Clear solution
• Orange tinted solution now available
Site Selection: Avoid Femoral
• Insertion of CVCs can lead to serious
and sometimes life-threatening
complications, whether of mechanical,
infectious, or thrombotic origin
• Higher rate of infectious complications in
study comparing femoral lines versus
– 19.8% vs 4.5%
Avoid and Remove
• Once placed, there should be
periodic, if not daily assessment, of
its continued need, with emphasis
on prompt removal
Empowerment of Nursing
• One of the most important steps in
preventing CLA-BSIs is to empower
the nursing staff to stop the central
line insertion procedure if the
guidelines were not followed
Line Care and Tubing
• A transparent, semi permeable polyurethane
dressing has many advantages over gauze but
both have shown no difference in infection rates
as long as they are used appropriately
• Benefits of a transparent dressing
– Ability to evaluate the insertion site while the dressing
is in place
– Wicking of moisture away from the skin
– Less frequent dressing changes compared with
standard gauze and tape dressings
• CDC guidelines recommend routine
changing of transparent dressing every 7
days and whenever either dressing is
soiled or nonadherent
• Antibiotic ointment at the catheter
insertion site should be avoided, as it
promotes fungal infections and antibiotic
• Study at UVA in 2005
Sorbaview is more
adherent, used less
nursing time, and
was better liked by
patients than either
tape and gauze
• Current CDC recommendation is to
replace intravenous administration
sets, including secondary sets and
add-on devices, no more frequently
than a 72 hour interval, unless
catheter-related infectious is
suspected or documented
• Prevention of
infection is the
foundation of any
• CLA-BSIs are one of
the most prevalent
• Centers for Disease Control and Prevention. Guidelines for the
prevention of intravascular catheter-related infections. MMWR
Morb Mortal Wkly Rep. 2002;51(RR- 10):3–36.
• Pittet D, Tarara D, Wenzel RP. Healthcare acquired bloodstream
infection in critically ill patients: excess length of stay, extra costs,
and attributable mortality. JAMA. 1994;271:1598–1601.
• Goeschal CA, Bourgault A, Palleschi M, et al. Developing and
implementing an innovative approach to patient safety: nursing
lessons from the MHA keystone ICU project. Crit Care Clin N Am.
• Lee TB, Baker OG, Lee JT, Scheckler WE, Steele L, Laxton CE.
Recommended practices for surveillance. Association for
Professionals in Infection Control and Epidemiology, Inc.
Surveillance Initiative Working Group. Am J Infect Control.
• National Nosocomial Infections Surveillance (NNIS) system
report: data summary from January 1992–June 2004, issued
October 2004. Am J of Infect Control. 2004; 32:470–485.
• Mermel LA. Prevention of intravascular catheter-related
infections. Ann Intern Med. 2000;132:391–402.
• Institute for Health Care Improvement. Saving 100,000 Lives
Campaign. Available at: http://www.ihi.org/IHI/
Programs/Campaign/. Accessed June 30, 2006.
• Larson E. Skin hygiene and infection prevention: more of the
same or different approaches? Clin Infect Dis. 1999;29:1287–
• Kent KH, Lipsky BA, Veenstra DL, Saint S. Using maximal
sterile barriers to prevent central venous catheterrelated
infections: a systematic evidence-based review. Am J Infect
• American Association of Critical Care Nurses practice alert:
preventing catheter related bloodstream infections. 2005.
Available at: http://www.aacn.org/AACN/practiceAlert
.nsf/vwdoc/PracticeAlertMain. Accessed June 30, 2006.
• Centers for Disease Control and Prevention. Guideline for hand
hygiene in health-care settings: recommendations of the
Healthcare Infection Control Practices Advisory Committee and
the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
MMWR Morb Mortal Wkly Rep. 2002;51(RR-16):1–56.
• Larson EL, Bryan JL, Adler LM, Blane C. A multi-faceted
approach to changing hand washing behavior. Am J Infect
• Pittet D, Dharan S, Touveneau S. Bacterial contamination of the
hands of hospital staff during routine patient care. Arch Intern
• Swoboda SM, Earsing K, Strauss K, et al. Electronic monitoring
and voice prompts improve hand hygiene and decreased
nosocomial infections in an intermediate care unit. Crit Care
• Arroliga AC, Budev MM, Gordon SM. Do as we say, not as we
do: healthcare workers and hand hygiene. Crit Care Med.
• Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S.
Chlorhexidine compared with povidone-iodine solution for
vascular catheter-site care: a meta-analysis. Ann Intern Med.
• Merrer J, DeJonghe B, Golliot F, et al. Complications of femoral
and subclavian venous catheterization in critically ill patients: a
randomized controlled trial. JAMA. 2001;286:700–707.
• Gillies D, O’Riordan L, Carr D, Frost J, Gunning R, O’Brien I.
Gauze and tape and transparent polyurethane dressings for
central venous catheters. Cochrane Database Syst Rev.
• 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.
• Gillies D, O’Riordan L, Wallen M, Rankin K, Morrison A, Nagy S.
Timing of intravenous administration set changes: a systemic
review. Infect Control Hosp Epidemiol. 2004;25(3):240–250.
• Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy
of antiseptic-impregnated central venous catheters in
preventing catheter-related bloodstream infection: a meta-
analysis. JAMA. 1999;281:261–267.
• Bassetti S, Hu J, D’Agostino RB Jr, Sherertz RJ. Prolonged
antimicrobial activity of a catheter containing chlorhexidine-
silver sulfadiazine extends protection against catheter infections
in vivo. Antimicrob Agents Chemother. 2001;45:1535–1538.
• Veenstra DL, Saint S, Sullivan SD. Cost-effectiveness of
antiseptic-impregnated central venous catheters for the
prevention of catheter related bloodstream infection. JAMA.
• Eggimann P, Harbarth S, Constantin MN, et al. Impact of a
prevention strategy targeted at vascular-access care on the
incidence of infections acquired in intensive care. Lancet.
• Sherertz RJ, Wesley E, Westbrook DM, et al. Education of
physicians-in-training can decrease the risk for vascular
catheter infection. Ann Intern Med. 2000;132:641–648.
• Anderson RN, Smith BL. Deaths: leading causes for 2002. Natl
Vital Stat Rep. 2005;53(17):1–90.