CLABSI Maintenance Bundle: Post-Insertion Central Line Infection Prevention

The central line maintenance bundle addresses the ongoing infection risks present throughout a catheter’s dwell — intraluminal contamination at hubs and connectors, extraluminal contamination at the insertion site, and prolonged unnecessary dwell. Studies analyzing CLABSI events consistently find that failures of maintenance practice, not insertion technique, are responsible for the majority of late-onset CLABSIs (those occurring >3 days after insertion).

Every nurse caring for a patient with a central line is a CLABSI prevention practitioner.

Parent guide: CLABSI Prevention: Complete Clinical Reference

The Core Maintenance Bundle Elements

1. Scrub-the-Hub (Hub Decontamination)

Standard: Before every access of a needleless connector or catheter hub, vigorously scrub the connector surface with a 70% isopropyl alcohol (IPA) pad for a minimum of 15 seconds using friction, then allow 15–30 seconds to air dry.

Why it matters: The needleless connector/hub is the most frequent intraluminal contamination point during catheter dwell. Even brief contact with unsterile hands, surfaces, or inadequately scrubbed connectors introduces organisms into the catheter lumen. Once inside, organisms establish a biofilm within hours. Studies show that clinicians routinely fail to scrub for the required duration — median scrub time in observational studies is <7 seconds.

The technique:

Hold the connector steady with one hand
Apply friction with IPA pad in a circular motion, covering the entire connector surface and threads
15 seconds minimum — time yourself; it is longer than most clinicians intuitively perform
Let air dry (the evaporating alcohol kills residual organisms on the connector surface)
Access immediately after dry — do not set down the connector between scrubbing and access

Passive disinfection caps: Alcohol-impregnated caps (Curos, SwabCap, etc.) that sit on the needleless connector between uses provide continuous alcohol exposure and reduce hub contamination. Evidence supports their use as an add-on to scrub-the-hub practice; they do not replace active scrub at the time of access.

2. CHG-Impregnated Dressings

Standard: Apply a CHG-impregnated gel patch (Biopatch equivalent) or CHG-impregnated sponge at the CVAD insertion site, covered by a transparent semi-permeable membrane (TSM) dressing.

Evidence: Multiple RCTs and meta-analyses support CHG-impregnated dressings as a significant CLABSI reduction intervention. Timsit et al. (2009, Lancet) found that CHG dressings reduced catheter-related infections by 60% compared to standard TSM alone. Current CDC 2011 guidelines and INS 2021 recommend CHG dressings for CVADs in adults (Category IB recommendation).

Mechanism: CHG binds to skin proteins and provides sustained bactericidal activity for 7+ days. The CHG concentration at the insertion site — the primary entry point for extraluminal infection — remains sufficient to prevent skin organism migration along the catheter throughout the dressing change interval.

Change interval: Every 5–7 days with routine TSM dressing change, or immediately if dressing is wet, soiled, loose, or non-intact.

Contraindications/cautions:

Neonates <7 days of age or <26 weeks gestation: CHG-impregnated products not recommended (skin permeability risk)
Patients with CHG allergy: use standard TSM dressing; consider alternative antiseptic approaches
Monitor for MARSI (medical adhesive-related skin injury) at each dressing change; consider alternative products if contact dermatitis develops

3. CHG Daily Bathing

Standard: Bathe patients with chlorhexidine gluconate (CHG) washcloths daily (2% CHG-impregnated cloths) in ICU settings and in non-ICU patients with CVADs.

Evidence: Multiple large RCTs demonstrate that daily CHG bathing reduces CLABSI rates by 30–50% in ICU patients:

Bleasdale et al. (2007): 46% reduction in CLABSI with daily CHG bathing
Climo et al. (2013, NEJM): 28% CLABSI reduction; also reduced MRSA and VRE acquisition

Mechanism: Whole-body CHG bathing reduces the skin bioburden that is the source of extraluminal catheter contamination. Even though the CHG dressing protects the insertion site directly, reducing overall skin flora density provides additive protection.

Application: 2% CHG-impregnated cloths used in place of standard soap-and-water bathing. Allow CHG to air dry on skin after application; do not rinse (rinsing removes the protective CHG residual). Avoid mucous membranes, eyes, and genitalia. Apply to body, including arms bearing CVADs.

Current status: CDC 2011 guidelines did not explicitly recommend daily CHG bathing (evidence was not yet available at publication). The 2023 CDC update acknowledges stronger evidence supporting CHG bathing for ICU patients with CVADs. INS 2021 recommends CHG bathing for adult patients with CVADs (Standard 43).

4. Needleless Connector Management

Standard: Change needleless connectors (NLC) per institutional protocol (typically every 96 hours with administration set changes, or immediately if contaminated, removed, or integrity compromised). Use positive displacement or neutral displacement connectors per institutional formulary.

Evidence: The type of needleless connector influences CLABSI risk. Positive-pressure mechanical valve connectors (PPMC) were associated with CLABSI outbreaks in several studies due to their complex internal mechanisms that are difficult to disinfect. Neutral displacement or simple connectors are generally preferred. Current guidance (Buetti et al., SHEA/IDSA 2022) recommends using connectors that have been independently tested for clinical performance and that have simple internal mechanisms.

Change schedule: Per INS 2021 Standard 37:

Change with each administration set change (every 96 hours for continuous infusions)
Do NOT change connectors more frequently than every 72–96 hours without clinical indication — excessive changes increase manipulation events and infection risk
Change immediately if: blood is visible in the connector, connector is cracked or damaged, contamination is suspected

Do not soak connectors in antiseptic solution — this does not sterilize the internal connector pathway and may compromise connector integrity.

5. Administration Set Change Intervals

Standard per INS 2021 Standard 37:

Infusate	Change Interval
Continuous infusions (non-lipid, non-blood)	Every 96 hours
Intermittent infusions	Per institutional policy; maximum 24 hours
Lipid-containing PN (3-in-1/TNA)	Every 24 hours
Lipid emulsion alone	Every 12 hours
Blood and blood products	Within 4 hours of transfusion completion (one set per unit maximum)
Propofol infusions	Every 12 hours (or per drug product labeling)

Label all administration sets with the date and time of initiation. Change sets when the label indicates they are due; do not extend change intervals.

Why 96 hours (not 72 or 48)? Earlier guidelines required 48-hour set changes. RCTs demonstrated no infection benefit from more frequent changes; extending to 96 hours reduces manipulation events (each tubing change is an opportunity for hub contamination) and nursing workload without increasing infection risk.

Daily Necessity Review

Standard: Daily review and documentation that each CVAD is still clinically indicated. Remove the device as soon as it is no longer required.

See Element 5 of the insertion bundle for full documentation requirements. In the maintenance context, the importance of daily necessity review is:

The majority of CLABSI events occur after day 7 of catheter dwell
Each additional catheter-day is an additional infection risk day
Removing unnecessary CVADs on the day clinical indication ends is the most direct way to reduce CLABSI

Implementation: EHR-based prompts at nursing handoff, physician rounding algorithms, VAT daily rounds, and nurse-driven removal protocols (allowing nursing to remove peripheral IVs without physician order) have each been associated with reduced unnecessary catheter-days.

Beyond the Core Bundle: Supplemental Interventions

For units with persistent CLABSI rates despite full bundle implementation, supplemental interventions (CDC “enhanced” recommendations) include:

Antimicrobial/antiseptic-impregnated catheters: Catheters impregnated with CHG-silver sulfadiazine (external surface) or minocycline-rifampin (internal and external surface) reduce CLABSI in high-rate settings. Consider when rates remain >2 per 1,000 catheter-days despite full bundle compliance.

Antimicrobial lock therapy (ALT): Antimicrobial lock solutions (ethanol, taurolidine, antibiotic locks) instilled into catheter lumens between uses reduce intraluminal infection for high-risk patients (long-term home TPN, hemodialysis catheters). Not routine practice; used in specific high-risk populations.

Passive disinfection caps: Alcohol-impregnated connector caps (Curos, SwabCap) reduce hub contamination and have been associated with CLABSI reduction in several studies. Relatively low-cost add-on to standard scrub-the-hub practice.

Bundle Compliance Auditing

Maintenance bundle compliance requires ongoing audit:

What to audit:

Dressing integrity at daily assessment (dry, occlusive, intact)
CHG gel patch present at insertion site
Scrub-the-hub observed during medication administration
Connector caps on unused lumens
Necessity documentation present in nursing note

How to audit: Direct observation (most accurate), chart review for documentation elements, targeted surveillance during nursing rounds. Audit results should be reported to nursing staff and unit leadership for feedback and improvement.

Related guides:

Related policies:

References

O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).
Buetti N, et al. (2022). Strategies to prevent CLABSI in acute care hospitals: 2022 update. Infect Control Hosp Epidemiol, 43(5):553–569.
Timsit JF, et al. (2009). CHG-impregnated sponge and risk of central venous catheter infection. Lancet, 373(9677):1709–1718.
Climo MW, et al. (2013). Effect of daily CHG bathing on hospital-acquired infection. N Engl J Med, 368(6):533–542.
Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice. J Infus Nurs, 44(Suppl 1).