CLABSI Prevention Framework: Complete Evidence-Based Reference for Clinical Teams

Central line-associated bloodstream infection (CLABSI) is one of the most preventable and most costly healthcare-associated infections. The evidence that CLABSIs are preventable — not merely reducible — was established by the Keystone ICU project, in which 103 Michigan ICUs reduced median CLABSI rates to zero within 18 months using a structured bundle approach. This framework consolidates the evidence base for CLABSI prevention into a clinical reference spanning definitions, epidemiology, the complete insertion and maintenance bundles, advanced prevention strategies, and implementation science.

Section 1: Definitions and Surveillance

CLABSI vs CRBSI

CLABSI (Central Line-Associated Bloodstream Infection): A surveillance definition used by NHSN for public reporting, regulatory compliance, and benchmarking. CLABSI is defined as a primary bloodstream infection (no other identified source) in a patient who had a central line present at the time of blood culture collection or within 48 hours before.

CRBSI (Catheter-Related Bloodstream Infection): A clinical diagnosis requiring more rigorous microbiologic criteria — paired quantitative blood cultures (catheter hub vs peripheral vein) or differential time-to-positivity (DTP) data confirming the catheter as the source. CRBSI rates are consistently lower than CLABSI rates at the same facility because NHSN CLABSI criteria are more inclusive.

Clinical implication: CLABSI is what you report to regulatory agencies and use for benchmarking. CRBSI is what your clinicians diagnose and treat. Both matter; they measure different things.

NHSN CLABSI Criteria (LCBI)

NHSN defines CLABSI as meeting one of three Laboratory Confirmed Bloodstream Infection (LCBI) criteria:

• LCBI 1: Recognized pathogen (e.g., S. aureus, gram-negative bacilli) cultured from ≥1 blood culture, and the organism is not related to an infection at another site
• LCBI 2: Common commensal (e.g., S. epidermidis, diphtheroids) cultured from ≥2 blood cultures drawn on separate occasions, patient has ≥1 sign/symptom (fever, chills, hypotension), and organism not related to infection at another site
• LCBI 3: Same as LCBI 2 but applies to patients ≤1 year with additional age-appropriate sign/symptom criteria

Central line definition (NHSN): An intravascular catheter that terminates at or close to the heart or in one of the great vessels — includes: PICC, CVC, tunneled CVC, implanted port (when accessed), hemodialysis catheter, umbilical catheters in neonates. Does NOT include: midline catheters, peripheral IVs.

Surveillance Metrics

Section 2: Epidemiology and Pathogenesis

Scope of the Problem

• US incidence: 30,000–41,000 CLABSIs per year (NHSN 2020 estimates)
• Attributable mortality: 12–25% of CLABSI patients die as a direct result of the infection
• Cost per event: $46,000–$68,000 (Pronovost 2011); adjusted for inflation, current estimates $55,000–$90,000
• Regulatory status: CLABSI is a Medicare non-reimbursable Hospital-Acquired Condition (HAC); hospitals bear full treatment cost

Pathogenesis Routes

1. Extraluminal route (most common for short-dwell CVCs): Skin organisms at the insertion site migrate along the outer catheter surface to the tip. Primary prevention: skin antisepsis + sterile insertion + CHG dressings
2. Intraluminal route (most common for long-dwell CVCs): Contamination at the catheter hub or connector during manipulation; organisms track along the inner lumen to the tip. Primary prevention: scrub-the-hub + passive disinfection caps + minimizing access events
3. Hematogenous seeding (uncommon): Organisms from a remote infection site deposit on the catheter fibrin sheath or thrombus. Prevention: treat remote infections; remove catheters when CLABSI risk is high

Common Pathogens

Section 3: The CLABSI Insertion Bundle

The CLABSI insertion bundle contains 5 elements, all of which must be completed for each CVC/PICC insertion:

Element 1: Hand Hygiene

Requirement: Perform WHO-compliant hand hygiene (alcohol hand rub or surgical hand scrub) immediately before donning sterile gloves. Hand hygiene after removing contaminated gloves before sterile gloving is essential.

Evidence: Hand hygiene reduces transient skin flora that is the most common source of insertion-site contamination.

Element 2: Maximum Sterile Barrier Precautions (MSB)

Requirement:

• Inserter: sterile gown, sterile gloves, mask, surgical cap
• Patient: full-body sterile drape from head to feet
• All personnel in the room during insertion: mask and cap

Evidence: Mermel et al. (1991) landmark study: MSB reduced CRBSI rates 6-fold compared to “mini-drape” technique.

Element 3: Chlorhexidine Gluconate (CHG) Skin Antisepsis

Requirement:

• Use 2% CHG in 70% isopropyl alcohol (CHG/IPA)
• Apply with back-and-forth scrubbing friction for ≥30 seconds
• Allow to fully dry before needle puncture (≥30 seconds on dry skin; up to 2 minutes on moist skin)

Evidence: Chaiyakunapruk (2002) meta-analysis: CHG reduces CRBSI risk by 49% vs povidone-iodine (RR 0.51, 95% CI 0.27–0.97).

Do not blot, fan, or wave to hasten drying — the drying process is part of the antimicrobial action.

Element 4: Optimal Site Selection

Priority for CLABSI prevention:

1. Subclavian vein (lowest CLABSI rate, but highest pneumothorax risk)
2. Internal jugular (moderate CLABSI risk)
3. Femoral vein (highest CLABSI rate — avoid when possible)

PICC vs non-tunneled CVC: For patients who are not critically ill, PICC has lower CLABSI risk than IJ or femoral CVC and should be strongly considered as an alternative to bedside CVC insertion.

Special populations:

• ESRD/CKD patients: avoid subclavian (central venous stenosis) → use IJ
• Coagulopathic patients: IJ preferred (compressible site)
• Burn patients at insertion sites: consult specialized burn/surgery team

Element 5: Daily Necessity Review

Requirement: Document daily assessment of whether each central line remains clinically necessary.

Evidence: Every unnecessary catheter-day represents cumulative CLABSI risk without clinical benefit. The Keystone bundle’s daily-removal component was among the most impactful elements in Michigan ICU CLABSI reduction.

Documentation: Must be specific — “PICC still needed for IV vancomycin, expected course 14 days, Day 5” is meaningful. “Still needed” is not sufficient documentation.

Section 4: The CLABSI Maintenance Bundle

The maintenance bundle protects the CVAD from intraluminal and hub-origin contamination during dwell.

Element 1: Scrub the Hub

Requirement: Before every access of a needleless connector or catheter hub, scrub the access surface with 70% isopropyl alcohol or CHG/IPA for 15 seconds of friction, followed by 15–30 seconds of drying time.

Evidence: Studies demonstrate median observed hub scrub time of <7 seconds in clinical practice — far below the evidence-supported 15 seconds. Proper scrub time is the most common maintenance bundle failure point.

Implementation tip: Count aloud or use a timer. “Wipe once and insert” is not hub decontamination.

Element 2: CHG-Impregnated Dressings

Requirement: Use CHG-impregnated disc (e.g., Biopatch, placed blue side toward skin) or CHG-impregnated transparent semipermeable dressing for all CVADs.

Evidence:

• Timsit et al. (2009, Lancet): CHG dressings reduced CRBSI by 60% vs standard transparent dressings (RR 0.40, 95% CI 0.18–0.89) — a landmark RCT
• PROTECT trial (2012): Confirmed CRBSI reduction with CHG disc at CVC sites

Replacement interval: CHG dressings follow the standard dressing change schedule (every 7 days for intact transparent dressings; every 2 days for gauze; immediately if soiled, wet, or lifted at edges).

Contraindication: Avoid CHG dressings in neonates <7 days old or <26 weeks gestational age due to skin absorption and systemic toxicity risk.

Element 3: Daily CHG Bathing

Requirement: Bathe ICU patients daily with 2% CHG cloths (or equivalent).

Evidence:

• Climo et al. (2013, NEJM): Daily CHG bathing reduced CLABSI by 28% (relative risk 0.72) and MRSA acquisition by 37% in a multicenter RCT
• Bleasdale et al. (2007): Additional ICU study confirming 32% CLABSI reduction with daily CHG bathing

Application: CHG bathing cloths cover all body surfaces except face, eyes, and mucous membranes. Do not rinse off after application — CHG provides residual antimicrobial activity that is eliminated by rinsing.

Element 4: Needleless Connector Management

Requirement:

• Use split-septum connectors (preferred) — lower CLABSI association than mechanical valve connectors
• Scrub before every access (see Element 1)
• Change connectors every 96 hours with administration set changes; change immediately if visibly contaminated or compromised
• Avoid positive-pressure mechanical valve connectors (PPMCs) — associated with CLABSI outbreaks in multiple investigations

Passive disinfection caps: Alcohol-impregnated passive disinfection caps (Curos, SwabCap) placed on connector between access events provide ongoing 70% IPA disinfection. INS 2021 Category IB recommendation for reducing intraluminal CLABSI risk.

Element 5: Administration Set Change Intervals

Section 5: Advanced Prevention Strategies

Antimicrobial Catheters

Two main types, used when standard bundle is not achieving target CLABSI rates:

CHG-silver sulfadiazine (CHG/SS) catheters: External surface impregnation; effective primarily against extraluminal organisms; generally limited to first 7–14 days.

Minocycline-rifampin (M/R) catheters: Internal and external surface impregnation; Darouiche (1999, NEJM) RCT demonstrated reduction from 3.4 to 0.3 CLABSI per 1,000 catheter-days (p<0.001). Superior to CHG/SS in head-to-head comparison.

When to use antimicrobial catheters (CDC category IB recommendation): Patients expected to have CVC for >5 days in settings where bundle-compliant CLABSI rate remains >2 per 1,000 catheter-days despite adherence to standard bundle.

Antimicrobial Lock Therapy (ALT)

ALT instills antimicrobial or antiseptic solutions into the catheter lumen to dwell between access events. Strategies:

• Ethanol 70% lock: Broad-spectrum, no resistance risk, effective against biofilm; used for long-term catheter salvage and prevention
• Taurolidine-citrate: Approved in Europe; antimicrobial and anti-biofilm; strong evidence for hemodialysis catheter CLABSI prevention
• Antibiotic locks (vancomycin, gentamicin-citrate): IDSA/CDC caution against routine use due to resistance promotion; appropriate in selected high-risk or recurrent CLABSI cases
• Citrate 4%: Anticoagulant with some antimicrobial properties; alternative to heparin lock in hemodialysis catheters

Section 6: CLABSI Zero Implementation Framework

The path from “reduced CLABSI” to “zero CLABSI” requires more than protocol implementation — it requires a culture shift in which every CLABSI is treated as a preventable harm, investigated individually, and used to drive improvement.

Infrastructure Requirements

1. Real-time surveillance: Infection control nurses reviewing blood culture results daily; CLABSI events identified within 24–48 hours of culture positivity
2. Individual case review: Every CLABSI is reviewed for root-cause analysis — what went wrong, when, and what can prevent the next one
3. Bundle compliance tracking: Real-time (not retrospective) tracking of insertion and maintenance bundle completion; deviations are investigated
4. Empowerment to stop unsafe procedures: Any team member can call a “time-out” if insertion is proceeding without proper sterile precautions — leadership must establish this culture

The Daily CLABSI Prevention Huddle

In high-performing ICUs, a brief (10-minute) daily safety huddle addresses:

• Are there any patients with fever or suspected CLABSI today?
• Which catheters are no longer needed and should be removed today?
• Were any insertions yesterday not fully bundle-compliant?

This daily habit keeps CLABSI prevention active rather than episodic.

Summary Reference: CLABSI Prevention at a Glance

Related Resources

Clinical guides:

• CLABSI Definition and Epidemiology
• CLABSI Insertion Bundle
• CLABSI Maintenance Bundle
• Chlorhexidine Gluconate for CLABSI Prevention
• Antimicrobial Catheters and Dressings
• Needleless Connector CLABSI Prevention

Related resources:

• VAD Competency and Credentialing Checklist
• Vascular Access Safety Report

References

1. Pronovost P, et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med, 355(26):2725–2732.
2. O’Grady NP, et al. (2011). CDC Guidelines for Prevention of Intravascular Catheter-Related Infections. MMWR, 60(RR-1).
3. Gorski LA, et al. (2021). INS Infusion Therapy Standards of Practice. J Infus Nurs, 44(Suppl 1).
4. Timsit JF, et al. (2009). Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related infections in critically ill adults. Lancet, 373(9665):694–702.
5. Climo MW, et al. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med, 368(6):533–542.
6. Chaiyakunapruk N, et al. (2002). Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med, 136(11):792–801.
7. Darouiche RO, et al. (1999). A comparison of two antimicrobial-impregnated central venous catheters. N Engl J Med, 340(1):1–8.