Pathogenesis continued...


Intravascular catheters have become indispensable in medical practice, particularly in critical care units (ICUs).  Although such catheters provide necessary vascular access, their use may put patients at risk for local and systemic infections.  Healthcare institutions purchase millions of intravascular catheters each year.  The incidence of catheter-related bloodstream infection (CRBSI) varies considerably by type of catheter, frequency of catheter manipulation, and patient-related factors (e.g., underlying disease and acuity of illness).


Incidence of infection in ICU is often higher than in the less acute inpatient or ambulatory settings where catheters are not as likely to become colonized with hospital-acquired organisms. In the ICU, CVCs are manipulated multiple times per day for the administration of fluids, drugs, and blood products and are accessed multiple times per day for hemodynamic measurements or to obtain samples for laboratory analysis.


CRBSI can be explained in relation to its sources:


  • Patient’s skin at procedure site; inadequate skin preparation before procedure.
  • Lack of sterile technique and appropriate procedure draping (healthcare worker).
  • Contamination of the catheter hub (other sources in the environment).
  • Hematogenous colonization of the catheter from an infection from somewhere else in the body.
  • Contaminated infusate (not common today) in healthcare.




Prevention of CRBSI is mulifactorial(1) and requires attention to details. Effort should be multidisciplinary and should not only involve healthcare professionals who insert and maintain intravascular catheters but also healthcare managers who allocate resources and patients who are capable of assisting in the care of their catheters.  Although several individual strategies have been studied and shown to be effective in reducing CRBSI, studies using multiple strategies have not been conducted.  Thus, it is not known whether implementing multiple strategies will have an additive effect in reducing CRBSI, but it is logical to use multiple strategies concomitantly.


The IHI (Institute for Healthcare Improvement) implemented the “5 Million Lives Campaign” as an initiative to engage U.S. hospitals in a commitment to implement changes in care proven to improve patient care and prevent avoidable deaths and has used this strategy to save patient lives.  One specific example was the Central Line Bundle.


The Central Line Bundle is a group of evidence-based interventions for patients with intravascular central catheters that, when implemented together, result in better outcomes than when implemented individually.


The key components of the Central Line Bundle are:

  • Hand hygiene
  • Maximal barrier precautions upon insertion

  • Chlorhexidine skin antisepsis
  • Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters

  • Daily review of line necessity with prompt removal of unnecessary lines


Healthcare worker education and training is another important factor in decreasing the risk of catheter-related infection.  Education of physicians is of utmost importance in decreasing the risk for catheter-related bloodstream infections.(2)




When prevention doesn’t work and a CRBSI occurs, appropriate intervention is of utmost importance.  See the following links on intervention:




(1) Gastmeier P., Geffers C. Prevention of catheter-related bloodstream infections: analysis of studies published between 2002 and 2005. J Hosp Infect. 2006;64:326–35.


(2) Sherertz R.J., Ely E.W., Westbrook D.M., Gledhill K.S., Streed S.A., Kiger B., Flynn L., Hayes S., Strong S., Cruz J., Bowton D.L., Hulgan T., Haponik E.F. Education of physicians-in-training can decrease the risk for vascular catheter infection. Ann Intern Med 2000;132:641–648.



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