Infectious Disease · Topic 5 of 10

Central Line–Associated Bloodstream Infection

Infectious disease · device-associated infection

Central Line–Associated Bloodstream Infection

A bloodstream infection with a central line in place: paired cultures before antibiotics, vancomycin, and pull the line for S. aureus, gram-negatives or Candida.

Key numbers

Line in place > 2 calendar days> 2 calendar days

Catheter culture positive ≥ 2 h earlierDTP ≥ 2 h

01 · What it isLine in place > 2 calendar days

CLABSI (NHSN) = laboratory-confirmed bloodstream infection, not secondary to another site, with an eligible central line in place > 2 consecutive calendar days and still present on the event date or the day before.

02 · Defined byCatheter culture positive ≥ 2 h earlier

Before antibiotics, draw paired blood cultures from the catheter and a peripheral vein. Catheter blood turning positive at least 2 hours earlier (differential time to positivity), or a ≥ 3-fold higher colony count, defines CRBSI.

03 · DoRemove the line: S. aureus, gram-negatives, Candida

Remove a short-term central catheter for CRBSI due to S. aureus, gram-negative bacilli, enterococci, fungi or mycobacteria; S. aureus and Candida require removal of any catheter.

Do right now

In this order

First moves

Catheter culture positive ≥ 2 h earlierDTP ≥ 2 h

→

Empiric vancomycin, plus gram-negative coverage if septic

→

Remove the line: S. aureus, gram-negatives, Candida

Why each step

Catheter culture positive ≥ 2 h earlierBefore antibiotics, draw paired blood cultures from the catheter and a peripheral vein. Catheter blood turning positive at least 2 hours earlier (differential time to positivity), or a ≥ 3-fold higher colony count, defines CRBSI.

Empiric vancomycin, plus gram-negative coverage if septicStart empiric vancomycin where MRSA is prevalent; add gram-negative coverage for critical illness, sepsis, neutropenia or a femoral catheter, choosing agents by local susceptibility data.

Remove the line: S. aureus, gram-negatives, CandidaRemove a short-term central catheter for CRBSI due to S. aureus, gram-negative bacilli, enterococci, fungi or mycobacteria; S. aureus and Candida require removal of any catheter.

Management

Orders

Insertion bundle: sterile barriers and chlorhexidine must knowInsert every CVC with hand hygiene, maximal sterile barriers (cap, mask, sterile gown and gloves, full-body drape), alcoholic chlorhexidine skin prep allowed to dry, ultrasound guidance and a checklist observer.

Prefer the subclavian site in the ICUIn the ICU, the subclavian vein is the preferred CVC site to reduce infection; avoid it in patients who need or may need hemodialysis (stenosis risk), and in emergencies the fastest site wins.

Review need daily; remove nonessential linesAssess the need for every central line daily on rounds and remove catheters that are no longer required; do not replace CVCs or arterial lines on a routine schedule.

Scrub the hub for at least 5 secondsBefore every access, scrub catheter hubs, needleless connectors and ports with alcoholic chlorhexidine (preferred) or 70% alcohol using friction for at least 5 seconds.

Daily chlorhexidine bathing and CHG dressings in ICUBathe ICU patients older than 2 months with chlorhexidine daily and use chlorhexidine-containing dressings on CVCs; change transparent dressings at least every 7 days and gauze every 2 days, or sooner if soiled or loose.

Candida on a line: echinocandin and removalSuspect catheter-related candidemia with parenteral nutrition, prolonged broad-spectrum antibiotics or hematologic malignancy: give an echinocandin, remove the catheter and continue 14 days after documented clearance.

Remove any line for these complicationsRemove even a long-term catheter for severe sepsis, suppurative thrombophlebitis, endocarditis, bacteremia persisting beyond 72 hours of active therapy, or infection with S. aureus, P. aeruginosa, fungi or mycobacteria.

Salvage long-term lines with antibiotic lockWhen a long-term catheter is kept in uncomplicated CRBSI, add antibiotic lock therapy to systemic antibiotics for 10–14 days — never lock therapy alone — and repeat blood cultures to confirm clearance.

Red flags & don'ts

Avoid harm

No antibiotic prophylaxis for central lines avoidDo not give systemic antimicrobial prophylaxis for catheter insertion or while a catheter is in place, and do not use PICCs as a CLABSI-prevention strategy — their infection risk approaches that of other CVCs.

The rules

Know these

Coagulase-negative staph: 5–7 days after removalUncomplicated coagulase-negative staphylococcal CRBSI: treat 5–7 days if the catheter is removed, or 10–14 days with antibiotic lock therapy if it is retained.

S. aureus CRBSI: remove, treat ≥ 14 daysS. aureus CRBSI: remove a short-term catheter immediately and treat at least 14 days after documented clearance, longer when a deep focus or endocarditis is found (see S. aureus bacteremia).

CLABSI or CRBSI?

Commonly confused

Used for	Surveillance and public reporting
Line requirement	Eligible line in place > 2 consecutive calendar days, present on the event date or the day before
Proof the line is the source	Not required — only that the BSI is not secondary to another site
Skin commensals	Same commensal in ≥ 2 separate blood specimens plus fever, chills or hypotension

More detail

Reference

Show 7 reference facts

Persistent fungemia or bacteremia after catheter removal (especially with endocarditis or suppurative thrombophlebitis) needs 4–6 weeks of therapy; uncomplicated enterococcal or gram-negative CRBSI usually needs 7–14 days.

Do not culture catheter tips routinely; culture the tip only when a catheter is removed for suspected CRBSI. Growth of > 15 CFU from a 5-cm tip segment by roll-plate culture means colonization.

CLABSI risk factors: long hospital stay before insertion, long catheter dwell, heavy skin or hub colonization, multilumen or multiple catheters, neutropenia, BMI > 40, parenteral nutrition and excessive catheter manipulation.

CLABSI is a surveillance definition used for benchmarking and public reporting; CRBSI is the clinical diagnosis that the catheter is the source, which depends on paired cultures, catheter removal and tip culture.

NHSN counts a skin commensal (eg, coagulase-negative staphylococci) only when the same organism grows from 2 or more blood specimens collected on separate occasions, plus fever > 38.0 °C, chills or hypotension.

Administration sets not used for blood, blood products or lipids may be changed at intervals up to 7 days; the 2022 SHEA update lengthened the earlier 4-day limit.

When CLABSI rates stay high despite essential practices, add antiseptic- or antimicrobial-impregnated catheters, preventive antimicrobial locks for long-term catheters with recurrent CLABSI, or an infusion team.

Pearl

The best line is no line: insert it with a full sterile bundle, scrub the hub every time, and ask every day whether it can come out.

Sources · Mermel LA et al. Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection: 2009 Update by the IDSA. Clin Infect Dis 2009;49:1–45 · Buetti N et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update (SHEA/IDSA/APIC Compendium). Infect Control Hosp Epidemiol 2022;43:553–569 · CDC NHSN Patient Safety Component Manual, Chapter 4: Bloodstream Infection Event (CLABSI and non-central line BSI), January 2026 · Merck Manual Professional — Candidiasis (invasive) · IDSA/ESCMID 2026 Consensus Statements on Staphylococcus aureus Bacteremia (published Sept 9, 2026) · O'Grady NP et al. CDC/HICPAC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 (> 0.5% chlorhexidine with alcohol) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).