Introduction

Central venous catheters or central lines (defined as a vascular infusion device that terminates at or close to the heart or in one of the great vessels^[1]) are used in inpatient and outpatient clinical settings to provide long-term venous access for patients with a wide variety of illnesses and conditions. The following are considered great vessels: aorta, pulmonary artery, superior vena cava, inferior vena cava, brachiocepahic veins, internal jugular veins, subclavian veins, external iliac veins, common femoral veins. A catheter introducer is considered an intravascular catheter and the umbilical artery in a neonate is considered a great vessel. Pacemaker wires are not considered central lines; they are not used to infuse or withdraw fluids.

Approximately 48% of patients in intensive care units (ICUs) have a central line, accounting for 15 million central line-days per year.^[2,3] Central lines disrupt the integrity of the skin, making patients vulnerable to bacterial and fungal infections, including central line-associated bloodstream infections (CLABSI). The Centers for Disease Control and Prevention (CDC) defines CLABSI as an infection in a patient who had a central line in place within the 48-hour period before the onset of infection.^[4]

An estimated 250,000 to 500,000 CLABSI occur in US hospitals each year.^[1] CLABSI are an important cause of morbidity and excess cost of care for hospitalized patients. Studies of CLABSI that control for the underlying severity of illness suggest that the attributable mortality rate is 4% to 20%.^[3,5] Put another way, an estimated 500 to 4000 patients die annually from CLABSI in the United States, and the reported range for patient care cost attributed to CLABSI is $3700 to $29,000 per episode.^[3,6]

The high incidence of CLABSI, the associated morbidity and mortality, our increasing understanding of pathogenesis and prevention strategies, and a growing unwillingness of payers, patient advocates, and patients to accept healthcare-associated infections (HAIs) as a risk of hospitalization, have led to a culture of "zero-tolerance" -- setting the goal for HAI rates at 0, treating every infection as if it should never happen, and holding everyone accountable -- for HAIs, particularly CLABSI, which are increasingly viewed as preventable or "never" events.

Clinical practice guidelines that provide recommendations for preventing and detecting HAIs^[7] and CLABSI have been published and widely disseminated.^[5,8] This review summarizes the existing guidelines and other literature, with an emphasis on measures that have been shown to be most successful and provide the greatest yield for prevention of infections.