Zero risk for central line-associated bloodstream infection: Are we there yet?*

Central line-associated bloodstream infections (CLABSIs) are among the top four sites for healthcare-associated infections and the most costly (1). High CLABSI rates are not uncommon in Australia: 3.7 (95% confidence interval [CI] 2.5–5.3)/1,000 line days from pooled data from seven teaching intensive care units (ICUs) for the period 1998–2000 (2), and 6.4 (95% CI 5.6–7.2)/1,000 line days from pooled data from 13 teaching hospitals during 2002–2004 (3). The most recent mean rates in adult teaching ICUs in the United States that contribute to the National Healthcare Safety Network Report system range from 1.2 to 5.6/1,000 line days, and median rates range from 1.2 to 3.8/1,000 line days (4). Surveillance systems were in place in these ICUs (1–4) but surveillance alone does not necessarily result in sustained, low CLABSI rates. As such, CLABSI has gained international attention, with stakeholders agreeing that with judicious clinical practice the risk for CLABSI should be zero (5). Multiple prevention strategies have been successful in reducing CLABSI (6), ranging from improved technology of the device (7–10), which are expensive but appropriate for extended exposure to central venous lines (CVLs) (6), to inexpensive aseptic insertion (11–13), early removal of lines (14, 15), and postinsertion care (16). Strategies that have included the insertion bundle have resulted in CLABSI rates coming close to but not entirely achieving or sustaining zero risk (11–13, 17, 18). Similarly, our statewide intervention of insertion bundles in 34 Australian public teaching ICUs achieved a significant reduction in the aggregated CLABSI rate, from 3.0 to 1.2 per 1000 line days, but did not reach zero risk at anytime during the 18-month project (19). Guidelines (14, 15) include the importance of a short catheter dwell time based on two studies (20, 21), although neither illustrated a direct link between judicious removal of lines and reduced CLABSI. Yet the advice is logical – the shorter the dwell time the lower the risk for CLABSI. Previously, surveillance data (2) were analyzed for risk of CLABSI by dwell time and found the longest dwell time associated with the closest zero risk for CLABSI was the first 5 line days, when the prob*See also p. 657. From the School of Public Health and Community Medicine (MLM), the University of New South Wales, Sydney, and the Clinical Excellence Commission (MLM, ARB), Intensive Care Coordination and Monitoring Unit, New South Wales Department of Health, New South Wales, Australia. Supported, in part, by the New South Wales Health Department. The authors have not disclosed any potential conflicts of interest. For information regarding this article, E-mail: m.mclaws@unsw.edu.au Copyright © 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins