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The Five-Day Blues: A New Delineation for Late-Onset Central-Line Infections


When James Davis, BSN, RN, CCRN, CIC, first began his nursing career, central venous catheters were widely considered a welcome convenience. “And then we found out that if patients don’t need that line to save their lives, it could kill them, and we need to get them out,” says Davis, now a senior infection prevention analyst with the Pennsylvania Patient Safety Authority in Harrisburg.

Many facilities have dramatically lowered their rates of central-line-associated bloodstream infections (CLABSIs) through a bundled approach focused on proper insertion protocols. But as Davis and other researchers have found, that’s not nearly enough. “If you listen to the infection prevention specialists out there, they’re saying, ‘Well, we’ve done all this, we’ve gotten good results, but there has to be something else because we’re seeing reductions but we still have these infections,’” he says.

Listen to James Davis

That something else, as he discovered in a recent study, may very well be the breakdown of central-line maintenance that causes a late-onset CLABSI, especially after five days post-insertion. From analyzing reports submitted to the National Healthcare Safety Network by 104 acute-care facilities in Pennsylvania, Davis found that nearly 72% of the reported CLABSIs in 2010 were late in onset, occurring after the fifth day.1

CLABSI expert Marcia Ryder, PhD, MS, RN, research scientist at Ryder Science in San Marcos, Calif., says the study is the first to obtain a clear picture of the average time to event from a large hospital-based data set. Dr. Ryder says the results also strongly suggest that most CLABSIs are caused by maintenance failures and bacterial biofilm formation in the catheter’s internal lumen rather than insertion problems and the presence of an extraluminal biofilm.

I like to say that the most important risk factor for a CLABSI is the presence of a central line. If a CVC is not needed, it needs to be removed. The longer they stay in, the higher the cumulative risk of CLABSI.

—Sheri Chernetsky Tejedor, MD, SFHM, assistant professor, division of hospital medicine, Emory University School of Medicine, Atlanta

The study may help reinforce a message that many CLABSI experts are already sharing with their colleagues. “I like to say that the most important risk factor for a CLABSI is the presence of a central line,” says Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta. “If a CVC is not needed, it needs to be removed. The longer they stay in, the higher the cumulative risk of CLABSI.

Current Practices Not Enough

Dr. Ryder says the new research highlights the absurdity of efforts that focus primarily on ICUs. “We’ve always been doing surveillance and monitoring in critical-care units, which is not where the major problem is,” she says. In the U.S., the average length of stay in a critical-care unit is roughly four days. “If most infections are happening after that, they’re never even being picked up, and they’re saying, ‘Well, we have zero infections,’ when indeed they don’t,” she says.

Davis says infection-prevention specialists—hospitalists included—should be regularly reviewing their facility’s central-line-maintenance practices. Perhaps the most important first step is to begin recording both the catheter insertion date and the infection date—line items that are still voluntary in many states like Pennsylvania. With that critical data, studies by Davis and other researchers can provide a better sense of CLABSI origins. “Can we put a fulcrum between insertion and maintenance and show facilities how to look to see which way their scale is tipping?” he asks. If so, those facilities will know how to reallocate their resources accordingly.

Bryn Nelson, PhD, is a freelance writer based in Seattle.


  1. Davis J. Central-line associated bloodstream infection: comprehensive, data-driven prevention. Pa Patient Saf Advis. 2011;8:100-105.

Five Tips for Creating a Bundled Maintenance Plan for Central Lines

Few studies have focused on best practices for central-line maintenance. Even so, Dr. Ryder has identified a few important pointers:

1. Choose a needleless connector design that has minimal potential for bacterial transfer.

2. Reinforce the message that all injection ports, catheter hubs, and stopcocks are potential portals for bacteria.

3. Disinfect all potential portals before accessing the line. Dr. Ryder recommends either the passive disinfectant SwabCap as a cover for the needleless connector, or Site-Scrub, a product she’s worked on that acts as a more active disinfectant for catheter access sites.

4. Develop a policy for when needleless connectors should be replaced. One week, Dr. Ryder says, is clearly too long.

5. Consider using catheters with an intraluminal antimicrobial coating, which has been shown to reduce both biofilm and catheter thrombus formation.

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