Several factors increase a neonate's risk of developing a CLABSI:
• Patient-Related: Prematurity and low birthweight are significant risk factors. Infants requiring a PICC are at increased risk due to poor skin integrity, an immature immune system, and multiple invasive procedures1.
• Device-Related: Use of Central Venous Catheters (CVCs), including peripherally inserted central venous catheters (PICCs) and umbilical catheters, with risk increasing with the duration of central venous access.
• Medication-Related: Prolonged parenteral nutrition and the use of IV lipid emulsions are known risk factors, as lipid emulsions can potentiate microbial growth and impair host defenses. Postnatal administration of corticosteroids also increases risk.
Common Pathogens in CLABSI
• Coagulase-Negative Staphylococci (CoNS): These are the most predominant pathogens, accounting for over 50% of infections. Staphylococcus epidermidis is a common example8. CoNS are lower-virulence pathogens but can form biofilms on devices.
• Gram-Negative Organisms: Account for approximately 20% of infections.
• Staphylococcus aureus: Accounts for 4%–9% of CLABSIs1. Methicillin-resistant S. aureus (MRSA) is an increasing concern.
• Enterococcus species: Account for 3%–5% of infections.
• Candida species (Fungi): Account for approximately 10% of infections1. Malassezia furfur is an unusual lipophilic yeast that can cause catheter-related infections in infants receiving intralipid therapy.
Management and Prevention Strategies
Prevention is paramount in controlling CLABSIs. Key strategies include:
• Hand Hygiene: The single most important strategy for avoiding transmission of contagions in the NICU.
• Infection Control Bundles: Most institutions adopt "care bundles" of practices for central line insertion and maintenance that have proven effective in reducing CLABSI rates12. These bundles were disseminated through collaboratives like the California Perinatal Quality Care Collaborative (CPQCC).
◦ During Catheter Insertion:
▪ Hand hygiene.
▪ Aseptic technique.
▪ Skin antisepsis: Chlorhexidine is the preferred antiseptic for catheter site care over povidone-iodine13. The solution must be allowed to air-dry completely.
▪ Sterile dressing technique.
◦ During Catheter Maintenance:
▪ Daily review of line necessity: CVCs should be removed as soon as they are no longer necessary. Line stewardship focuses on this daily review.
▪ Daily inspection of the insertion site and dressing: Opaque dressings should be removed and the site inspected visually if there are signs of possible CLABSI.
▪ Standardization of practices around IV tubing changes.
▪ "Scrubbing the hub" of the central line to minimize contamination.
▪ Replacing transparent dressings on short-term central line sites at least every 7 days, with consideration for pediatric patients where the risk of dislodging may outweigh the benefit.
▪ Some NICUs have incorporated bathing strategies for patients with central lines.
• Antibiotic Stewardship: Minimizing indiscriminate use of antibiotics is mandatory as it has been associated with increased nosocomial sepsis. Prophylactic antibiotics for central lines are generally not recommended due to limited data and concerns about resistance and side effects.
• Breastfeeding: Promotion of fresh maternal milk is considered a key step in preventing NICU infections due to its anti-infective properties.
• Probiotics: May help restore gut immune function and potentially reduce the risk of late-onset sepsis (LOS).
• Antifungal Prophylaxis: Specific antifungal prophylaxis with fluconazole has been associated with a significant reduction in invasive fungal infections and is recommended in NICUs with high rates of invasive candidiasis.
Treatment of CLABSI
• Empiric Antibiotic Therapy: Treatment is often initiated before a definitive causative agent is identified. For nosocomial sepsis, which includes CLABSIs, the flora of the NICU must be considered. Vancomycin plus an aminoglycoside (e.g., gentamicin or amikacin) is usually begun for staphylococcal coverage. Some NICUs use cefazolin or nafcillin instead of vancomycin for staphylococcal coverage.
• Catheter Removal:
◦ For CLABSIs due to gram-negative or fungal pathogens, catheters should be removed as early as possible.
◦ For CLABSIs caused by CoNS, catheter removal should occur if culture results are persistently positive or if the patient’s condition is unstable17. Delaying CVC removal for 3 to 5 days after starting anticoagulant therapy may be considered due to emboli risk, though this is controversial.
• Duration of Therapy: The length of antibiotic therapy is not data-driven, but 7 to 10 days is a common duration of treatment. Inflammatory markers like C-reactive protein (CRP) may be used to guide the length of therapy.