Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections [7–15]. Category IA
Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters [7–15]. Category IA
Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. [14–28]. Category IA
Ensure appropriate nursing staff levels in ICUs. Observational studies suggest that a higher proportion of "pool nurses" or an elevated patient–to-nurse ratio is associated with CRBSI in ICUs where nurses are managing patients with CVCs [29–31]. Category IB
In adults, use an upper-extremity site for catheter insertion. Replace a catheter inserted in a lower extremity site to an upper extremity site as soon as possible. Category II
In pediatric patients, the upper or lower extremities or the scalp (in neonates or young infants) can be used as the catheter insertion site [32, 33]. Category II
Select catheters on the basis of the intended purpose and duration of use, known infectious and non-infectious complications (e.g., phlebitis and infiltration), and experience of individual catheter operators [33–35]. Category IB
Avoid the use of steel needles for the administration of fluids and medication that might cause tissue necrosis if extravasation occurs [33, 34]. Category IA
Use a midline catheter or peripherally inserted central catheter (PICC), instead of a short peripheral catheter, when the duration of IV therapy will likely exceed six days. Category II
Evaluate the catheter insertion site daily by palpation through the dressing to discern tenderness and by inspection if a transparent dressing is in use. Gauze and opaque dressings should not be removed if the patient has no clinical signs of infection. If the patient has local tenderness or other signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually. Category II
Remove peripheral venous catheters if the patients develops signs of phlebitis (warmth, tenderness, erythema or palpable venous cord), infection, or a malfunctioning catheter [36]. Category IB
Weigh the risks and benefits of placing a central venous device at a recommended site to reduce infectious complications against the risk for mechanical complications (e.g., pneumothorax, subclavian artery puncture, subclavian vein laceration, subclavian vein stenosis, hemothorax, thrombosis, air embolism, and catheter misplacement) [37–53]. Category IA
Avoid using the femoral vein for central venous access in adult patients [38, 50, 51, 54]. Category 1A
Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for nontunneled CVC placement [50–52]. Category IB
No recommendation can be made for a preferred site of insertion to minimize infection risk for a tunneled CVC. Unresolved issue
Avoid the subclavian site in hemodialysis patients and patients with advanced kidney disease, to avoid subclavian vein stenosis [53,55–58]. Category IA
Use a fistula or graft in patients with chronic renal failure instead of a CVC for permanent access for dialysis [59]. Category 1A
Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. Ultrasound guidance should only be used by those fully trained in its technique. [60–64]. Category 1B
Use a CVC with the minimum number of ports or lumens essential for the management of the patient [65–68]. Category IB
No recommendation can be made regarding the use of a designated lumen for parenteral nutrition. Unresolved issue
Promptly remove any intravascular catheter that is no longer essential [69–72]. Category IA
When adherence to aseptic technique cannot be ensured (i.e catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e, within 48 hours [37,73–76]. Category IB
Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR). Hand hygiene should be performed before and after palpating catheter insertion sites as well as before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained [12, 77–79]. Category IB
Maintain aseptic technique for the insertion and care of intravascular catheters [37, 73, 74, 76]. Category IB
Wear clean gloves, rather than sterile gloves, for the insertion of peripheral intravascular catheters, if the access site is not touched after the application of skin antiseptics. Category IC
Sterile gloves should be worn for the insertion of arterial, central, and midline catheters [37, 73, 74, 76]. Category IA
Use new sterile gloves before handling the new catheter when guidewire exchanges are performed. Category II
Wear either clean or sterile gloves when changing the dressing on intravascular catheters. Category IC
Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange [14, 75, 76, 80]. Category IB
Use a sterile sleeve to protect pulmonary artery catheters during insertion [81]. Category IB
Prepare clean skin with an antiseptic (70% alcohol, tincture of iodine, or alcoholic chlorhexidine gluconate solution) before peripheral venous catheter insertion [82]. Category IB
Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives [82, 83]. Category IA
No comparison has been made between using chlorhexidine preparations with alcohol and povidone-iodine in alcohol to prepare clean skin. Unresolved issue.
No recommendation can be made for the safety or efficacy of chlorhexidine in infants aged <2 months. Unresolved issue
Antiseptics should be allowed to dry according to the manufacturer’s recommendation prior to placing the catheter [82, 83]. Category IB
Catheter Site Dressing Regimens
Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site [84–87]. Category IA
If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved [84–87]. Category II
Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled [84, 85]. Category IB
Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance [88, 89]. Category IB
Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower) [90–92]. Category IB
Replace dressings used on short-term CVC sites every 2 days for gauze dressings. Category II
Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing [87, 93]. Category IB
Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. Category II
No recommendation can be made regarding the necessity for any dressing on well-healed exit sites of long-term cuffed and tunneled CVCs. Unresolved issue
Ensure that catheter site care is compatible with the catheter material [94, 95]. Category IB
Use a sterile sleeve for all pulmonary artery catheters [81]. Category IB
Use a chlorhexidine-impregnated sponge dressing for temporary short-term catheters in patients older than 2 months of age if the CLABSI rate is not decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis, and MSB [93, 96–98]. Category 1B
No recommendation is made for other types of chlorhexidine dressings. Unresolved issue
Monitor the catheter sites visually when changing the dressing or by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing should be removed to allow thorough examination of the site [99–101]. Category IB
Encourage patients to report any changes in their catheter site or any new discomfort to their provider. Category II
