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A central line (a Hickman, PICC or port) lets germs straight into the blood, so every touch is planned. Hands are cleaned, the connector is scrubbed with antiseptic each time, the dressing is kept clean and dry and changed weekly, and every day someone asks whether the line is still needed. Families caring for a line at home are taught the same steps before they leave hospital.
Maintenance rests on the SHEA/IDSA/APIC 2022 compendium (essential practices for all acute hospitals, graded by quality of evidence), CDC/HICPAC 2011 (updated 2017), epic3 (England, 2014) and NICE CG139 for care at home. Essential: hand hygiene before any contact (epic3 Class A); aseptic technique; scrub hubs, needleless connectors and injection ports before each access (SHEA moderate; CDC IA), with alcoholic chlorhexidine preferred and friction for at least 5 seconds (SHEA) or 15 seconds (epic3 Class D/GPP); access only with sterile devices; chlorhexidine in alcohol for site care at dressing changes (epic3 Class A); transparent dressings changed at least every 7 days and gauze every 2 days, or sooner if soiled, loose or damp (SHEA moderate); chlorhexidine-containing dressings over 2 months of age (SHEA high), which CDC 2017 recommends at IA only from age 18 and leaves unresolved in children; daily review and removal of non-essential lines (SHEA moderate, CDC IA); administration sets up to 7 days (SHEA high) or 96 hours (epic3 Class A); no systemic antimicrobial prophylaxis, routine antibiotic locks or routine line replacement; and unit surveillance of CLABSI per 1,000 catheter days.
Daily chlorhexidine bathing is graded high for ICU patients over 2 months, but SHEA notes benefit in adult haematology-oncology was not seen in children, and a Children's Oncology Group randomised trial (2021) found more CLABSI with chlorhexidine bathing in children with cancer, concluding it does not support routine use. Antiseptic caps, antimicrobial lock therapy for recurrent CLABSI and vascular access teams are additional approaches where rates stay high.
Why: Most line infections come from how the line is handled, so every pair of hands that touches it needs the same technique.
“Before discharge from hospital, patients and their carers should be taught any techniques they may need to use to prevent infection and safely manage a vascular access device.”
Why: Hands carry the skin germs that most often cause line infections; gloves do not replace hand cleaning.
“Hands must be decontaminated, with an alcohol-based hand rub or by washing with liquid soap and water if soiled or potentially contaminated with blood or body fluids, before and after any contact with the intravascular catheter or insertion site.”
Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · Class A
Why: An aseptic technique keeps the parts that enter the blood untouched by anything unclean.
“Maintain aseptic technique for the insertion and care of intravascular catheters”
CDC/HICPAC 2011 · Category IB
Why: About half of hubs and connectors carry germs in ordinary practice; scrubbing removes them before they are pushed into the line.
“Before accessing catheter hubs, needleless connectors, or injection ports, vigorously apply mechanical friction with an alcoholic chlorhexidine preparation, or 70% alcohol.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
Why: The two guidelines set different minimum times; neither has been tested on every connector type.
“Apply mechanical friction for a minimum of 5 seconds to reduce contamination.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022
Why: A non-sterile syringe tip undoes the scrub.
“Minimize contamination risk by scrubbing the access port with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol) and accessing the port only with sterile devices”
CDC/HICPAC 2011 · Category IA
Why: Chlorhexidine in alcohol kills skin germs and keeps working after it dries.
“Use a single-use application of 2% chlorhexidine gluconate in 70% isopropyl alcohol (or povidone iodine in alcohol for patients with sensitivity to chlorhexidine) to clean the central catheter insertion site during dressing changes, and allow to air dry.”
Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · Class A
Why: A lifted or wet dressing lets germs track along the line into the vein.
“For nontunneled CVCs in adults and children, change transparent dressings and perform site care with a chlorhexidine-based antiseptic at least every 7 days or immediately if the dressing is soiled, loose, or damp.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
Why: These dressings reduce line infections in adults; in children the evidence is thinner and CDC makes no recommendation under 18 (see variants).
“Use chlorhexidine-containing dressings for CVCs in patients over 2 months of age (Quality of Evidence: HIGH)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: HIGH
Why: Bath water and swimming pools can carry germs into the line; a cover makes showering possible.
“Do not submerge the catheter or catheter site in water.”
CDC/HICPAC 2011 · Category IB
Why: Every day a line is in is a day it can become infected.
“Assess the need for continued intravascular access on a daily basis during multidisciplinary rounds.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
Why: More frequent changes add handling without reducing infection. SHEA allows up to 7 days and epic3 96 hours (Class A); blood and lipids support germ growth, so epic3 changes blood sets when the transfusion ends or every 12 hours, and lipid sets every 24 hours.
“Routine replacement of administration sets not used for blood, blood products, or lipid formulations can be performed at intervals up to 7 days (Quality of Evidence: HIGH)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: HIGH
Why: Preventive antibiotics do not lower line infections and they breed resistance.
“Do not use antimicrobial prophylaxis for short-term or tunneled catheter insertion or while catheters are in situ (Quality of Evidence: HIGH)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: HIGH
Why: Routine replacement adds insertion risks without preventing infection.
“Do not routinely replace central venous access devices to prevent catheter-related infection.”
Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · Class A
Why: A unit that measures its rate can see whether the bundle is working and when to add more.
“Measure unit-specific incidence of CLABSI (eg, CLABSI per 1,000 catheter days) and report the data on a regular basis to the units, physician and nursing leadership, and hospital administrators overseeing the units.”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: HIGH
Why: These are additional approaches with costs or risks, kept for where the essentials are not enough.
“Use an antiseptic-containing hub/connector cap/port protector to cover connectors (Quality of Evidence: MODERATE)”
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · Quality of Evidence: MODERATE
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Run the essential practices of the SHEA/IDSA/APIC 2022 compendium as one bundle, with the UK guidelines filling in detail: hand hygiene and aseptic technique, hub and connector scrubbing before every access with alcoholic chlorhexidine, chlorhexidine in alcohol for site care, transparent dressings changed at least weekly or when compromised, chlorhexidine-containing dressings in adults, a daily review of need, no preventive antibiotics or scheduled line changes, and unit surveillance. Where the guidelines differ, both are stated: hub scrub time is at least 5 seconds in SHEA and at least 15 seconds with drying in epic3 (Class D/GPP); administration sets may run up to 7 days in SHEA (high quality) but up to 96 hours in epic3 (Class A); chlorhexidine dressings are recommended from 2 months in SHEA (high quality) but from 18 years in CDC 2017 (Category IA), with no recommendation for children and a recommendation against them for premature neonates. Daily chlorhexidine bathing is an essential practice for ICU patients in SHEA, but it is not established for children with cancer: SHEA records no benefit in them and the Children's Oncology Group trial found more infections with it.
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · CDC/HICPAC 2011 · Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · NICE 2012 · Cancer 2021
Where it differs: Decontaminates the hub with 2% chlorhexidine in 70% alcohol for a minimum of 15 seconds and lets it dry before access, against SHEA's minimum of 5 seconds of friction. NICE CG139 asks for decontamination before and after access, with no time.
Evidence: epic3 grades it Class D/GPP (good practice); SHEA's 5 seconds rests on laboratory studies and it notes the time may not apply to untested connectors.
Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 · SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · NICE 2012
Where it differs: Recommends chlorhexidine-impregnated dressings with an FDA-cleared label for short-term non-tunnelled CVCs in patients aged 18 and over, recommends against them in premature neonates because of skin reactions, and makes no recommendation for other children. SHEA recommends them from 2 months.
Evidence: CDC Category IA for adults, IC against in premature neonates, unresolved issue for other children; SHEA quality of evidence high.
CDC/HICPAC 2011 · SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022
Where it differs: SHEA makes daily chlorhexidine bathing an essential practice for ICU patients over 2 months, and CDC 2011 suggests a 2% chlorhexidine wash for daily skin cleansing (Category II). In a Children's Oncology Group double-blind trial of 174 evaluable children with cancer or allogeneic transplant, CLABSI was 5.44 per 1,000 line days with chlorhexidine cloths against 3.10 with control cloths, and staphylococci with reduced chlorhexidine susceptibility were more often acquired.
Evidence: SHEA quality of evidence high for ICU patients; it calls the role outside the ICU unclear and notes benefit in adult haematology-oncology was not seen in children. The paediatric trial stopped early for poor accrual; its authors concluded that the data do not support routine chlorhexidine bathing in these children.
SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 · CDC/HICPAC 2011 · Cancer 2021
Where it differs: Some paediatric centres fill the line with 70% ethanol between uses to prevent infection, especially after a line infection.
Evidence: A randomised double-blind trial in 94 children and young people with cancer or haematological disorders and a new CLABSI stopped for futility: treatment failure was 44% with ethanol and 43% with placebo, and line blockage needing a clot-dissolving drug was more common with ethanol (58% against 33%); its authors do not recommend routine ethanol locks for treatment or secondary prophylaxis. A 2023 meta-analysis, mostly of before-and-after studies, reported fewer infections with ethanol locks and more thrombosis and catheter breakage. SHEA lists antimicrobial lock therapy as an additional approach for recurrent CLABSI and asks that the adverse effects of ethanol locks be carefully considered.
The Lancet Infectious Diseases 2018 · Journal of Pediatric Pharmacology and Therapeutics 2023 · SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Disinfect hubs, needleless connectors and injection ports before access “Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter (Quality of Evidence: MODERATE)” | Quality of Evidence: MODERATE | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Decontaminate the hub for at least 15 seconds and allow to dry “The hub should be cleaned for a minimum of 15 s and allowed to dry before accessing the system.” | Class D/GPP | Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 |
| Chlorhexidine-containing dressings over 2 months of age | Quality of Evidence: HIGH | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Bathe ICU patients over 2 months daily with chlorhexidine “Bathe ICU patients >2 months of age with a chlorhexidine preparation on a daily basis (Quality of Evidence: HIGH)” | Quality of Evidence: HIGH | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Promptly remove any line that is no longer essential “Promptly remove any intravascular catheter that is no longer essential” | Category IA | CDC/HICPAC 2011 |
| Administration sets in continuous use need not be replaced more often than every 96 hours “Administration sets in continuous use do not need to be replaced more frequently than every 96 h, unless device-specific recommendations from the manufacturer indicate otherwise, they become disconnected or the intravascular access device is replaced.” | Class A | Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 |
| Use bundled performance improvement initiatives | Category IB | CDC/HICPAC 2011 |
| Antimicrobial lock therapy for long-term lines (additional approach) “Use antimicrobial lock therapy for long-term CVCs (Quality of Evidence: HIGH)” | Quality of Evidence: HIGH | SHEA, IDSA, APIC (Infection Control and Hospital Epidemiology) 2022 |
| Antibiotic lock solutions should not be used routinely “Antimicrobial lock solutions should not be used routinely to prevent catheter-related bloodstream infections.” | Class D/GPP | Journal of Hospital Infection (Loveday et al., commissioned by the Department of Health) 2014 |
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