• Blood cultures are positive, and there is no more likely infection source, and
• Testing supports the catheter as the source, for example:
  • The same organism grows from the catheter tip and peripheral blood, or
  • A blood culture drawn through the catheter becomes positive at least 2 hours earlier than a simultaneously drawn peripheral blood culture.

CRBSI versus CLABSI

CLABSI prevention bundle

1. Insertion bundle

1. Assess necessity
   Insert a central line only when clearly indicated. Consider peripheral IV or midline access where suitable.
2. Hand hygiene
   Perform hand hygiene immediately before insertion.
3. Optimal site selection
   • Avoid the femoral vein in adults when possible.
   • Prefer subclavian access when clinically appropriate, while balancing mechanical and patient-specific risks.
4. Chlorhexidine skin antisepsis
   Prepare skin with alcohol-containing chlorhexidine and allow it to dry completely before insertion. Use an alternative antiseptic if chlorhexidine is contraindicated.
5. Maximal sterile barrier precautions
   The inserter wears cap, mask, sterile gown, and sterile gloves. Cover the patient with a large sterile full-body drape.
6. Insertion checklist and trained observer
   Use a checklist. A trained observer should be able to stop the procedure if sterile practice is breached.

2. Maintenance bundle

1. Daily review of line necessity
   Remove the central line as soon as it is no longer essential.
2. Hand hygiene before every contact
   Clean hands before and after touching the line, dressing, or connections.
3. Aseptic access and “scrub the hub”
   Disinfect catheter hubs, needleless connectors, and injection ports before every access. Use sterile technique for all line manipulation.
4. Dressing and site care
   • Keep dressing clean, dry, and intact.
   • Change immediately if damp, loose, visibly soiled, or disrupted.
   • Use chlorhexidine-containing dressings where indicated by local policy and patient factors.
5. Minimize line entry
   Avoid unnecessary blood sampling, disconnections, and manipulation. Keep lumens closed when not in use.
6. Daily bathing where appropriate
   In many ICU protocols, daily chlorhexidine bathing is used for eligible patients.
7. Surveillance, audit, and feedback
   Monitor bundle compliance and CLABSI rates, then give regular feedback to the care team.

Classic 5-element Keystone CLABSI bundle

1. Hand hygiene
2. Maximal sterile barrier precautions
3. Chlorhexidine skin antisepsis
4. Avoid femoral insertion site when possible
5. Prompt removal of unnecessary central lines

Core CDC CLABSI-prevention recommendations

Before and during line insertion

• Use a central line only when indicated and select the lowest-risk appropriate device/site.
• Ensure staff are trained, competent, and periodically assessed.
• Perform hand hygiene before insertion and before any maintenance activity.
• For central venous catheters, use maximal sterile barrier precautions: cap, mask, sterile gown, sterile gloves, and a large sterile full-body drape.
• Prepare skin with greater than 0.5% chlorhexidine in alcohol and allow it to dry completely. If chlorhexidine cannot be used, iodine tincture, iodophor, or 70% alcohol are alternatives.
• For adults, avoid femoral venous access when possible because of higher infection risk, while balancing mechanical complications and patient factors.
• Use an insertion checklist and empower observers to stop the procedure when aseptic practice is broken.

Maintenance

• Review line necessity every day and promptly remove any catheter that is no longer essential.
• Maintain aseptic technique for all access and manipulation.
• Disinfect hubs, ports, and needleless connectors with an appropriate antiseptic before access, and access only with sterile devices.
• Cover the insertion site with sterile gauze or a sterile transparent semipermeable dressing.
• Replace dressings promptly if they are damp, loose, or visibly soiled.
• Do not routinely replace central lines, PICCs, or hemodialysis catheters just to prevent infection.
• Do not routinely give systemic antimicrobial prophylaxis for prevention.

Additional measures for ongoing high CLABSI rates

• For adults with short-term, non-tunneled CVCs, CDC recommends an FDA-cleared chlorhexidine-impregnated dressing that is labeled to reduce CRBSI/CABSI.
• Consider an antimicrobial or antiseptic-impregnated CVC if the line is expected to remain for more than 5 days and CLABSI rates remain elevated despite full implementation of basic measures.
• Daily bathing with 2% chlorhexidine wash may be used to reduce catheter-related bloodstream infection risk.
• A sutureless securement device may be used to reduce infection risk.

Important pediatric point

CAP Trial: Caffeine for Apnea of Prematurity

Main CAP Trial findings

Long-term CAP follow-up

• At 5 years: the combined outcome of death or disability was not statistically different between caffeine and placebo groups. This is important because it did not show a late safety concern. JAMA follow-up, PMID 22253394
• At 11 years: no adverse effect on general intelligence, attention, or behavior was found. Children who received caffeine had modestly better fine-motor, visuomotor, visual-perception, and visuospatial scores. Pediatrics follow-up, PMID 29643070

Clinical importance

• Prophylactic versus therapeutic initiation
• Earlier initiation after birth
• High-dose versus standard-dose caffeine
• Best time to stop treatment

Standard-dose vs high-dose caffeine in preterm infants

Evidence summary

1. Standard dose

• Loading: caffeine citrate 20 mg/kg IV or enterally
• Maintenance: 5 mg/kg once daily, often titrated to 10 mg/kg/day for persistent apnea, depending on local policy.

2. High dose

• High loading dose: >20 mg/kg caffeine citrate
• High maintenance dose: >10 mg/kg/day caffeine citrate.

3. Recent HI-CAF trial

• High dose: 40 mg/kg loading, 10 mg/kg/day maintenance
• Standard dose: 20 mg/kg loading, 5 mg/kg/day maintenance

Safety caution

Bottom line

• Use standard-dose caffeine citrate as the routine regimen.
• Consider escalation within local NICU protocol for persistent apnea or planned extubation.
• High-dose caffeine can improve extubation-related outcomes and may reduce BPD, but it increases tachycardia and has limited long-term comparative data.
• There is currently insufficient evidence to recommend high-dose caffeine routinely for all preterm infants.