CRBSI refers to the development of bloodstream infections (BSI) in hospitalized patients which is attributed to the presence of a central line as a source of infection and is not associated with any other secondary cause of BSI. There is another related terminology called CLABSI (central line-associated bloodstream infection), which is strictly used only for surveillance purpose.

central Line or central venous catheter

A central line (CL) is an intravascular device that terminates in the great vessels. It is needed for various purposes such as central venous pressure monitoring and administration of drugs, total parenteral nutrition, etc. and for hemodialysis access (hemodialysis catheters)

Central line can be classified in various ways depending up on:

- Its intended life span, e.g. temporary or short-term (<72 hrs) versus permanent or long-term  (≥72 hrs)

- Its site of insertion (e.g. subclavian, femoral, internal jugular and peripheral veins)

- Its pathway from skin to great vessel (e.g. tunneled versus non-tunneled).

Epidemiology

 Approximately <3% of hospitalized patients require central line at some time during their stay, out of which 3-8 % develop CLABSI. The CLABSI rate varies from 0% to 2.9 % depending up on the location (wards or ICUs).

Pathogenesis

There are several routes by which the organisms gain access to the extraluminal or intraluminal surface of the CVC as given below in the decreasing order of frequency (Fig. 1).

1. Migration of patient’s skin flora along the surface of the catheter with colonization of catheter tip

 2. Direct contamination of the catheter or its hub through the hands of healthcare workers (HCWs)

3. Hematogenous route from other focus of infection

4. Contamination of the device or fluid at the production level.

Fig1. Routes of access of organisms to central line.

There are various risk factors associated with pathogenesis of CRBSI, described in Table 1. The source of infection may be intraluminal (contamination occurs during device or fluid production) or extraluminal (contamination at the time of insertion) (Table 2). Following events take place after the entry of the organism into the CL.

Table1. risk factors for CRBSI.

Table 2. Intrinsic and extrinsic contamination of central line.

- Foreign body reaction, around the catheter insertion site

- Colonization of the organism by microbial adherence

- Biofilm formation on catheter surface: This is observed with many organisms such as coagulase-negative

staphylococci, S. aureus, Pseudomonas aeruginosa, and Candida species.

Diagnosis of CRBSI

T he diagnosis of CRBSI is established when a patient on CL meets the clinical criteria and microbiological criteria; in the absence of evidence of other sources of BSI.

- Clinical criteria: Presence of fever, chills, rigor or hypotension after the insertion of CL and/or signs of catheter site infection such as erythema, tenderness, warmth, swelling at the catheter exit site

- Microbiological criteria: Simultaneous blood culture from CL and peripheral line (PL) is carried out and the CL blood culture bottle flags ≥2 hrs earlier to peripheral line blood culture (i.e. differential time to positivity ≥2 hrs).

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