CVC-associated BSI prevention: review of WHO guidelines, 2026

Disclaimer: This post is for academic purposes only. Please read the original document if you intend to use them for clinical purposes.

This document summarises the 2026 WHO guidelines for the prevention of CVC-associated Bloodstream Infections (BSIs) which focus on short- and long-term central venous catheters (CVCs) in adults, adolescents, children, and neonates (excluding hemodialysis and ECMO). BSIs associated with CVCs, present a critical challenge to global health systems. Central line-associated bloodstream infections (CLABSI) are among the most preventable HAIs, yet they carry a significant burden: a single case can cost up to US$ 46,000, with mortality and morbidity rates remaining high across all income levels. CLABSI rates in low- and middle-income countries (LMICs) can be as high as 44.6 per 1000 line days.The core strategy for reducing CLABSI involves a transition from single-intervention focus to a Multimodal Strategy (MMS) and the implementation of evidence-based care bundle.

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1. Global Burden:

The terminology for BSI associated with CVC varies globally, encompassing terms like CLABSI (CDC definition), CABSI {ICCQIP definition of UKHSA (erstwhile PHE)}, and CVC-BSI (WHO definition for limited-resource settings). Regardless of nomenclature, these infections significantly increase hospital stays and healthcare costs. The COVID-19 pandemic further exacerbated the issue, with many countries reporting increased rates of bacterial infections and higher diversity in microbial pathogens associated with intravascular devices.

Incidence:

2. Education:

The foundation of infection prevention rests on clinician competency and rigorous hygiene protocols. The WHO issues several Good Practice Statements (GPS) that represent unequivocally beneficial actions.

• Formal Education: Clinicians must be formally trained and regularly assessed on indications for insertion, maintenance, access, and removal of CVCs.
• Aseptic Technique: Training must emphasize avoiding direct contact with “key parts” and “key sites.”
• Hand Hygiene: Adherence to the “5 Moments” of hand hygiene is mandatory, preferably using alcohol-based hand rubs or soap and water with single-use towels.

3. Pre-Insertion and Insertion Protocols:

Effective prevention begins before the catheter is placed. Strategies focus on reducing the microbial load on the patient’s skin and maintaining a sterile environment during the procedure.

Skin Preparation and Disinfection:

• Daily Body Wash: For critically ill adults and children, daily washing with chlorhexidine-containing products (liquid or wipes) is suggested. (Caution: Not recommended for neonates due to chemical burn risks.)
• Antiseptics: Alcohol-based formulations are preferred over aqueous ones. Specifically, alcohol-chlorhexidine (1% or 2%) is the suggested first choice for skin disinfection prior to insertion.
• Drying Time: All antiseptics must be allowed to air dry for at least 30 seconds to achieve maximal effect.

Procedure Standards:

• Standardized Kits: The use of a standardized insertion kit is recommended to ensure all necessary sterile components are available.
• Maximal Sterile Barrier Precautions: This includes the use of a cap, mask, sterile gown, sterile gloves, and a sterile full-body drape. While the certainty of evidence is low, the balance of effects favors these precautions over lesser standards.
• Ultrasound Guidance: While ultrasound is excellent for reducing mechanical complications (e.g. pneumothorax) and insertion attempts, the evidence is inconclusive regarding its direct impact on infection prevention.

4. Maintenance and Access:

Ongoing care of the CVC is critical as the risk of infection often increases with the dwell time of the catheter.

Dressing and Site Care:

• Dressing Type: Both transparent semi-permeable and gauze dressings are suggested. Transparent versions allow for easier visual inspection of the site for signs of inflammation.
• Schedules: A formal schedule for dressing changes is suggested, with intervals of at least 3 days. However, dressings must be replaced immediately if they become moistened, soiled, or disrupted.
• Antiseptic Patches: The use of chlorhexidine-impregnated sponges or dressings is suggested for adults and children to further reduce microbial entry.

Fluid Management and Flushing:

• “Lock-off” Flushing: The guidelines suggest using normal sterile saline over heparinized saline. This avoids the risks of heparin-induced thrombocytopenia and bleeding, while providing comparable efficacy for short-term lines.
• Administration Sets: Tubing used for routine IV fluids should be changed every 7 days. However, sets used for total parenteral nutrition (TPN) or lipids should be changed much more frequently (generally within 24 hours).

5. Site and Catheter Selection:

The physical characteristics and location of the CVC impact the risk of pathogen colonization.

• Site Preference: The Subclavian vein is preferred over the jugular or femoral veins for reducing infection risk. The femoral site is generally avoided due to its proximity to the groin and higher risk of contamination.
• Lumen Count: For long-term lines, a single lumen is suggested over multi-lumen catheters unless clinical needs dictate otherwise. Each additional lumen represents an extra pathway for bacterial entry.
• Coated Catheters: Antiseptic-coated catheters are suggested, particularly for high-risk populations (immunocompromised, burn patients). Antibiotic-impregnated catheters are also an option but carry concerns regarding the development of antimicrobial resistance (AMR).

6. Replacement, Removal, and Other Measures:

• Indication-Based Removal: CVCs should be inspected daily and removed promptly when no longer essential for patient care. Routine replacement (changing the line at set intervals) is suggested against; lines should be replaced only if clinically indicated.
• Prophylactic Antibiotics: The guidelines suggest against the use of systemic IV prophylactic antibiotics at the time of insertion, as they do not significantly reduce BSI risk and contribute to AMR and Clostridium difficile infections.
• Antiseptic Line Caps: These may be used to protect the hub, though evidence of their superiority over standard caps is currently low.

7. Multimodal Strategy (MMS) & Care Bundle:

Infection Prevention and Control (IPC) activities must be implemented using a Multimodal approach consisting of 5 key components:

1. Build it (System Change): Ensuring the availability of alcohol-based hand rubs, sterile supplies, and appropriate infrastructure.
2. Teach it (Training and Education): Formalizing clinician competency.
3. Check it (Monitoring and Feedback): Establishing national and facility-level HAI surveillance programmes to track CLABSI rates and AMR.
4. Sell it (Reminders and Communication): Using posters and checklists to reinforce practices.
5. Live it (Culture Change): Strengthening the institutional safety climate where every staff member prioritizes infection prevention.

CVC care bundle (grouping 3–5 evidence-based practices) is also suggested. While there is no universal consensus on the exact components, they typically include hand hygiene, maximal sterile barriers, chlorhexidine skin antisepsis, and daily review of line necessity. Success depends on reliable adherence to every measure in the bundle.

_{Citation: Guidelines for the prevention of bloodstream infections and other infections associated with the use of intravascular catheters. Part 2: central venous catheters. Geneva: World Health Organization; 2026. Licence: CC BY-NC-SA 3.0 IGO.}