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 Table of Contents  
Year : 2019  |  Volume : 3  |  Issue : 1  |  Page : 43-48

Central line-associated bloodstream infections in the Kingdom of Saudi Arabia

1 Department of Intensive Care, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Department of Intensive Care, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia
3 Department of Intensive Care, Respiratory Services, College of Medicine, King Saud bin Abdul-Aziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdul-Aziz Medical City, Riyadh, Saudi Arabia

Date of Web Publication30-May-2019

Correspondence Address:
Raymond M Khan
Department of Intensive Care, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, P. O. Box: 22490, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2543-1854.259482

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Healthcare-associated infections (HAI) are a preventable cause of morbidity and mortality in the Kingdom of Saudi Arabia and internationally. They are associated with increased length of stay, mortality, antibiotics cost, and overall hospital cost. About 250,000 central line-associated bloodstream infections (CLABSI) occur in the US yearly, with a rate of 0.8 per CL-days and attributed mortality of 12%–25%. CLABSI constitutes 14.2%–38.5% of HAIs in the Kingdom, with rates varying from 2.2 to 29.7/1000 CL-days and crude device-associated mortality of 16.8%–41.9%. This article highlights the scope of the problem and outlines preventive strategies.

Keywords: CLABSI, outcomes and future, prevention, Saudi Arabia

How to cite this article:
Khan RM, Subhani J, Arabi YM. Central line-associated bloodstream infections in the Kingdom of Saudi Arabia. Saudi Crit Care J 2019;3:43-8

How to cite this URL:
Khan RM, Subhani J, Arabi YM. Central line-associated bloodstream infections in the Kingdom of Saudi Arabia. Saudi Crit Care J [serial online] 2019 [cited 2023 Jun 4];3:43-8. Available from: https://www.sccj-sa.org/text.asp?2019/3/1/43/259482

  Introduction Top

Healthcare-associated infections (HAI) are preventable causes of morbidity and mortality globally. Approximately 250,000 central line-associated bloodstream infections (CLABSI) occur in patients yearly in the United States.[1] Each episode is estimated to cost the hospital up to $46,485 USD due to prolonged length of stay, increased antibiotics cost, and the additional cost of medical care.[2] According to the National Healthcare Safety Network (NHSN), the CLABSI rate in US intensive care units (ICUs) is estimated to be 0.8/1000 central line (CL) days, which is associated with a significantly increased odds of in-hospital death of 2.75 (CI, 1.86–4.07)[3] and an attributed mortality of 12%–25%.[4] The International Nosocomial Infection Control Consortium (INICC) surveillance data from 703 ICUs in 50 mostly developing countries for 2010–2015, reported a CLABSI rate of 4.1/1000 CL days, with a pool crude mortality of 38.4%.[5] In a recent report from six hospitals in three GCC countries, the overall CLABSI rate was 3.1/1000 CL days, which was higher than NHSN hospitals but lower than INICC hospitals.[6] In addition, a study from 12 Ministry of Health hospitals in the Kingdom of Saudi Arabia during 2013–2016 showed that CLABSI rates varied from 2.2 to 10.5/1000 CL days, with crude device-associated mortality of 41.9%.[7]

Central lines (CL) are essential part of managing ICU patients, they are used for hemodynamic monitoring, hemodialysis, blood withdrawal, and administration of medications, fluids, blood products, and total parenteral nutrition. CLABSI develops as pathogens either migrate along the outer surface of the catheter into deeper tissue and the bloodstream or as pathogens are introduced into the catheter hub then proceed along the lumen. In an attempt to reduce CLABSI, the Agency for Healthcare Research and Quality funded the Keystone ICU Project in 2003, in which interventional bundle with a combination of technical and socio-adaptive elements were implemented in 108 ICUs in the USA. Over an 18-month period, the project resulted in decreasing CLABSI rates from 2.7 to 0/1000 CL days.[8] In a recent meta-analysis involving data from 2216 adult ICUs, the median CLABSI rate significantly decreased from 5.7 to 2.0/1000 CL days after implementing a prevention bundle.[9]

  Prevention of Central Line-Associated Bloodstream Infections Top

The Institute for Healthcare Improvement (IHI) recommends the use of an infection prevention bundle: hand hygiene, maximal sterile barriers during catheter insertion, chlorhexidine skin disinfection, optimal catheter site selection, and daily review of line necessity with prompt removal of unnecessary lines to prevent these infections. Despite the availability of evidence-based interventions summarized in numerous guidelines, CLABSI remains a substantial threat for hospitalized patients.[10] In recent years, it has become clear that the limiting factor to infection prevention resides in the implementation of published recommendations. A systematic review of 584 ICUs suggests that quality improvement interventions contribute to the prevention of CLABSIs and implementation of care bundles and checklists appear to yield the strongest risk reductions.[10]

Prior to catheter insertion


Education remains the cornerstone of the prevention of CLABSI and other nosocomial infections. Several studies have shown that an educational program with a self-study module, staff in-service lectures and placement of fact sheet and posters in the ICU was associated in the reduction of CLABSIs. In addition, the use of hands-on, simulation-based training in proper CL insertion as a supplement to didactic lectures also contributes to lowering CLABSI rates.[11] Educational programs should be coupled with a formal credentialing process to ensure the procedural competency of health-care worker and periodic reassessment of knowledge regarding infection-prevention practices should be instituted to promote continued adherence to evidence-based practices.

At the time of catheter insertion

Hand hygiene

Current guidelines recommend an alcohol-based waterless product or antiseptic soap and water before catheter insertion regardless of the fact that sterile gloves will be donned during the procedure. The most common underlying etiology of CLABSI is through microorganisms introduced at the time of insertion of the catheter. This can be extraluminally mediated through skin flora of the patient, or due to the lack of hand washing on the inserter's part.[12]

Maximal barrier precautions

Protective sterile barriers help minimize the risk of contamination and colonization of the catheter and insertion site during CL placement. The use of maximal sterile barrier (cap, mask, surgical gown, sterile gloves, and a large drape that covers the patient from head to toe) has been associated with decreased mortality, catheter colonization, and incidence of HAI.[12]

Chlorhexidine skin antisepsis

Current guidelines recommend that an alcohol-based chlorhexidine solution with a minimum chlorhexidine gluconate concentration of 0.5% be applied to the skin surface and allowed to dry before catheter insertion.[12]

Optimal catheter site selection

The femoral site has been associated with a greater risk of CLABSIs and thrombosis and is not recommended as the initial choice for nonemergent CL insertion. While the subclavian vein is associated with a lower risk of CLABSI and thrombosis, this greatly depends on the experience of the operator. Using ultrasound for catheter insertion has also been shown to reduce the risk of CLABSI and other mechanical complications and is highly recommended.[12]

Systems-based intervention

  1. A dedicated procedure cart and CL insertion kit promote greater adherence to best care practices
  2. Catheter insertion checklist prompts compliance and ensures accurate documentation of infection-prevention strategies
  3. A trained healthcare professional should be appointed to observe the insertion of the CL, review the checklist, monitor sterile technique, and should be empowered to terminate the procedure if breaches are identified.

After catheter insertion – maintenance bundle

Daily review of line necessity

The risk of CL colonization increases with catheter duration. Thus, one of the most effective ways to reduce CLABSIs is to remove CLs as soon as they are no longer necessary. A systematic approach on a daily basis using daily goals sheet, nurse-driven protocols, electronic reminders, or multidisciplinary catheter rounds are possible interventions.[13]

Catheter care

Dressing protocol

Chlorhexidine-impregnated dressings have shown to decrease CLABSI and catheter tip colonization. Further, a dressing change should be performed every 5–7 days in the absence of visible soiling or break in the seal, or earlier if soiled, loose, or damp.[12]

Hub care

Catheter manipulation for drug administration or blood withdrawals presents an opportunity for contamination and potential transmission of pathogenic organisms. When access ports are accessed, they should be scrubbed/cleaned with an antiseptic solution, such as chlorhexidine, povidone-iodine, an iodophor, or 70% alcohol for between 5 and 15 s.[12],[13] The use of the hub and port disinfectant caps/covers removes the requirement of scrubbing before infusions and draws, and are associated with statistical significance reduction in CLABSI.[13]

Needleless securement devices or sutureless securement devices

There is growing evidence that these devices can be safe alternatives to suturing CLs and reduce dislodgment, CLABSI, and occupational needle sticks.[13]

Intravenous medications

Frequent accessing of CL may increase the risk of infections, so when possible change intravenous (IV) medications to per os (oral), especially electrolyte supplements, acetaminophen, and analgesics.

Blood extractions

Implement a “Choosing Wisely” initiative to reduce unnecessary blood draws and laboratory.

Special considerations

Antiseptic- or antimicrobial-impregnated catheters

These catheters can be used if: CLABSI rate is still high despite good compliance with prevention strategies; patient has limited access and a history of recurrent CLABSI; and the patient has a high risk of sequelae from CLABSI, example recently implanted intravascular device.[12]

Antibiotic lock

Lock therapy can be used in patients with long-term catheters, limited access, and recurrent CLABSIs.[12]

Recombinant tissue plasminogen activating factor

Tissue plasminogen activating may be used once weekly after hemodialysis.[12]

  Initiatives for Preventing Central Line–associated Bloodstream Infections in the Kingdom of Saudi Arabia Top

Most initiatives for improving CL care reported to date have focused on CLABSI prevention using a care bundle concept. In an epidemiology study of device-associated nosocomial infections (DA-HAIs) performed in 12 Ministry of Health hospitals in 9 cities of the Kingdom of Saudi Arabia, CLABSI comprised 14.2% of 13,492 DA-HAIs. There were 13,714 CL days in the study period (2013–2016), with the CLABSI varying between hospitals from 2.2 to 10.5/1000 device days.[7] Al-Tawfiq et al., in a prospective study of DA-HAI rates conducted between 2004 and 2011 in the adult ICUs of the Saudi Aramco Medical Services, Dhahran, revealed that CLABSI constituted 38.5% of DA-HAIs, with an overall rate of 8.95, 5.43 and 15.24/1000 CL days for the cardiac, surgical, and medical ICUs, respectively.[14]

Balkhy and associates, using the US NHSN surveillance method, collected data from six tertiary care hospitals in three GCC countries (Saudi Arabia, Oman, and Bahrain) between 2008 and 2013. There were 461 CLABSI during the 6-year period with 150,492 CL days and an overall rate of 3.1/1000 CL days. After adjusting for differences in the type of ICU, the standardized infection ratio risk of CLABSI in GCC hospitals was 146% higher than NHSN hospitals but 33% lower than INICC hospitals.[6] Further, Aloush et al. in a multicenter study of 58 IUCs in three Middle Eastern Countries (Egypt, Jordan, and Saudi Arabia) showed that compliance with published prevention guidelines was only 18.9%. The CLABSI rate was 29.7/1000 CL days, with attributed mortality of 16.8%.[15] These studies shed light on the current state of CLABSI in our region and provide a benchmark for patient safety and improvement projects.

Khalid et al. conducted a pre- and post-intervention study in Jeddah and found that during the study period (2009–2012) the implementation of a CLABSI prevention bundle resulted in a significant reduction in the incidence of CLABSI from 6.9 to 0/1000 CL days. Further, they were able to maintain zero CLABSI for the entire last year of their study.[16] In another study in Jeddah using the IHI prevention bundle, CLABSI rates decreased from 2.0 to 0 cases/1000 CL days and bundle compliance increased from 37% to 100% over the 8-year study period.[17] Al-Abdely et al. implemented the INICC care bundle in 6 ICUs in five different cities in the Kingdom of Saudi Arabia. In the 2-year study period, there was 3769 patients with 24,238 CL days. The CLABSI rate decreased from 6.9 to 3.1/1000 CL days, while compliance with hand hygiene (29%–72%) and daily assessment of the need for CL (62%–84%) were among the most improved bundle elements. In addition, CL utilization ratio significantly decreased from 0.96 to 0.73 (P = 0.001). Further, logistic regression analysis showed that the intervention (INICC bundle) decreased the risk of CLABSI (OR, 0.53: 95% CI, 0.33–1.04).[18]

There are several other studies [Table 1] published about CLABSI prevention in Saudi Arabia. All of these studies were pre- and post-intervention design. Most implemented the IHI bundle with varying rates of success. The total number of CL days was 87,842, with the highest reported (24,238) by Al-Abdely et al.[18] The overall bundle compliance improved from 69% to 95% (an increase of 26%), with Yaseen et al.[17] reporting the greatest improvement (63%). The average rate of CLABSI decreased from 6.5 to 2.8/1000 CL days, and the biggest improvement was reported by Khalid et al.[16] Two groups were able to achieve zero CLABSI and maintain for at least 1 year.[16],[17] Our data at the Ministry of National Guard Health Affairs, Riyadh in medical ICU spans 10 years with 38,656 CL days and an average rate of 2.8/1000 CL days. We have implemented an active surveillance program by infection control department, a structured education process for those inserting CLs, insertion and maintenance bundles, reminders on the daily goals sheet and electronic progress notes, and frequent reports to front-line staff and stakeholders.[22]
Table 1: A summary of published studies on CLABSI prevention in the Kingdom of Saudi Arabia

Click here to view

  the Future of Central Line-Associated Bloodstream Infections Prevention in the Kingdom Top

Many healthcare facilities in North America have reported and maintained zero CLABSI for several years. While the incidence of CLABSI in the Middle East is higher, great strides have been made in this field. To achieve the 0 CLABSI target, we need to transform our healthcare organizations by implementing improvement science. The implementation of Comprehensive Unit-based Safety Program is an excellent framework to move toward this goal; it is designed to improve local safety cultures and to guide organizations to learn from mistakes by utilizing a validated and structured framework. These improvement strategies can foster cooperation among hospitals in Saudi Arabia, allowing organizations to grow and adapt evidence-based practices to reduce CLABSIs. Further, in the near future using web-based “Data Mining Models” and “Multitiered Surveillance System” may help us better predict patients at risk of CLABSI, thus healthcare workers can be more vigilant with these patients.[23],[24]


Prevention of CLABSI requires:

  1. A dedicated team
  2. Daily surveillance, data, and feedback
  3. Stake-holders buy-in
  4. A well-structured training program for healthcare workers inserting CLs and IV cannulation
  5. A dedicated “observer” during the insertion process
  6. The use of ultrasound for all CLs if possible
  7. Well-defined insertion and maintenance bundles.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Nelson RE, Angelovic AW, Nelson SD, Gleed JR, Drews FA. An economic analysis of adherence engineering to improve use of best practices during central line maintenance procedures. Infect Control Hosp Epidemiol 2015;36:550-6.  Back to cited text no. 2
Ziegler MJ, Pellegrini DC, Safdar N. Attributable mortality of central line associated bloodstream infection: Systematic review and meta-analysis. Infection 2015;43:29-36.  Back to cited text no. 3
Raad I, Hanna H, Maki D. Intravascular catheter-related infections: Advances in diagnosis, prevention, and management. Lancet Infect Dis 2007;7:645-57.  Back to cited text no. 4
Rosenthal VD, Al-Abdely HM, El-Kholy AA, AlKhawaja SA, Leblebicioglu H, Mehta Y, et al. International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module. Am J Infect Control 2016;44:1495-504.  Back to cited text no. 5
Balkhy HH, El-Saed A, Al-Abri SS, Alsalman J, Alansari H, Al Maskari Z, et al. Rates of central line-associated bloodstream infection in tertiary care hospitals in 3 Arabian Gulf countries: 6-year surveillance study. Am J Infect Control 2017;45:e49-e51.  Back to cited text no. 6
Gaid E, Assiri A, McNabb S, Banjar W. Device-associated nosocomial infection in general hospitals, Kingdom of Saudi Arabia, 2013-2016. J Epidemiol Glob Health 2018;7 Suppl 1:S35-40.  Back to cited text no. 7
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Al-Tawfiq JA, Amalraj A, Memish ZA. Reduction and surveillance of device-associated infections in adult intensive care units at a Saudi Arabian hospital, 2004-2011. Int J Infect Dis 2013;17:e1207-11.  Back to cited text no. 14
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Khalid I, Al Salmi H, Qushmaq I, Al Hroub M, Kadri M, Qabajah MR. Itemizing the bundle: Achieving and maintaining “zero” central line-associated bloodstream infection for over a year in a tertiary care hospital in Saudi Arabia. Am J Infect Control 2013;41:1209-13.  Back to cited text no. 16
Yaseen M, Al-Hameed F, Osman K, Al-Janadi M, Al-Shamrani M, Al-Saedi A, et al. Aproject to reduce the rate of central line associated bloodstream infection in ICU patients to a target of zero. BMJ Qual Improv Rep 2016;5. pii: u212545.w4986.  Back to cited text no. 17
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Bukhari S, Banjar A, Baghdadi S, Baltow B, Ashshi A, Hussain W. Central line associated blood stream infection rate after intervention and comparing outcome with National Healthcare Safety Network and International Nosocomial Infection Control Consortium data. Ann Med Health Sci Res 2014;4:682-6.  Back to cited text no. 19
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Gupta SK, Al Khaleefah FK, Al Harbi IS, Ahmed F, Jabar S, Torre MA, et al. An intervention study for the prevention and control of health care-associated infection in the critical cares area of a tertiary care hospital in Saudi Arabia. Indian J Crit Care Med 2018;22:858-61.  Back to cited text no. 21
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