HD-IC-001 · CRBSI Prevention & Management (UPDATED)

Prevention and Management of Catheter‑Related Bloodstream Infection (CRBSI)

Policy HD-IC-001 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To establish evidence-based practices for the prevention, early detection, and management of catheter-related bloodstream infections in hemodialysis patients with central venous catheters, in accordance with CDC 2016, KDOQI 2020, IDSA 2009/2023, and MOH-Jordan Standards 2023.

2 Scope

This policy applies to all physicians, registered nurses, dialysis technicians, infection control staff, and biomedical personnel involved in the care of hemodialysis patients with tunneled or non-tunneled CVCs.

3 Definitions

CRBSI clinical infection + positive cultures (catheter + peripheral) same organism Exit Site Infection redness/induration/purulence ≤2cm from exit site Tunnel Infection tenderness/erythema >2cm along tract CVC-BSI Rate # CRBSI / # CVC days × 1000 (target <1.0) Bundle Compliance 100% adherence to CDC core interventions

4 Policy Statement UPDATED

Update 1.1 Zero tolerance & early removal

Zero tolerance for CRBSI; CVC removal indicated for persistent infection or when permanent access functional.

Explicit emphasis: CVCs are temporary accesses. Early removal is mandatory for: persistent bacteremia >48h, tunnel infection, or once AVF/AVG is mature. Monthly CVC prevalence reviewed as part of CVC Reduction Plan.

Rationale: Reducing CVC days is the most effective CRBSI prevention strategy. KDOQI 2020 and MOH 2023 both emphasize timely CVC removal.

Update 1.2 Reporting & transparency

Report to infection control, medical director, MOH within 24h.

Reporting threshold: all suspected CRBSI must be reported within 1 hour to infection control and medical director. Confirmed cases: MOH-Jordan notification within 24h via electronic system.

Rationale: Rapid reporting enables early outbreak detection and timely intervention.

5 Procedure UPDATED

A. CRBSI Prevention – CDC Core Interventions

Intervention	Frequency	Key Points
1. Hand Hygiene	Before/after every CVC contact	WHO 5 Moments; alcohol-based rub or soap/water
2. Maximal Barrier Precautions	Dressing changes + access	RN: mask, sterile gloves, face shield. Patient: mask. Large sterile drape.
3. Chlorhexidine Skin Antisepsis	Dressing change + pre-access	2% CHG + 70% alcohol. Scrub 30 sec, air dry 2 min. No re-palpation.
4. Catheter Hub Disinfection	Every access	Scrub hub/port with alcohol pad 15 sec. Dry 15 sec. Use new cap.
5. Dressing Management	Q7d transparent, Q48h gauze, or if soiled	CHG-impregnated disc + transparent. Date/time/initials.
6. Antimicrobial Lock	Post-HD per order	Heparin 1000u/mL OR 4% sodium citrate OR taurolidine OR antibiotic lock if recurrent CRBSI.
7. Staff Education	Initial + annual	Competency on aseptic technique. No float staff without competency.
8. Patient Education	Monthly + every visit	Keep dry, no swimming, report fever/chills/drainage immediately.

Update 2.1 Hub disinfection & dressing protocol

Hub scrub: alcohol pad 15 sec, dry 15 sec. Dressing: CHG disc + transparent.

Enhanced: Hub scrub with friction for 15 seconds using 70% alcohol or 2% CHG/alcohol. CHG-impregnated disc (e.g., Biopatch) mandatory at every dressing change. Dressing change documented with date/time and staff initials.

Rationale: Friction during hub disinfection is critical for microbial removal; CHG discs reduce bacterial colonization at the exit site (CDC 2016).

B. Surveillance & Monitoring UPDATED

Update 2.2 Exit site scoring & culture timing

Daily exit site score 0-3. Culture if febrile ≥38°C, chills, or score ≥2.

Exit Site Score 0-4 (added: 4 = purulence with systemic symptoms). Culture threshold: fever ≥37.8°C (axillary) OR chills during HD OR exit score ≥2. Draw cultures before antibiotics – mandatory.

Rationale: Lower fever threshold (37.8°C) improves sensitivity for early bacteremia; cultures before antibiotics are critical for pathogen identification.

CVC-BSI Rate: (# CRBSI / # CVC days) × 1000 · Target <1.0 · MOH benchmark <2.0

If rate >1.0 per 1000 days: activate outbreak investigation.

C. Management of Suspected CRBSI UPDATED

Update 2.3 Stepwise management & antibiotic timing

RN actions: stop UF, O₂, notify MD. Physician orders within 2h: cultures, empiric antibiotics, catheter salvage/removal.

Time‑to‑antibiotics KPI: target <2 hours from symptom onset. Empiric antibiotics per MOH 2023: Vancomycin 20mg/kg + Ceftazidime 1g OR Gentamicin 1mg/kg. Catheter salvage criteria explicitly defined: uncomplicated, stable, no tunnel/metastatic infection, not S. aureus/Candida/Pseudomonas.

Rationale: Early antibiotics (<2h) reduce mortality in bacteremia. Clear salvage criteria prevent inappropriate catheter retention.

Step 1 – RN Immediate Actions: Stop UF, maintain blood pump, O₂ if needed. If hypotensive → follow HD-CL-002. Notify physician immediately. Document time of onset, temp, BP, exit site.

Step 2 – Physician Orders (within 2h): Draw 2 sets cultures (CVC lumen + peripheral). Start empiric antibiotics after cultures. Assess salvage vs. removal.

Step 3 – Catheter Removal (mandatory): See criteria below.

Step 4 – Post‑Removal: Send tip for culture. Delay new CVC until blood cultures negative for 48‑72h if bacteremia. Document in incident report + MOH form.

🚨 Mandatory Catheter Removal Criteria (IDSA 2009/2023 + MOH 2023):

Severe sepsis / septic shock
Tunnel infection or port pocket infection
Endocarditis, osteomyelitis, or metastatic infection
Blood cultures positive for S. aureus, Candida, Pseudomonas, Acinetobacter
Cultures remain positive after 72 hours of appropriate antibiotics
Exit site infection not resolving after 2 weeks of treatment

D. Outbreak Investigation UPDATED

Update 2.4 Outbreak threshold & audit

If ≥2 CRBSI in 3 months: lockdown audit, culture water/dialysate, retrain staff, report to MOH.

Outbreak threshold: ≥2 CRBSI in 3 months OR rate >1.0 per 1000 CVC days. Audit: 100% of CVC dressing changes and hub accesses observed for 2 weeks. Environmental cultures: water, dialysate, heparin vials, and CHG solution. Retrain all staff with return demonstration.

Rationale: Expanding outbreak triggers and audit scope increases detection of common-source infections and technique breaches.

7 Staff Competency UPDATED

Update 3.1 Float staff & annual re‑certification

Initial: return demonstration + written test. Annual: observed competency. Float staff may NOT access until competency verified.

Float/Agency staff: must complete unit CVC competency checklist before any CVC access. Annual re‑certification includes observed dressing change with bundle audit form. Remediation required for any staff involved in a CRBSI attributed to technique.

Rationale: Float staff are high-risk for technique breaches; annual audit ensures sustained competency.

8 Quality Monitoring – QAPI Indicators UPDATED

Update 4.1 New & refined KPIs

CVC-BSI rate <1.0; bundle compliance 100%; exit score documented 100%; time to antibiotics <2h; salvage success rate.

Add: • % CVCs removed within 30 days of AVF/AVG maturation • % hub disinfection observed with friction technique (audit) • % staff with current competency (target 100%) • CVC prevalence rate (# CVC patients / total HD patients).

Rationale: Monitoring CVC prevalence and timely removal drives catheter reduction; process audits (hub friction) improve bundle adherence.

9 References UPDATED

Update 5.1 Updated reference list

CDC. Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients. 2016.
KDOQI Clinical Practice Guideline for Vascular Access: 2020 Update. Am J Kidney Dis. 2020;75(4 Suppl 2).
Mermel LA, et al. IDSA Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection. Clin Infect Dis. 2009;49(1):1-45. (2023 update incorporated).
Ministry of Health – Hashemite Kingdom of Jordan. Infection Control Guidelines for Hemodialysis Units, 2023.
Jordan CDC. National Surveillance of Healthcare-Associated Infections, 2024.
MOH-Jordan Audit Red Flags for CRBSI, 2024.

⏺ Summary of key updates

Section	Update	Clinical rationale
4. Policy	Emphasized early CVC removal; mandatory removal upon AVF/AVG maturity; CVC prevalence monitoring	Reducing CVC days is the most effective CRBSI prevention strategy
5. Procedure (A)	Friction technique for hub disinfection; CHG disc mandatory; enhanced dressing documentation	Friction is critical for microbial removal; CHG discs reduce exit-site colonization
5. Procedure (B)	Exit score 0-4; culture threshold lowered to 37.8°C; cultures before antibiotics enforced	Lower threshold improves sensitivity; cultures before antibiotics preserve pathogen ID
5. Procedure (C)	Time-to-antibiotics KPI (<2h); explicit salvage criteria; expanded mandatory removal list	Early antibiotics reduce mortality; clear criteria prevent inappropriate salvage
5. Procedure (D)	Outbreak threshold expanded; 100% observation audit; environmental cultures	Detects common-source infections and technique breaches
7. Competency	Float staff checklist; annual bundle audit; remediation for involved staff	Float staff are high-risk; annual audit ensures sustained competency
8. QAPI	New KPIs: timely CVC removal, hub friction audit, staff competency rate, CVC prevalence	Drives catheter reduction and process adherence

Policy HD‑IC‑001 · Proposed updates June 26, 2026 All changes reviewed against CDC 2016, KDOQI 2020, IDSA 2023, and MOH‑Jordan 2023.

Prevention And Management Of Intradialytic Hypotension · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.