Centers for Disease Control and Prevention (CDC) Dialysis Bloodstream Infection (BSI) Prevention Collaborative Protocol
This protocol outlines a suggested approach to cleaning catheter hubs prior to accessing the catheter for dialysis. It is based on evidence where available and incorporates practice recommendations from collaborative members and theoretical rationale when published evidence is unavailable.
Catheter refers to the central venous catheter (CVC)
Hub refers to the end of the CVC that connects to the blood lines or cap
Cap refers to a device that screws on to and occludes the hub
Limb refers to the catheter portion that extends from the patient’s body to the hub
Blood lines refer to the arterial and venous ends of the extracorporeal circuit that connect the patient’s catheter to the dialyzer
Catheter Connection and Disconnection Steps:
1. Perform hand hygiene and don new clean gloves.
2. Clamp the catheter (Note: Always clamp the catheter before removing the cap. Never leave an uncapped catheter unattended).
3. Disinfect the hub with caps removed using an appropriate antiseptic (see notes).
a. (Optional) Prior to cap removal, disinfect the caps and the hub that is visible and discard the antiseptic pad (i.e., use a separate antiseptic pad for the subsequent disinfection of the hub).
b. Remove the caps and disinfect the hub with a new antiseptic pad for each hub. Clean the sides (threads) and end of the hub thoroughly with friction, making sure to remove any residue (e.g., blood).
c. Using the same antiseptic pad, apply antiseptic with pressure to the catheter, moving from the hub at least several centimeters towards the body. Hold the limb while allowing the antiseptic to dry.
d. Use a separate antiseptic pad for each hub/catheter limb. Leave hubs “open” (i.e.,
uncapped and disconnected) for the shortest time possible.
4. Always handle the catheter hubs aseptically. Once disinfected, do not allow the catheter hubs to touch nonsterile surfaces.
5. Attach sterile syringe, unclamp the catheter, withdraw blood, and flush per facility protocol.
6. Repeat for other limb (this might occur in parallel).
7. Connect the ends of the blood lines to the catheter aseptically. Disinfecting the ends of the blood lines is not required IF the blood lines have been handled aseptically prior to connection and care has been taken to not contaminate the blood lines.
8. Remove gloves and perform hand hygiene.
1. Perform hand hygiene and don new clean gloves.
2. Clamp the catheter (Always clamp the catheter before disconnecting. Never leave an uncapped catheter unattended).
3. Disinfect the catheter hub before applying the new cap using an appropriate antiseptic (see
a. (Optional) Disinfect the connection prior to disconnection. If this is done, use a separate antiseptic swab for the subsequent disinfection of the hub.
b. Disconnect the blood line from the catheter and disinfect the hub with a new antiseptic pad. Clean the sides (threads) and end of the hub thoroughly with friction, making sure to remove any residue (e.g., blood).
c. Use a separate antiseptic pad for each hub. Leave hubs “open” (i.e., uncapped and disconnected) for the shortest time possible.
4. Always handle the catheter hubs aseptically. Once disinfected, do not allow the catheter hubs to
touch nonsterile surfaces. Hold the catheter until the antiseptic has dried.
5. Attach the new sterile caps to the catheter aseptically. Use caution if tape is used to secure caps to the catheter (see notes).
6. Ensure that catheter is still clamped.
7. Remove gloves and perform hand hygiene.
Notes / Discussion
Antiseptic Use and Selection
As described in the 2011 CDC/Healthcare Infection Control Practices Advisory Committee (HICPAC) Guidelines for the Prevention of Intravascular Catheter-Related Infections, prior to accessing the catheter hub it should be disinfected with an appropriate antiseptic (greater than 0.5% chlorhexidine with alcohol, 70% alcohol, or 10% povidone-iodine). There is not enough evidence to recommend one antiseptic over the others. Generally, antiseptics should be allowed to dry for maximal effect.
If using 70% alcohol, sterile antiseptic pads should be used (sterile pads are labeled sterile and
packaging for nonsterile pads often does not state whether the pads are sterile or nonsterile). For
practical reasons, pads or similar products might be preferred over other forms of antiseptics (e.g., swabsticks) for disinfecting the catheter as they are malleable and allow for vigorous cleaning of small spaces.
If using an antiseptic that leaves a residue (e.g., chlorhexidine), avoid allowing large amounts of antiseptic to enter the lumen of the catheter to avoid potential toxicities to the patient.
If using chlorhexidine, ensuring that all blood residue is removed is particularly important to maximize the effect of the antiseptic.
The role of soaking caps in an antiseptic prior to removing them is not clear. It is not a CDC/HICPAC recommendation. This procedure is described in the 2000 National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) Vascular Access Guidelines but was not included in the 2006 update.
Handling Catheter Hubs
Catheter hubs should always be handled aseptically. Once disinfected, the catheter hubs should not be allowed to touch nonsterile surfaces. This might be best performed by holding them until the antiseptic dries. During this time, the staff member performing the procedure can also ensure that the catheter remains clamped.
When disinfecting catheter hubs, only clean, nonsterile gloves are required if aseptic technique is maintained.
When accessing the line, disinfecting the ends of the blood lines is not required if care has been taken not to contaminate the ends of the blood lines (i.e., through careful aseptic technique). Blood lines can become contaminated during connections and disconnections, as well as during the priming process. Contact with contaminated prime waste from prime buckets that have not been properly cleaned and disinfected or through backflow from waste handling ports must be avoided. Disinfecting the bloodlines does not address this issue.
Disconnection and Line Reversals
Catheter hubs should be disinfected again after disconnecting from bloodlines and before replacing a new cap at the end of a treatment. This should be done in a manner similar to that used when disinfecting the hub prior to accessing. Disinfecting the catheter hub and the end of the extracorporeal blood line should also be performed if, during a treatment, a patient must be disconnected and their blood is re-circulated. Anytime a patient is disconnected this should be done aseptically and the number of times a patient’s catheter is disconnected from the blood lines should be minimized to the extent possible.
Securing Caps with Tape
Caution should be used if taping caps on to hubs between treatments. Tape can leave residue on the hubs that might make disinfecting them more difficult.
Use of Masks
Although data supporting the use of masks during catheter accessing/deaccessing to prevent vascular access infections is lacking, this practice is recommended for patients and staff in the 2000 KDOQI guidelines and is included in the Centers for Medicare and Medicaid Services (CMS) End Stage Renal Disease Program Interpretive Guidance.
Personal Protective Equipment (PPE)
Proper PPE should always be worn by staff to avoid exposure to potentially infectious blood and body fluids when connecting/disconnecting catheters.
This includes practices that prevent the contamination of clean/sterile items and surfaces. Once tasks
requiring aseptic technique have been started, care must be taken to avoid contamination of gloves and other clean/sterile items that can occur when touching dirty surfaces (e.g., positioning patient, using computer keyboard).
1. National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 2006; 48 (suppl 1):S1-S322.
2. National Kidney Foundation. KDOQI Clinical Practice Guidelines for Hemodialysis Adequacy,
2000. Am J Kidney Dis 2001; 37 (suppl 1):S7-S64.
3. O’Grady NP, Alexander M, Burns LM, et al. Guideline for the prevention of intravascular
catheter-related infections. Clin Infect Dis 2011; 52:e162-e193.