*3. Use of full-barrier precautions during CVC insertion*

Bottom Line: Maintain aseptic technique for the insertion of intravascular catheters. Category IA: Maximal sterile barrier precautions (e.g., cap, mask, sterile gown, sterile gloves, and large sterile drape) during the insertion of CVCs substantially reduce the incidence of catheterrelated bloodstream infection (CR-BSI) compared with standard precautions (e.g., sterile gloves and small drapes) [29].

#### *4. Avoid the femoral site*

Bottom Line: A subclavian site is preferred for infection control purposes, although other factors (e.g., the potential for noninfectious and catheter-operator skill) should be considered for deciding where to place the catheter. Category IA: The site at which a catheter is placed influences the subsequent risk for catheter-related infection and phlebitis. For adults, lower extremity insertion sites are associated with a higher risk of infection than upper extremity sites. As a result, authorities recommend that CVCs be placed in the subclavian site instead of a jugular or femoral site to reduce the risk for infection [29].

#### *5. Remove unnecessary central venous catheters*

Bottom Line: Promptly remove any intravascular catheter that is no longer essential. Category IA: One of the most effective strategies for preventing CR-BSIs is to eliminate, or at least reduce, exposure to central venous catheters. The decision regarding the need for a catheter, however, is complex and therefore difficult to standardize into a practice guideline. Nonetheless, to reduce exposure to central venous catheters, the ICU team should adopt a strategy to systematically evaluate daily whether any catheters or tubes can be removed [29].

#### *6. Hygienic management of catheters*

Minimize the manipulation of the connections and clean the injection sites of the catheter with isopropyl alcohol 70° before its use. Category IA: Another characteristic of this study was that the people in charge of the catheters needed to do an auto-test online, assist to safety meetings before they can be part of the study [32]. This study was performed in 68% of all ICUs in Spain, with a reduction of 50% in the bacteremia related to catheter in a two-year period [19].

In addition to the intervention to reduce the rate of catheter-related bloodstream infection, the ICUs implemented the use of a daily goal to improve clinician-to-clinician communication within the ICU, an intervention to reduce the incidence of ventilator-associated pneumonia, and a comprehensive unit-based safety program to improve the safety culture. The period necessary for the implementation of each intervention was estimated to be 3 months [29].

#### **8.2. Our recommendations for developing countries**

After analyzing the literature and the results in the different countries and our own experience, we made some recommendations that could help any HD program in developing countries for reducing their bacteremia incidence, and thus reducing the risk of IE.
