Risk factors for catheter-related bloodstream infection in children undergoing blood purification therapy: a retrospective cohort study

Introduction

Blood purification techniques are increasingly employed in the management of pediatric critical conditions such as severe renal injury, sepsis/multiple organ dysfunction, and complex metabolic disorders. Central venous catheters (CVCs) have become a crucial means of establishing vascular access for these procedures. However, CVCs also represent one of the most significant portals for iatrogenic bloodstream infections. Catheter-related bloodstream infection (CRBSI) in the pediatric population can substantially increase mortality, prolong hospital stays, and escalate healthcare costs, making it a key safety indicator in pediatric intensive care and blood purification therapy quality. Recent systematic reviews indicate that while the overall incidence of central line-associated bloodstream infection (CLABSI) in children shows a declining trend, it remains high in specific high-risk subgroups, with reported rates varying considerably across centers, suggesting numerous modifiable risk factors awaiting clarification (1,2). Acute kidney injury (AKI), one of the main indications for blood purification, has been reported to occur in approximately 25–30% of critically ill children in pediatric intensive care units (ICUs), and only a small proportion (around 1–2%) require continuous renal replacement therapy (CRRT), typically representing the most severely ill subgroup (3,4). Importantly, children requiring CRRT have been reported to experience high mortality rates, commonly ranging from 40% to over 50%, reflecting the severity of underlying disease and multi-organ dysfunction (5).

Compared to adults, children, particularly those requiring blood purification, exhibit distinct differences in anatomical and physiological characteristics, spectrum of primary diseases, and immune status, rendering their risk for catheter-related infections more complex. Children undergoing blood purification often have severe underlying conditions such as AKI, sepsis/multiple organ failure (MOF), or hematologic diseases, with some being immunocompromised, predisposing them to persistent or recurrent bacteremia. Moreover, factors unique to blood purification, including long-term reliance on CVCs for high-flow extracorporeal circulation, frequent catheter exchanges, and the use of larger-diameter catheters, are also considered potential contributors to increased bacterial adhesion and biofilm formation (6,7). Previous studies in adult and some regional hemodialysis cohorts suggest that the prevalence of CRBSI in maintenance hemodialysis patients can exceed 30%, with catheter type, indwelling duration, and lock solution choice closely linked to infection risk (8,9). However, much of this evidence derives from adult cohorts, with pediatric data being relatively scarce.

In recent years, several studies have explored risk factors and prevention strategies for pediatric CVC-related bloodstream infections from catheter and nursing perspectives, encompassing site selection, catheter diameter and type, indwelling time, presence of chronic underlying diseases or immunosuppression, use of parenteral nutrition (PN), and the standardization of catheter maintenance protocols (10,11). Some research, utilizing Delphi and fuzzy analytic hierarchy processes to synthesize expert opinion, identifies healthcare-related factors and staff knowledge/skills as core determinants of pediatric CLABSI, underscoring the importance of standardized procedures and nursing protocols (12,13). Concurrently, chlorhexidine-based skin antisepsis and dressings have been validated in multiple systematic reviews and randomized controlled trials (RCTs) for reducing catheter colonization and CRBSI incidence. However, their efficacy is not entirely consistent across studies within pediatric critical care and blood purification contexts, indicating that their real-world benefit in specific pediatric subgroups requires further verification (14,15).

Within the highly specialized and critically ill population of children receiving blood purification, prior research has predominantly focused on treatment efficacy and prognosis, with relatively insufficient systematic evaluation of catheter-related infections, especially a lack of large-sample data based on the Chinese population. This single-center retrospective cohort study systematically collects information on general demographic characteristics, catheter- and blood purification therapy-related factors, and nursing practices, aiming to provide an evidence-based foundation for optimizing catheter management strategies, refining nursing protocols, and formulating targeted preventive measures for this patient group. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0047/rc).

Methods

Study design

This was a single-center retrospective cohort study. Participants were pediatric inpatients who underwent blood purification therapy and had an indwelling CVC at our hospital between June 2022 and November 2025. All eligible patients during the study period were consecutively included. A complete-case analysis was performed, and no imputation methods were applied. As is shown in Figure 1. The study protocol was reviewed and approved by the Ethics Committee of Hebei Children’s Hospital (approval No. 2025074). As a retrospective case analysis utilizing existing clinical data without imposing additional risks to patients, the ethics committee granted a waiver for informed consent. Data collection and analysis strictly adhered to the principles of the Declaration of Helsinki and its subsequent amendments, and relevant privacy protection regulations. Only information necessary for the study was extracted. All cases were assigned unique codes for anonymization. Results were reported in aggregate form without disclosing individual patient identities. The research team committed to maintaining the confidentiality of original data, which were used solely for the academic purposes of this study.

Figure 1 Flowchart of the study. CRBSI, catheter-related bloodstream infection; CVC, central venous catheter.

Inclusion criteria: (I) children aged 0–18 years; (II) those requiring blood purification therapy (e.g., for acute renal failure, multiple organ dysfunction syndrome, toxic/metabolic disturbances) with a CVC inserted as vascular access; (III) availability of complete clinical records and catheter care documentation.

Exclusion criteria: (I) catheter removal or patient death within 48 hours post-insertion (insufficient indwelling time for infection assessment); (II) presence of active infection (e.g., sepsis) prior to catheterization or confirmed source of bloodstream infection at the time of catheter insertion.

Observation indicators and definitions

Observational indicators were categorized into four groups: (I) general demographic and baseline clinical characteristics; (II) catheter- and blood purification therapy-related factors; (III) nursing practice-related factors; (IV) primary outcome measure. All data were extracted from medical records and nursing charts.

(I) General demographic and baseline clinical characteristics

Basic demographic information included age, sex, and weight. Age was recorded in years, converted to decimal for infants under 1 year. Weight was measured on admission. The presence of underlying chronic diseases was recorded as “yes” if any of the following conditions were present: chronic kidney disease, congenital heart disease, chronic liver disease, immunodeficiency disorders, hematologic malignancies, and other chronic systemic diseases requiring ongoing medical management. Immunosuppressed status was assessed and defined according to the following criteria: recent chemotherapy (≤30 days), continuous systemic corticosteroid use ≥0.5 mg/kg/day (≥7 days), post-organ transplant immunosuppressant use, or significant CD4⁺ T-cell depletion (<500/µL). Given the heterogeneity of these conditions, a descriptive classification of immunosuppression subtypes was performed. These indicators reflected susceptibility to infection.

The primary disease necessitating blood purification was recorded (e.g., AKI, sepsis/MOF, hematologic disease with AKI, intoxication/metabolic disturbances). Admission to the ICU, requirement for invasive mechanical ventilation, and initial inflammatory markers such as C-reactive protein (CRP), the only inflammatory biomarker routinely collected in this study, were recorded.

(II) Catheter- and blood purification therapy-related factors

Catheter-related factors included insertion site (internal jugular, femoral, or subclavian vein), catheter diameter [categorized as ≥7 or <7 Fr, selected based on common clinical practice to ensure adequate blood flow during CRRT/intermittent hemodialysis (IHD)], and indwelling time (days). Repeated catheterization (≥2 times) was recorded, defined as two or more separate catheter placement events during the study period. Blood purification mode (CRRT vs. IHD) and treatment parameters (single session duration >8 hours was considered high workload, based on clinical practice where sessions exceeding 8 hours are generally regarded as prolonged and more resource-intensive) were noted.

Hemodynamic instability [use of vasoactive drugs (e.g., norepinephrine, epinephrine) or significant mean arterial pressure drop, defined as a decrease of ≥20% from baseline or a reduction to <60 mmHg, or requiring vasoactive support (16,17) was recorded. Administration of total or partial PN (TPN/PPN) was noted due to potential infection risk from hyperosmolar solutions. The lowest platelet count during catheterization was recorded, with <50×10⁹/L defined as thrombocytopenia.

CVCs were defined as vascular access devices with the distal tip located in a central vein (e.g., lower third of the superior vena cava or cavoatrial junction), regardless of insertion route, including centrally, femorally, and peripherally inserted central catheters.

(III) Nursing practice-related factors

Nursing indicators extracted from records and quality control systems included: whether catheter maintenance was led by a specialist intravenous therapy nurse, implementation of a standardized catheter care checklist, skin antisepsis method, timeliness of dressing changes, and completeness of nursing assessment documentation. Nursing audits were conducted based on routinely collected clinical records and were not performed blinded to infection status.

Specialist nurse involvement was defined if ≥80% of routine maintenance was performed by such nurses. Skin antisepsis using chlorhexidine-alcohol was deemed standard; using povidone-iodine or alcohol alone was considered non-standard. Timely dressing change required transparent dressings to be changed every 7 days or immediately upon becoming damp, loose, or soiled; failure to meet either criterion was untimely. Completeness of nursing records (including skin condition, exudate, catheter patency) was assessed.

(IV) Primary outcome measure: CRBSI

The primary outcome was the occurrence of CRBSI, diagnosed per Centers for Disease Control and Prevention (CDC) criteria: bloodstream infection during catheter use or within 48 hours of removal, plus one of the following: (i) positive CVC blood culture with matching pathogen from peripheral blood; (ii) positive catheter tip culture with identical peripheral blood culture; (iii) clinically evident bloodstream infection after excluding other sources. In this study, CRBSI was defined according to CDC criteria; however, microbiologically confirmed and clinically diagnosed cases were not consistently distinguished in the original dataset, and therefore were analyzed as a single outcome. For the same patient, a new infection after catheter reinsertion was considered a new event; only the first event was recorded if multiple infections occurred with the same catheter.

Statistical analysis

Data were analyzed using SPSS software (version 26.0). Descriptive statistics summarized patient characteristics, catheter usage, and infection rates. Continuous variables were expressed as mean ± standard deviation or median (interquartile range, IQR) and compared between infected and non-infected groups using independent samples t-tests or Mann-Whitney U tests, as appropriate. Categorical variables were presented as counts (percentages) and compared using Chi-squared (χ²) tests. Variables with P<0.05 in univariate analysis were first assessed for multicollinearity. All candidate variables showed variance inflation factor values <5 and were therefore retained. These variables were subsequently entered simultaneously into a multivariate logistic regression model using the enter (input) method, with CRBSI occurrence as the dependent variable (yes =1, no =0). Categorical variables were dummy-coded. Statistical significance was set at α=0.05. Adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were reported for variables retained in the final model. A P value <0.05 was considered statistically significant.

Results

Comparison of general and baseline clinical characteristics

The proportion of children with chronic underlying diseases was higher in the infection group (64.06% vs. 46.63%; χ²=6.596, P=0.01). The prevalence of immunosuppressed status was also higher in the infection group (40.63% vs. 24.16%; χ²=7.523, P=0.006). Among patients classified as immunosuppressed, the underlying conditions included chemotherapy, corticosteroid therapy, transplant-related immunosuppression, and CD4 depletion; these categories were not mutually exclusive. No statistically significant differences were observed between groups in age, sex, weight, nutritional status, distribution of primary diseases, immediate ICU admission, mechanical ventilation use, or initial CRP level (all P>0.05; Table 1).

Comparison of catheter characteristics and blood purification therapy-related factors

Compared with the non-infection group, the infection group had a higher frequency of femoral vein catheterization (65.63% vs. 42.42%; χ²=11.766, P=0.01), a higher proportion of catheters with diameter ≥7 Fr (42.19% vs. 29.49%; χ²=4.056, P=0.044), and longer catheter indwelling time [15.50 (13.00–18.75) vs. 11.00 (8.00–14.00) days; Z=−7.133, P<0.001]. The incidence of repeated catheterization (≥2 times) was also higher in the infection group (31.25% vs. 14.89%; χ²=10.114, P=0.001), as was the use of TPN (53.13% vs. 34.83%; χ²=7.736, P=0.005). No significant differences were observed between groups in CRRT mode utilization, single-session duration>8 hours, hemodynamic instability, or thrombocytopenia (all P>0.05; Table 2).

Comparison of catheter maintenance-related nursing practices

The non-infection group had higher compliance rates for several nursing measures. The use of chlorhexidine-alcohol for skin antisepsis was higher in the non-infection group (88.76% vs. 71.88%; χ²=13.000, P<0.001), and the rate of timely and standardized dressing change was also higher (87.36% vs. 70.31%; χ²=12.205, P<0.001).

Other measures, including specialist nurse involvement, use of standardized care checklists, and completeness of nursing assessment documentation, showed lower rates in the infection group, but differences between groups were not statistically significant (all P>0.05; Table 3).

Multivariate logistic regression analysis of risk factors for catheter-related infection

Multivariate logistic regression identified immunosuppressed state (OR =2.182, 95% CI: 1.101–4.327, P=0.03), femoral vein catheterization (OR =2.445, 95% CI: 1.275–4.689, P=0.007), catheter diameter ≥7 Fr (OR =2.201, 95% CI: 1.006–4.812, P=0.048), and catheter indwelling time (OR =1.344, 95% CI: 1.229–1.469, P<0.001) as independent risk factors for CRBSI. Standardized dressing change was an independent protective factor (OR =0.355, 95% CI: 0.142–0.889, P=0.03). Chronic underlying disease (P=0.64), repeated catheterization ≥2 times (P=0.50), TPN use (P=0.057), and chlorhexidine-alcohol antisepsis (P=0.08) were not independently associated with CRBSI in the multivariate analysis (Table 4).

Pathogen distribution in CRBSI

Pathogen distribution was analyzed based on available microbiological data from patients with CRBSI. Gram-positive cocci predominated, accounting for 51.56% of isolates. Coagulase-negative staphylococci (CNS) were the most common pathogens (26.56%, 17/64), followed by Staphylococcus aureus (18.75%, 12/64) and Enterococcus spp. (6.25%, 4/64). Gram-negative bacilli collectively constituted 32.38%, including Escherichia coli (10.94%, 7/64), Klebsiella spp. (9.38%, 6/64), Pseudomonas aeruginosa (7.81%, 5/64), and other Gram-negative bacilli (6.25%, 4/64). Fungal infections comprised 14.06%, with Candida albicans (5 isolates, 7.81%) and other/unidentified fungi (4 isolates, 6.25%) (Table 5).

Discussion

Focusing on CRBSI in children undergoing blood purification, this single-center retrospective cohort study systematically analyzed general clinical features, catheter-related factors, and nursing practices. It identified immunosuppression, femoral vein catheterization, catheter diameter ≥7 Fr, and prolonged indwelling time as independent risk factors, while timely and standardized dressing changes were associated with a lower risk. These findings suggest that in the high-risk setting of pediatric blood purification, alongside patient susceptibility, catheter selection and nursing quality may significantly influence infection risk.

Regarding host factors, this study found that an immunosuppressed state was associated with approximately a twofold increase in the risk of CRBSI, aligning closely with recent systematic reviews and expert consensus on pediatric CVC infection risk factors. A meta-analysis by Li et al. (11) of 15,221 children indicated that congenital diseases, central nervous system disorders, and TPN were associated with an increased risk of CLABSI, implying that immune compromise or prolonged critical illness may represent a common basis. Ardahan Sevgili and Kahraman (12), using Delphi and fuzzy analytic hierarchy processes to weight pediatric CLABSI risk factors, ranked healthcare-related factors and professional knowledge/skills as primary indicators, indirectly reflecting that immunocompromised children may be particularly vulnerable to infection when exposed to suboptimal procedural or maintenance environments. For the blood purification population, underlying disease and immunosuppression often coexist, which may suggest the need for infection risk stratification prior to catheter insertion and implementation of stricter maintenance protocols and monitoring for high-risk children.

Catheter-related structure and usage patterns represent another critical aspect of CRBSI prevention. This study found that femoral vein catheterization, catheter diameter ≥7 Fr, and each additional day of indwelling time significantly associated with an increased risk of CRBSI. Studies in adult and mixed populations similarly confirm higher CLABSI rates with femoral sites compared to internal jugular and subclavian veins, which may be attributed to factors like local moisture, contamination risk, and limited mobility of the patient. In pediatric blood purification, clinical practice often favors larger catheters and femoral access for ease of fixation and to meet flow demands. However, our results suggest that this convenience-first approach may require re-evaluation. A meta-analysis by Guo et al. (7) on CRBSI in hemodialysis catheters also identified insertion site, catheter type, and indwelling time as significant risk factors, consistent with our findings. An earlier systematic review by Marik et al. (18) reported a significantly lower CRBSI risk for internal jugular versus femoral catheters (risk ratio ≈1.90). A recent study on non-tunneled, dual-lumen dialysis catheters (19) found that while the difference in CRBSI risk between jugular and femoral access was smaller, jugular access was associated with longer catheter survival and lower mortality, hinting at the prognostic implications of access choice and long-term management. For long-term dialysis patients, CVC use has been associated with higher rates of catheter-related, exit-site, or tunnel infections (20). Therefore, when feasible, internal jugular or subclavian veins may be preferred, and the smallest feasible catheter diameter may be selected while meeting therapy goals. Incorporating a mandatory “daily assessment of catheter necessity” into CRRT/IHD protocols may be important to help minimize indwelling time.

A key finding of this study is that timely and standardized dressing change was associated with a lower risk of CRBSI, whereas the use of chlorhexidine-alcohol for skin antisepsis showed only a non-significant trend towards risk reduction. Research in pediatric critical care/CVC populations has shown that chlorhexidine-gluconate (CHG)-impregnated dressings do not consistently reduce the incidence of CLABSI/CRBSI, although they may decrease catheter colonization rates (15). A review by Poletti et al. (21) of RCTs on pediatric CHG dressings [2000–2025] found no significant reduction in CLABSI but suggested decreased skin colonization. An adult ICU RCT using CHG/vancomycin-impregnated dressings primarily improved catheter colonization, rather than demonstrating a clear reduction in bloodstream infection (22). A systematic review specific to pediatric patients also indicated uncertain or non-significant protective associations of CHG dressings alone against CLABSI/CRBSI (23). Correspondingly, recent systematic reviews and meta-analyses emphasize that for CVC patients (adults and children combined), a combination of dressing + securement device + scheduled/indication-triggered changes + standardized nursing protocols may be important for reducing CRBSI (24). This evidence is consistent with our study: within an established “bundle” approach to catheter care, the consistency and timing of protocol execution often may outweigh the incremental benefit of any single material upgrade. For children on blood purification, with their delicate skin, increased perspiration, frequent peri-catheter bleeding, and potential dialysate contamination, failure to change dressings promptly when damp, loose, or soiled may facilitate microbial invasion despite appropriate antiseptic choice. Thus, promoting standardized dressing change protocols based on both scheduled intervals (e.g., every 7 days) and clinical indications (change immediately upon soiling) may be considered a priority for nursing quality improvement.

Notably, repeated catheterization (≥2 times) and TPN use, which were significantly associated with infection in univariate analysis, did not remain independent risk factors after multivariate adjustment. While a large-scale meta-analysis (11) has reported that TPN, multiple catheters/repeated insertion, and prolonged indwelling time are significantly associated with pediatric CLABSI risk, and “chronic CVC + TPN” has been identified as an independent risk factor even in settings with high bundle adherence (10), our multivariate model did not retain TPN and repeated catheterization as independent factors. Potential explanations include limited sample size and the fact that patients receiving TPN or requiring multiple catheters often concurrently exhibit more upstream confounding factors like immunosuppression, critical illness, and prolonged catheter use, whose effects may have attenuated the contributions of TPN/re-catheterization in the model. Therefore, this does not necessarily imply that TPN and multiple insertions are harmless but may highlight the need for stricter control of catheter insertions and judicious assessment of TPN indications in future research and practice.

Regarding pathogen spectrum, Gram-positive cocci constituted over half of the isolates in this study, with CNS and Staphylococcus aureus being most prevalent. Gram-negative bacilli and fungi also accounted for substantial proportions. This distribution is broadly consistent with large surveillance data and recent reviews. StatPearls summaries on CLABSI pathogens indicate Gram-positive cocci, especially CNS, Staphylococcus aureus, and Enterococcus, remain predominant, while Gram-negative bacilli and Candida constitute about one-third (25). The pediatric meta-analysis by Li et al. (11) reports a similar profile. A summary of recent CLABSI pathogens by Weiner-Lastinger et al. (26) also highlights the importance of Gram-positive cocci (especially CNS) and fungi (Candida), alongside notable Gram-negative bacteria. Devrim et al. (27), analyzing pathogen distribution after implementing a central-line bundle in pediatric patients, found CNS remained the primary isolate, with Candida proportions decreasing post-bundle but fungi and Gram-negative bacilli still present. For children on blood purification, these findings suggest that empirical antibiotic therapy may need to cover methicillin-resistant staphylococci and common Gram-negative bacilli, while candidemia may need to be considered in patients with long-term catheterization and prior broad-spectrum antibiotic exposure. In an era of increasing antimicrobial stewardship, the local pathogen profile provided by this study may also help inform optimization of empirical therapy and de-escalation strategies.

From nursing and management perspectives, our results are consistent with recent infection prevention strategies for CRRT and blood purification patients. An infection control index system for CRRT developed via the Delphi method by Zhao et al. (28) demonstrated that comprehensive interventions across structure, process, and outcome levels were associated with a reduction in catheter infection rates from 16.1% to 3.1%. Research also indicates that standardized dressing + catheter securement + maintenance bundles may be associated with a decrease in catheter-related complications, including CRBSI and tip colonization (24). The study by Ardahan Sevgili and Kahraman emphasizes that healthcare staff knowledge/skills and protocol implementation level carry the highest weight among pediatric CLABSI risk factors (12). Combined with our findings, it is reasonable to conclude that for pediatric blood purification patients, standardized catheter maintenance protocols and high-compliance dressing change strategies may represent important components for mitigating infection risk atop a high baseline vulnerability. In practice, incorporating catheter site selection, diameter assessment, daily line necessity evaluation, dressing condition checks, and documentation completeness into CRRT/IHD quality control indicator systems, coupled with ongoing audit and feedback, may help foster closed-loop improvement.

Of course, this study has several limitations. First, as a single-center retrospective study with a limited sample drawn from critically ill children in a tertiary hospital, the results may overestimate infection risk for the general population, and generalizability is constrained. Second, potential confounders such as antibiotic exposure history, operator experience for catheter insertion, and catheter tip position were not analyzed, possibly leading to residual confounding. Third, due to the retrospective nature of the study, the exact timing of infection onset was not consistently available, which precluded time-to-event analysis and the use of Cox proportional hazards regression. In addition, logistic regression treated CRBSI as a binary outcome without accounting for variable catheter indwelling time. Since catheter duration represents both an exposure window and a risk factor, this may introduce time-at-risk bias and potentially lead to overestimation of effect sizes. Fourth, while using CDC criteria for CRBSI definition facilitates international comparison, distinguishing catheter-related infection from primary sepsis remains challenging. In addition, because the CDC definition includes clinically diagnosed bloodstream infection without mandatory microbiological confirmation, this may have led to potential misclassification and possible over-attribution of infection to the catheter. In addition, immunosuppression was defined using heterogeneous clinical criteria, including chemotherapy, corticosteroid use, transplant-related immunosuppression, and CD4 depletion, which may differ in magnitude and mechanisms of infection risk and may have influenced the observed associations. In addition, the lack of blinding in nursing audits may have introduced potential assessment bias. Some potentially relevant variables, such as prior bacteremia and concurrent catheter use, were not included due to incomplete documentation in this retrospective dataset. Future multicenter prospective studies incorporating microbial molecular typing and more granular nursing process indicators are warranted to further validate and refine these findings.

Conclusions

In summary, this study focusing on the specific population of children undergoing blood purification suggests that immunosuppression, femoral vein catheterization, large-diameter catheters, and prolonged indwelling time are associated with an increased risk of CRBSI, whereas high-quality, standardized dressing changes may be associated with a lower risk of CRBSI. Clinical practice may consider prioritizing rational vascular access and catheter size selection, as well as reinforcing stratified management for high-risk children, and establishing a comprehensive prevention system centered on catheter maintenance protocols and nursing quality control. This approach may help maximize the reduction of catheter-related infection risk and alleviate the burden on young patients while ensuring adequate blood purification delivery.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0047/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0047/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0047/prf

Funding: This study was supported by 2019 Hebei Provincial Health Department Scientific Research Fund Project: Scientific and Technological Achievement Promotion Project (No. 20190844).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0047/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study protocol was reviewed and approved by the Ethics Committee of Hebei Children’s Hospital (approval No. 2025074). As a retrospective case analysis utilizing existing clinical data without imposing additional risks to patients, the ethics committee granted a waiver for informed consent. Data collection and analysis strictly adhered to the principles of the Declaration of Helsinki and its subsequent amendments, and relevant privacy protection regulations.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Nunn JL, Takashima MD, Wray-Jones EM, et al. Central venous access device adverse events in pediatric patients with cancer: a systematic review and meta-analysis. Support Care Cancer 2024;32:662. [Crossref] [PubMed]
2. Prestel C, Fike L, Patel P, et al. A Review of Pediatric Central Line-Associated Bloodstream Infections Reported to the National Healthcare Safety Network: United States, 2016-2022. J Pediatric Infect Dis Soc 2023;12:519-21. [Crossref] [PubMed]
3. Buccione E, Guzzi F, Colosimo D, et al. Continuous Renal Replacement Therapy in Critically Ill Children in the Pediatric Intensive Care Unit: A Retrospective Analysis of Real-Life Prescriptions, Complications, and Outcomes. Front Pediatr 2021;9:696798. [Crossref] [PubMed]
4. Meena J, Mathew G, Kumar J, et al. Incidence of Acute Kidney Injury in Hospitalized Children: A Meta-analysis. Pediatrics 2023;151:e2022058823. [Crossref] [PubMed]
5. Ding JJ, Hsia SH, Jaing TH, et al. Prognostic Factors in Children with Acute Kidney Injury Requiring Continuous Renal Replacement Therapy. Blood Purif 2024;53:511-9. [Crossref] [PubMed]
6. Opoku-Asare B, Boima V, Ganu VJ, et al. Catheter-Related Bloodstream Infections among patients on maintenance haemodialysis: a cross-sectional study at a tertiary hospital in Ghana. BMC Infect Dis 2023;23:664. [Crossref] [PubMed]
7. Guo H, Zhang L, He H, et al. Risk factors for catheter-associated bloodstream infection in hemodialysis patients: A meta-analysis. PLoS One 2024;19:e0299715. [Crossref] [PubMed]
8. Robinson CH, Harvey E, Nemec R, et al. Use of 4% tetrasodium EDTA (KiteLock™) to prevent central venous catheter-related bloodstream infections in pediatric hemodialysis patients. Pediatr Nephrol 2025;40:1081-91. [Crossref] [PubMed]
9. Hajji M, Neji M, Agrebi S, et al. Incidence and challenges in management of hemodialysis catheter-related infections. Sci Rep 2022;12:20536. [Crossref] [PubMed]
10. Marks KT, Rosengard KD, Franks JD, et al. Risk factors for central line-associated bloodstream infection in the pediatric intensive care setting despite standard prevention measures. Infect Control Hosp Epidemiol 2024;45:1271-9. [Crossref] [PubMed]
11. Li L, Zheng Y, Deng W, et al. Central line-associated bloodstream infections in children: a systematic review and meta-analysis. Transl Pediatr 2025;14:799-811. [Crossref] [PubMed]
12. Ardahan Sevgili S, Kahraman A. Determination of risk factors for central line associated bloodstream infections in children: A Delphi and Fuzzy Analytic Hierarchy Process study. J Pediatr Nurs 2026;86:443-50. [Crossref] [PubMed]
13. Gerçeker GÖ, Yardımcı F, Aydınok Y. Randomized controlled trial of care bundles with chlorhexidine dressing and advanced dressings to prevent catheter-related bloodstream infections in pediatric hematology-oncology patients. Eur J Oncol Nurs 2017;28:14-20. [Crossref] [PubMed]
14. Puig-Asensio M, Marra AR, Childs CA, et al. Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis. Infect Control Hosp Epidemiol 2020;41:1388-95.
15. Duyu M, Karakaya Z, Yazici P, et al. Comparison of chlorhexidine impregnated dressing and standard dressing for the prevention of central-line associated blood stream infection and colonization in critically ill pediatric patients: A randomized controlled trial. Pediatr Int 2022;64:e15011. [Crossref] [PubMed]
16. Mao R, Zhou Z, Yang Y, et al. Effects of colloid versus crystalloid priming on early haemodynamics in critically ill patients receiving CRRT: protocol for a randomised controlled trial. BMJ Open 2025;15:e089777. [Crossref] [PubMed]
17. Shawwa K, Kompotiatis P, Jentzer JC, et al. Hypotension within one-hour from starting CRRT is associated with in-hospital mortality. J Crit Care 2019;54:7-13. [Crossref] [PubMed]
18. Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med 2012;40:2479-85. [Crossref] [PubMed]
19. Phatpituk T, Anumas S, Chatkrailert A. Catheter-Related Infection in Uncuffed, Non-Tunneled Dual-Lumen Catheters: Incidence and Risk Factors by Internal Jugular Versus Femoral Site in a Retrospective Cohort. Hemodial Int 2025;29:557-64. [Crossref] [PubMed]
20. Miller LM, Clark E, Dipchand C, et al. Hemodialysis Tunneled Catheter-Related Infections. Can J Kidney Health Dis 2016;3:2054358116669129. [Crossref] [PubMed]
21. Poletti G, Mariani A, Brovarone S, et al. Efficacy of Chlorhexidine-Impregnated Dressings Compared to Standard Dressings in Preventing CLABSI/CRBSI and Catheter Colonization in Pediatric Patients: A Literature Review. Hygiene 2025;5:59. [Crossref]
22. Lessa GC, Zanella CC, Krause GP, et al. Dressing Impregnated with Chlorhexidine and Vancomycin for the Prophylaxis of Central Venous Catheter-Related Infections-A Randomized Trial. Infect Dis Rep 2025;17:102. [Crossref] [PubMed]
23. Deng Z, Qin J, Sun H, et al. Effectiveness of Impregnated Central Venous Catheters on Catheter-Related Bloodstream Infection in Pediatrics. Front Pediatr 2022;10:795019. [Crossref] [PubMed]
24. Xu H, Hyun A, Mihala G, et al. The effectiveness of dressings and securement devices to prevent central venous catheter-associated complications: A systematic review and meta-analysis. Int J Nurs Stud 2024;149:104620. [Crossref] [PubMed]
25. Haddadin Y, Annamaraju P, Regunath H. Central Line–Associated Blood Stream Infections. Treasure Island (FL): StatPearls Publishing; 2026.
26. Weiner-Lastinger LM, Haass K, Gross C, et al. Pathogens attributed to central-line-associated bloodstream infections in US acute-care hospitals during the first year of the coronavirus disease 2019 (COVID-19) pandemic. Infect Control Hosp Epidemiol 2023;44:651-4. [Crossref] [PubMed]
27. Devrim İ, Sandal OS, Çelebi MY, et al. The impact of central line bundles on the timing of catheter-associated bloodstream infections and their microbiological distribution in critically ill children. Eur J Pediatr 2023;182:4625-32. [Crossref] [PubMed]
28. Zhao Z, Zhao H, Yang Y, et al. Establishment and application of an infection prevention and control system for patients undergoing continuous renal replacement therapy. Front Med (Lausanne) 2025;12:1506188. [Crossref] [PubMed]