Reassessing the Risk: A Retrospective Analysis of CLABSI Risk in Femoral, Internal Jugular, and Subclavian Central Venous Catheters.

Background: Central line-associated bloodstream infections (CLABSIs) represent a significant healthcare challenge due to their association with increased morbidity, mortality, and financial burden. Current guidelines discourage the use of the femoral vein (FV) for central venous catheter (CVC) placement due to a perceived higher infection risk compared to the internal jugular vein (IJV) or subclavian (SCV) sites. However, recent evidence questions this assumption and suggests that femoral CVCs may carry similar risks to other sites, emphasizing the need for updated analyses. Objective: The goal of this study was to address the misconception that femoral CVCs have a higher associated risk for developing CLABSI compared to other central line sites. This study evaluates risk for CLABSI across FV, IJV, and SCV sites. Methods: Using the TriNetX Research Network to conduct a retrospective cohort analysis, initial queries identified 99,216 patients who were encountered between 2014 and 2025 for CVC placement. Following propensity score matching, 65,265 of these patients were retained for statistical analysis. Patients were categorized based on anatomic CVC placement sites into IJV, SCV, and FV cohorts. CLABSI incidence was determined using ICD-10-CM codes within 1 day to 1 month post-CVC insertion. Sensitivity analyses were conducted for the 2014-2025 period, as well as for the 2014-2019 and 2019-2025 periods to assess overall risk and evaluate for changes in CLABSI risk by anatomic site over time. Outcomes were compared using risk percentages, risk ratios, and odds ratios with 95% confidence intervals to compare differences in risk for CLABSI across different sites. Results: Overall, femoral CVCs were not associated with a statistically significant higher risk of CLABSI compared to IJV or FV CVCs from the overall period of 2014-2025. Only the risk difference between IJV and SCV CVCs over 2014-2025 showed a statistically significant difference. IJV CVCs were associated with a higher risk of CLABSI compared with SCV CVCs, with a risk difference of 0.089% (95% CI: 0.006%, 0.171%, Z = 2.11, p=0.0348), a risk ratio of 1.708 (95% CI: 1.033, 2.826), and an odds ratio of 1.71 (95% CI:1.033, 2.831). Over the 2014-2019 period, there was no statistically significant risk difference between the IJV and FV cohorts (risk difference 0.09%, 95% CI: -0.035%, 0.215%, Z = 1.415, p=0.1569). Comparing the IJV to SCV CLABSI rates for the 2014-2019 period, the risk difference was 0.112% (95% CI: -0.009%, 0.234%, Z = 1.81, p=0.07). For the 2019-2025 period between the IJV and FV cohorts, the risk difference was -0.077% (higher risk in the FV cohort), which was not a statistically significant difference (95% CI: -0.193%, 0.04%, Z = -1.289, p=0.1974). Comparing the IJV to SCV CLABSI rates for the 2019-2025 period, the risk difference was 0.117% (95% CI: = -0.006%, 0.24%, Z = 1.861, p=0.0627), which was not a statistically significant difference. Conclusions: This study challenges the prevailing assumption that femoral CVCs carry a higher risk of CLABSI compared to IJV and SCV sites, showing no significant difference in risk. These findings suggest that avoidance of the FV for CVC placement out of concern for infection may unnecessarily limit clinical options without improving patient outcomes. Emphasizing site-specific risks like technical complications and anatomical considerations over infection concerns could simplify decision-making and enhance personalized care in CVC placement.