 this article describes a cluster of central line associated bloodstream infections clabsi at a hospital where after a period of no clabsis from april 2019 to november 2020 experienced 7 clabsis from november 2020 to march 2021 this report describes the investigation into the outbreak and its principal findings which included changes in the use of chg impregnated dressings as well as deviations in nursing training documentation and standard practices in central line dressing care 