Investigation of the case numbers of catheter-related bloodstream infection overestimated by the central line-associated bloodstream infection surveillance definition

Descriptive epidemiology of central line-associated bloodstream infections at an academic medical center in Iowa, 2019-2022

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) increased nationally during the COVID-19 pandemic. We described CLABSIs at our institution during 2019 to 2022.

METHODS

This retrospective observational study examined CLABSIs among adult inpatients at an 866-bed teaching hospital in the Midwest. CLABSI incidence was trended over time and compared to monthly COVID-19 admissions. Manual chart review was performed to obtain patient demographics, catheter-associated variables, pathogens, and clinical outcomes.

RESULTS

We identified 178 CLABSIs. The CLABSI incidence (cases per 1,000 line days) tripled in October 2020 as COVID-19 admissions increased. CLABSIs in 2020 were more frequently caused by coagulase-negative staphylococci and more frequently occurred in the intensive care units 7+ days after central line insertion. The CLABSI incidence normalized in early 2021 and did not increase during subsequent COVID-19 surges. Throughout 2019 to 2022, about half of the nontunneled central venous catheters involved in CLABSI were placed emergently. One-quarter of CLABSIs involved multiple central lines. Chlorhexidine skin treatment adherence was limited by patient refusal.

CONCLUSIONS

The increase in CLABSIs in late 2020 during a surge in COVID-19 admissions was likely related to central line maintenance but has resolved. Characterizing CLABSI cases can provide insight into adherence to guideline-recommended prevention practices and identify areas for improvement at individual institutions.

Surveillance of central line associated bloodstream infection (CLABSI) - comparison of current (CDC/NHSN) and modified criteria: A prospective study

Background and Aims

There is a huge load of central line-associated bloodstream infection (CLABSI) being reported in developing countries, with increased mortality and healthcare costs. Effective surveillance is a must to reduce the incidence of CLABSI. The current criteria (Centre for Disease Control and Prevention/National Healthcare Safety Network [CDC/NHSN]) for CLABSI surveillance have their own shortcomings. For diagnosing CLABSI, current CDC/NHSN CLABSI surveillance criteria are laborious and time consuming with low predictive power. Hence, modified criteria have been postulated, which are simple and implementable at resource-constrained setups. The primary objective was to compare modified criteria with CDC criteria. The secondary objective was to determine the prevalence of CRBSI.

Material and Methods

A total of 98 patients with central line in situ or having the central venous line removed ≤24 hrs prior to the date of the event were enrolled. Paired blood cultures were obtained and results were analyzed using differential time to positivity.

Results

The incidence of CLBSI was 8.16% and the device utilization rate was 11.6%. The negative predictive value of both the surveillance criteria was found to be excellent and comparable (96.2% for modified criteria and 97.1% for CDC criteria), therefore both can be used for screening purposes. AUC for current CDC/NHSN criteria was better than modified criteria (0.76 versus 0.66, P < 0.0001), suggesting it to be a better criterion for surveillance of CLABSI.

Conclusion

Modified criteria were not superior to CDC/NHSN criteria for surveillance. Thus, there is a scope of improving the modified criteria for the purpose of surveillance. CLBSI load was higher; CLABSI bundle for prevention is thus highly recommended.

Central venous catheter contamination rate in suspected sepsis patients - an observational clinical study

BACKGROUND

More than 160,000 central-line-associated bloodstream infections (CLABSIs) are estimated for Europe each year leading to about 25,000 deaths. We aimed at characterising the contamination of administration sets in suspected CLABSI cases in the intensive care unit (ICU).

METHODS

In ICU patients (period 02/2017-02/2018) with suspected CLABSI, all sampled central venous catheters (CVCs) were examined in 4 segments (from CVC tip to connected tubing systems) for contamination. A risk factor analysis using binary logistic regression was performed.

RESULTS

52 consecutively sampled CVCs with 1,004 elements were analysed with 45 elements being positive for at least one microorganism (4.48%). There was a significant association with the duration of catheterisation (p=0.038, n=50) with a daily increase of contamination risk by 11.5% (OR 1.115). The mean number of CVC manipulations was 40 within 72 hours (SD: 20.5), with no association with contamination risk (p=0.381). The contamination risk of the CVC segments decreased from proximal to distal. Non-replaceable components of the CVC had a high risk (14 times higher; p=0.01). A significant positive correlation was detected between positive tip cultures and microbial growth in the administration set (r(49)=0.437, p=0.001).

CONCLUSION

Although only a minority of CLABSI-suspect patients had positive blood cultures, the contamination rate of central venous catheters and administration set was high, possibly indicating a relevant under-reporting. The finding of identical species in adjacent segments underlines the role of upward or downward spread of microorganisms within the tubes, therefore aseptic tasks should be emphasized.

Atomic force microscopy and scanning electron microscopy as alternative methods of early identification of pathogens causing catheter-related bloodstream infections of patients in ICU

Introduction

Vascular catheters are an indispensable element of the therapy of patients in intensive care. Their use is associated with the possibility of complications, including infectious. According to various sources, the incidence of catheter-related bloodstream infections (CRBSIs) ranges from 0.1 to 22.7 per 1,000 catheter days.

Materials and Methods

The central venous catheter tip culture samples were collected from 24 patients with suspected catheter-related bloodstream infection, from three intensive care units (ICUs). The results of microscopic examinations: atomic force microscope (AFM) and scanning electron microscope (SEM) were compared with the results of microbiological analysis of the central venous catheter tip and blood collected from the catheter.

Results

The microscopic examination and microbiological analysis of both the blood and central venous catheter samples confirmed the presence of microorganisms in 16 cases (double positive result). Our study was conducted in a short period of time (up to 6 hours) and it gave an initial answer to the question about the type of microorganisms colonising the central venous catheter. In one patient the infection was not caused by removal of the central venous catheter. However, not all results were fully consistent within the two diagnostic methods. The colonisation of the central venous catheter with Pseudomonas aeruginosa and Staphylococcus epidermidis was microbiologically confirmed, but it was not confirmed by the microscopic examination of the sample collected from patient No. 20. However, the examination enabled preliminary assessment of the microorganism colonising the catheter, which may have caused the blood infection. It cannot be ruled out that Pseudomonas aeruginosa bacilli were grown on the catheter that came into contact with blood from another source of infection, e.g. the respiratory, nervous or urinary systems. Information on the presence of cocci-shaped bacteria forming characteristic clusters or rods may enable initial diagnosis of catheter-related bloodstream infection if it is accompanied by typical clinical symptoms. Alternative diagnostics also provides valuable information on the presence of biofilm, which is a factor hindering the body’s response to infection and penetration of antibiotics.

Conclusions

Our pilot study presents new diagnostic possibilities of microscopic imaging with the atomic force microscope (AFM) and scanning electron microscope (SEM) to identify pathogens on routinely used disposable medical devices, such as the central venous catheter. On the other hand, this range of diagnostics reveals the potential to constantly improve medical materials which come into direct contact with patients’ tissues. It is important to create a database of microscopic images, which would be a repeatable diagnostic pattern and fully correlated with the results of microbiological analysis, because it would facilitate initial quick diagnosis of a potential CRBSI.

Five-year outcome of peripherally inserted central catheters in adults: a separated infectious and thrombotic complications analysis

OBJECTIVE

To assess infectious and thrombotic complications of peripherally inserted central catheters (PICCs) in adults.

DESIGN

A 5-year prospective cohort study.

SETTING

Tertiary-care teaching hospital in Seville, Spain.

PATIENTS

Adult patients undergoing PICC insertion.

METHODS

Catheter-associated bloodstream infection (CABSI) including catheter-related bloodstream infection (CRBSI), primary bacteremia (PB), and upper extremity deep vein thrombosis (UEDVT) were recorded. Independent predictors of complications were assessed by multivariate analysis.

RESULTS

In total, 1,142 PICCs were inserted, with 153,191 catheter days (median, 79). Complications included 66 cases of CABSI (5.78%; 0.43‰ catheter days), 38 cases of CRBSI (3.33%; 0.25‰ catheter days), 28 cases of PB (2.45%; 0.18‰ catheter days), and 23 cases of UEDVT (2.01%; 0.15‰ catheter days). The median times to infection were 24, 41, and 60 days for CRBSI, PB, and UEDVT, respectively. Parenteral nutrition (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.77-6.52) and admission to the hematology ward (OR, 4.90; 95% CI, 2.25-10.71) were independently associated with CRBSI and PB, respectively. Admission to the hematology ward (OR, 12.46; 95% CI, 2.49-62.50) or to the oncology ward (OR, 7.89; 95% CI, 1.77-35.16) was independently associated with UEDVT. The crude mortality rate was 24.8%. Only 2 patients died of complications.

CONCLUSIONS

PICCs showed a low rate of thrombotic and infectious complications. Compared to PB, CRBSI showed significantly different risk factors, a higher incidence density per catheter days, and a shorter median time to infection. Separate analyses of CRBSI and PB are more specific and clinically useful when analyzing infectious complications.

Characterization of Pseudomonas aeruginosa isolated from various environmental niches: New STs and occurrence of antibiotic susceptible "high-risk clones"

The aim of this study was to investigate the antimicrobial phenotypes, major virulence factors, and the molecular typing of 66 P. aeruginosa isolates collected from various sources: human patients and hospital environment, raw milk, poultry meat, chicken/sheep fecal samples, wastewater, thermal water, and seawater. All isolates, except one, were susceptible to all tested antibiotics. exoA, lasB, rhlR, and lasR genes were harbored by 60 isolates. Forty-six, 18, and 2 isolates amplified exoS, exoU, and exoS+exoU genes, respectively. Twenty-one isolates showed high elastase and pigment production. The PFGE typing identified 26 pulsotypes. Some pulsotypes included isolates from different environmental niches and areas. Twelve selected isolates were typed by MLST and eight different STs were found, three of them were new. Our results highlighted the dissemination of some clones amongst different settings and the occurrence of antibiotic susceptible 'high-risk clones' that might be very harmful when acquiring genes encoding antibiotic resistance.

Effectiveness of intracavitary electrocardiogram-guided peripherally inserted central catheter tip placement in premature infants: a multicentre pre-post intervention study

This pre-post intervention study was conducted in Neonatal Intensive Care Units in two Chinese hospitals. The objective was to evaluate the effectiveness and safety of intracavitary electrocardiogram (IC-ECG)-guided peripherally inserted central catheter (PICC) placement and tip positioning in premature infants. A total of 161 premature infants who required a PICC were enrolled and divided into two groups: pre-intervention group (n = 83) from October 2017 to July 2018 and post-intervention IC-ECG group (n = 78) from August 2018 to March 2019. Nurses were trained from May 2018 to July 2018. The reposition rate in the IC-ECG group and pre-interventions group was 3.85% and 19.28%, respectively (OR 5.970; 95% CI 1.666-21.395; p = 0.002). More infants achieved optimal tip position at the first attempt in the IC-ECG group than the pre-intervention group (93.59% vs 73.49%; OR 0.190; 95%CI 0.068-0.531; p = 0.001). The overall catheter-related complications in the pre-intervention group were 14.46% compared to 3.84% in the IC-ECG group (OR 2.962; 95%CI 1.013-8.661; p = 0.040). However, no significant differences were observed between the individual complication leakage, phlebitis and catheter-related blood stream infection.Conclusions: IC-ECG-guided peripherally inserted central catheter placement and tip positioning technology might decrease reposition rates, achieve more accurate tip positioning at the first attempt and might reduce catheter-related complications in premature infants. Further robust RCTs are needed to confirm the effectiveness of IC-ECG-guided PICC placement and tip positioning in neonates.What is Known:• Chest radiography is the gold standard for tip position confirmation of peripherally inserted central catheter placement.• Studies in adult patients have shown that electrocardiogram guidance in the placement of central venous catheters can be beneficial, while evidence in neonates is limited.What is New:• Intracavitary electrocardiogram-guided peripherally inserted central catheter placement might be superior to chest radiography in preterm infants.• Decreasing the repositioning rates and correct tip position of peripherally inserted central catheters might reduce catheter-related complications.

Catheter-Related Bloodstream Infections in Adults Receiving Home Parenteral Nutrition: Substantial Differences in Incidence Comparing a Strict Microbiological to a Clinically Based Diagnosis

BACKGROUND

A common complication in patients receiving home parenteral nutrition (HPN) is catheter-related bloodstream infections (CRBSIs). The CRBSI incidence has been advocated as an outcome parameter assessing the quality of care. This study aimed to illustrate how the use of different CRBSI definitions affects the reported incidence.

MATERIALS AND METHODS

In an observational study based on the Copenhagen intestinal failure database, all clinically reported CRBSIs from 2002-2013 were compared with data from the affiliated microbiological database according to recommended CRBSI criteria.

RESULTS

Clinically, 1034 CRBSIs were observed in 548 adults receiving HPN for 1410 catheter-years. Thus, the clinically assessed CRBSI incidence was 1.95/1000 catheter-days. However, based on the microbiological evaluation, only 47% of our episodes fulfilled the Centers for Disease Control and Prevention (CDC) and European Society for Clinical Nutrition (ESPEN) CRBSI criteria. Employing a catheter-salvaging strategy, 40% of the CRBSI diagnoses were supported by the paired blood culture positivity criteria and only 6% by a positive catheter tip. In 53%, CRBSIs were categorized as a clinical or "probable CRBSI" diagnosis. In 20% of all episodes, missing information/blood cultures hampered a CDC/ESPEN CRBSI diagnosis. Thereby, according to CDC/ESPEN CRBSI definitions, the incidence was 0.92/1000 days or 46% lower than clinically assessed.

CONCLUSION

This study illustrates the practical and methodological challenges and great variability in reporting of the CRBSI incidence. Nonetheless, it is recommended as a marker of the quality of care. Consensus regarding CRBSI definitions is a prerequisite for a meaningful comparison of this important outcome parameter between HPN centers.

Implementation of a national bundle care program to reduce central line-associated bloodstream infections in intensive care units in Taiwan

BACKGROUND/PURPOSE

This study assessed the effect of the central line bundle on the rate of central line-associated bloodstream infections (CLABSI) in intensive care units (ICUs) in Taiwan.

METHODS

This national study was conducted in 27 ICUs with 404 beds total, including 15 medical ICUs, 11 surgical ICUs, and one mixed ICU. The study period was divided into two phases: a pre-intervention (between June 1, 2011 and October 31, 2011) and intervention phase (between December 1, 2011 and October 31, 2012). Outcome variables, including CLABSI rates (per 1000 catheter-days) and catheter utilization rates, were measured.

RESULTS

The overall rate of CLABSI significantly decreased by 12.2% (p < 0.001) from 5.74 per 1000 catheter-days in the pre-intervention phase to 5.04 per 1000 catheter-days in the intervention phase. The catheter utilization rate decreased by 1.1% from 55.3% in the pre-intervention phase to 54.2% in the intervention phase. The decline in CLABSI varied significantly among hospital and ICU levels, except surgical ICUs (p = 0.59).

CONCLUSIONS

Implementing a multidimensional central-line bundle significantly reduced the rates of CLABSI by 12.2% in nearly all participating ICUs, except surgical ICUs.

Economic Evaluation of Quality Improvement Interventions for Bloodstream Infections Related to Central Catheters: A Systematic Review

IMPORTANCE

Although quality improvement (QI) interventions can reduce central-line-associated bloodstream infections (CLABSI) and catheter-related bloodstream infections (CRBSI), their economic value is uncertain.

OBJECTIVE

To systematically review economic evaluations of QI interventions designed to prevent CLABSI and/or CRBSI in acute care hospitals.

EVIDENCE REVIEW

A search of Ovid MEDLINE, Econlit, Centre for Reviews & Dissemination, New York Academy of Medicine's Grey Literature Report, Worldcat, prior systematic reviews (January 2004 to July 2016), and IDWeek conference abstracts (2013-2016), was conducted from 2013 to 2016. We included English-language studies of any design that evaluated organizational or structural changes to prevent CLABSI or CRBSI, and reported program and infection-related costs. Dual reviewers assessed study design, effectiveness, costs, and study quality. For each eligible study, we performed a cost-consequences analysis from the hospital perspective, estimating the incidence rate ratio (IRR) and incremental net savings. Unadjusted weighted regression analyses tested predictors of these measures, weighted by catheter-days per study per year.

FINDINGS

Of 505 articles, 15 unique studies were eligible, together representing data from 113 hospitals. Thirteen studies compared Agency for Healthcare Research and Quality-recommended practices with usual care, including 7 testing insertion checklists. Eleven studies were based on uncontrolled before-after designs, 1 on a randomized controlled trial, 1 on a time-series analysis, and 2 on modeled estimates. Overall, the weighted mean IRR was 0.43 (95% CI, 0.35-0.51) and incremental net savings were $1.85 million (95% CI, $1.30 million to $2.40 million) per hospital over 3 years (2015 US dollars). Each $100 000-increase in program cost was associated with $315 000 greater savings (95% CI, $166 000-$464 000; P < .001). Infections and net costs declined when hospitals already used checklists or had baseline infection rates of 1.7 to 3.7 per 1000 catheter-days. Study quality was not associated with effectiveness or costs.

CONCLUSIONS AND RELEVANCE

Interventions related to central venous catheters were, on average, associated with 57% fewer bloodstream infections and substantial savings to hospitals. Larger initial investments may be associated with greater savings. Although checklists are now widely used and infections have started to decline, additional improvements and savings can occur at hospitals that have not yet attained very low infection rates.

A clinical practical approach to the surveillance definition of central line-associated bloodstream infection in cancer patients with mucosal barrier injury

BACKGROUND

The Centers for Disease Control and Prevention recently introduced the concept of mucosal barrier injury (MBI) in an attempt to recognize the possibility of a gastrointestinal source for certain bloodstream infections. This could underestimate the central venous catheter (CVC) as the source of central line-associated bloodstream infection (CLABSI) in cancer. The definition of catheter-related bloodstream infection (CRBSI) by the Infectious Diseases Society of America is a more specific and stringent definition that identifies the CVC as the source of infection. In our study, we compared the 2 definitions in cancer patients.

METHODS

We retrospectively reviewed 149 CLABSI cases that occurred at our center between January 2013 and March 2014 who had 2 simultaneously positive blood cultures drawn from the CVC and peripheral site or concurrent paired tip and blood cultures.

RESULTS

Of the 149 patients with CLABSI, only 70 (47%) had definite CRBSI. CRBSI was identified more commonly in non-MBI CLABSI cases than MBI CLABSI (69% vs 18%, P < .0001).

CONCLUSIONS

The CRBSI definition may be more accurate in identifying the catheter as the source of bloodstream infection in patients with MBI. Because CRBSI continues to occur in patients with MBI, we caution against excluding all MBI patients from CLABSI surveillance.

The Effect of Infection Control Nurses on the Occurrence of Pseudomonas aeruginosa Healthcare-Acquired Infection and Multidrug-Resistant Strains in Critically-Ill Children

Background

Healthcare-acquired Pseudomonas aeruginosa (P. aeruginosa) infections in the Pediatric Intensive Care Unit (PICU), which have a high incidence, increase treatment costs and mortality, and seriously threaten the safety of critically ill children. It is essential to seek convenient and effective methods to control and prevent healthcare-acquired infections (HAIs). This research was conducted to study the effect of infection control nurses on the occurrence of P. aeruginosa HAIs and multi-drug resistance (MDR) strains in PICU.

Methods

The clinical data was divided into two groups, with the age ranging from 1 month to 14 years. One group of the critically ill patients(N = 3,722) was admitted to PICU from 2007 to 2010, without the management of infection control nurses. The other group of the critically ill patients (N = 3,943) was admitted to PICU from 2011 to 2013, with the management of infection control nurses. Compare the mortality, morbidity and the incidence of acquired P. aeruginosa infections to evaluate the effect of infection control nurses.

Results

After implementation of the post of infection control nurses, the patient's overall mortality fell from 4.81% to 3.73%. Among the patients with endotracheal intubation more than 48 hours, the incidence of endotracheal intubation-related pneumonia decreased from 44.6% to 34.32%. The mortality of patients with endotracheal intubation decreased from 16.96% to 10.17%, and the morbidity of HAIs with P. aeruginosa decreased from 1.89% to 1.07%. The mutual different rate (MDR) dropped from 67.95% to 44.23%. There were remarkable differences in these rates between the two groups (p<0.05).

Conclusion

Implementing the post of infection control nurses is associated with effectively reducing the HAI rate, especially the incidence and morbidity of P. aeruginosa HAIs, reducing PICU mortality, improving P. aeruginosa drug resistance.

Update on infections caused by Stenotrophomonas maltophilia with particular attention to resistance mechanisms and therapeutic options

Stenotrophomonas maltophilia is a Gram-negative, biofilm-forming bacterium. Although generally regarded as an organism of low virulence, S. maltophilia is an emerging multi-drug resistant opportunistic pathogen in hospital and community settings, especially among immunocompromised hosts. Risk factors associated with S. maltophilia infection include underlying malignancy, cystic fibrosis, corticosteroid or immunosuppressant therapy, the presence of an indwelling central venous catheter and exposure to broad spectrum antibiotics. In this review, we provide a synthesis of information on current global trends in S. maltophilia pathogenicity as well as updated information on the molecular mechanisms contributing to its resistance to an array of antimicrobial agents. The prevalence of S. maltophilia infection in the general population increased from 0.8-1.4% during 1997-2003 to 1.3-1.68% during 2007-2012. The most important molecular mechanisms contributing to its resistance to antibiotics include β-lactamase production, the expression of Qnr genes, and the presence of class 1 integrons and efflux pumps. Trimethoprim/sulfamethoxazole (TMP/SMX) is the antimicrobial drug of choice. Although a few studies have reported increased resistance to TMP/SMX, the majority of studies worldwide show that S. maltophilia continues to be highly susceptible. Drugs with historically good susceptibility results include ceftazidime, ticarcillin-clavulanate, and fluoroquinolones; however, a number of studies show an alarming trend in resistance to those agents. Tetracyclines such as tigecycline, minocycline, and doxycycline are also effective agents and consistently display good activity against S. maltophilia in various geographic regions and across different time periods. Combination therapies, novel agents, and aerosolized forms of antimicrobial drugs are currently being tested for their ability to treat infections caused by this multi-drug resistant organism.