Incidence of central venous catheter hub contamination

PURPOSE

To investigate microorganisms causing central venous catheter contamination and how this contamination differs across different catheter metrics.

MATERIALS AND METHODS

After obtaining IRB approval and informed consent, 830 cultures were prospectively obtained from 45 ICU patients with central venous catheter or peripherally inserted central catheter. Bacterial colonies were identified by mass spectrometry.

RESULTS

Bacterial contamination of central catheter hubs occurred 44% of the time in this study in the ICU setting. Coagulase-positive staphylococci cultures had higher median (±interquartile range) CFUs (12±232) versus coagulase-negative (3±10) and other bacteria (1±3; P<0.001). Bacterial contamination was associated with various metrics. Higher incidence (P<0.05) of coagulase-positive staphylococci cultures was associated with hub-only connections (a "hub" being a female connection; 10.9% vs. 7.9% male connections), connections without a manifold (1lumen device that mixes multiple infusions together; 9.7% vs. 0% with manifold); and central venous pressure monitoring connections (25.8% vs. 7.1% without). Internal jugular sites (10.0% vs. 2.7% femoral, 6.2% PICC, P=0.031) and medial lumens of triple lumen catheters (11.9% vs. 5.6% distal, 7.0% proximal, P=0.049) had increased incidence of higher bacteria loads (>15 CFUs).

CONCLUSIONS

This study found a high incidence of central access catheter hub bacterial contamination, which correlated with positive blood cultures in 2 of 3 total bacteremia cases identified in the 45 patients.

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

The Effect of Multiple Concurrent Central Venous Catheters on Central Line–Associated Bloodstream Infections

Objective

The current central line–associated bloodstream infection (CLABSI) surveillance rate calculation does not account for multiple concurrent central venous catheters (CVCs). The presence of multiple CVCs creates more points of entry into the bloodstream, potentially increasing CLABSI risk. Multiple CVCs may be used in sicker patients, making it difficult to separate the relative contributions of multiple CVCs and comorbidities to CLABSI risk. We explored the relative impact of multiple CVCs, patient comorbidities, and disease severity on the risk of CLABSI.

Design

Case-control study.

Setting

A total of 197 case patients and 201 control subjects with a CVC inserted during hospitalization at a tertiary care academic medical center from January 1, 2008, to December 31, 2010.

Methods

Multiple CVCs was the exposure of interest; the primary outcome was CLABSI. Multivariable logistic regression was conducted to estimate odds ratios (ORs) and 95% confidence intervals (CIs) describing the association between CLABSI and multiple CVCs with and without controlling for Acute Physiology and Chronic Health Evaluation (APACHE) II and Charlson comorbidity index (CCI) scores as measures of disease severity and patient comorbidities, respectively.

Results

Patients with multiple CVCs (n = 78) showed a 4.2 (95% CI, 2.2–8.4) times greater risk of CLABSI compared with patients with 1 CVC after adjusting for CLABSI risk factors. When including APACHE II and CCI scores, multiple CVCs remained an independent risk factor for CLABSI (OR, 3.4 [95% CI, 1.7–6.9]).

Conclusions

Multiple CVCs is an independent risk factor for CLABSI even after adjusting for severity of illness. Adjustment for this risk may be necessary to accurately compare rates between hospitals.

Infect Control Hosp Epidemiol 2014;35(9):1140-1146

Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Device Use Ratio Measured Weekly Can Reliably Estimate Central Line–Days for Central Line–Associated Bloodstream Infection Rates

Six hospitals joined to perform surveillance for central line–associated bloodstream infections outside of intensive care units (ICUs). To facilitate the counting of device-days, a weekly measure of the device use ratio was validated as an estimate of central line–days outside the ICU.

Electronic Algorithmic Prediction of Central Vascular Catheter Use

Objective.

To develop prediction algorithms for the presence of a central vascular catheter in hospitalized patients with use of data present in an electronic health record. Such algorithms could be used for measurement of device utilization rates and for clinical decision support rules.

Design.

Criterion standard.

Setting.

John H. Stroger, Jr, Hospital of Cook County, a 464-bed public hospital in Chicago, Illinois.

Participants.

Patients admitted to the medical intensive care unit from May 31, 2005 through June 26, 2006 (derivation data set, May 31, 2005-September 28, 2005; validation data set, September 29, 2005-June 28, 2006).

Methods.

Covariates were collected from the electronic medical record for each patient; the outcome variable was presence of a central vascular device. Multivariate models were developed using the derivation set and the generalized estimating equation. Three models, each with increasing database requirements, were validated using the validation set. Device utilization ratios and performance characteristics were calculated.

Results.

Although Charlson score and duration of intensive care unit stay were significant predictors in all models, factors that indicated use or presence of a central line were also important. Device utilization rates derived from the algorithmic models were as accurate as those obtained using manual sampling.

Conclusions.

Automated calculation of central vascular catheter use is both feasible and accurate, providing estimates statistically similar to those obtained using manual surveillance. Prediction modeling of central vascular catheter use may enable automated surveillance of bloodstream infections and enhance important prevention interventions, such as timely removal of unnecessary central lines.

Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia

BACKGROUND AND OBJECTIVE

Peripherally inserted central venous catheters (PICCs) are alternatives to short-term central venous catheters and provide intravenous access in the acute hospital setting. In this study, we describe the rate of PICC-associated bloodstream infections (BSI).

DESIGN AND SETTING

Prospective cohort study using data on PICC lines reviewed from January to December 2009.

METHODS

The infection control team was responsible for prospective BSI case findings. The infection rate was calculated per 1000 device-days.

RESULTS

During the study period, 92 PICC lines were inserted with a total of 3336 device-days of prospective surveillance. The most frequent reasons for the insertion of the PICC lines were chemotherapy (n=19, 20.7%), intravenous antimicrobial therapy (n=34, 37%), and for patients in the medical intensive care unit (ICU) (n=16, 17.4%). The overall BSI rate was 4.5/1000 PICC days. The PICC line-associated BSI rates for a specific indication were as follows: chemotherapy 6.6/1000 device-days, intravenous antimicrobial therapy 1.2/1000 device-days, medical ICU 7.3/1000 device-days, surgical ICU 4.6/1000 device-days, and total parental nutrition patients 2.4/1000 device-days (P<.001). The rates were not adjusted for patient severity of illness.

CONCLUSIONS

Our data suggest that underlying conditions and indications for the PICC line use may play an important role in the development of BSI.

Central Line-Associated Blood Stream Infection in the Critically Ill Trauma Patient

Blood stream infections in the critically ill are a common cause of morbidity. Strict adherence to sterile technique can reduce central line-associated blood stream infections (CLBSIs) and has become a quality improvement measure. We did a retrospective review of 6,014 trauma admissions representing 10,370 catheter days. CLBSI was defined as a positive blood culture with central venous access without evidence of other infectious sources. Thirty-five CLBSIs were identified in the study period (3.26/1,000 line days). The average Injury Severity Score was 32, the average intensive care unit stay was 24 days, and the average overall length of stay was 34 days, which is higher than that of nonCLBSI patients. In 25/35 cases, there was a break in sterile technique during central venous catheter placement (71%). Of the 25 cases, 16 of them were performed in the intensive care unit (64%), five in the operating room (20%), and four in the emergency department (16%). Twenty of the 35 patients with CLBSI (57%) had a total of 24 infections, a 2-fold increase in infectious complications for a given Injury Severity Score. Seventeen (17) of the 25 “dirty” central lines (68%) were changed within 24 hours in an effort to reduce the risk of CLBSI without success. A large percentage of CLBSI can be traced to the initial placement of a central venous line under less than ideal sterile technique. Changing a line within 24 hours may not be sufficient to reduce the risk of CLBSI. Every effort should be made to adhere to proper sterile technique while placing central venous catheter.

Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters

BACKGROUND

Peripherally inserted central venous catheters (PICCs) serve as an alternative to short-term central venous catheters (CVCs) for providing intravenous (IV) access in the hospital. It is not clear which device has a lower risk of central line-associated bloodstream infection (CLABSI). We compared CVC- and PICC-related CLABSI rates in the setting of an intervention to remove high-risk CVCs.

METHODS

We prospectively followed patients with CVCs in the non-intensive care units (ICUs) and those with PICCs hospital-wide. A team evaluated the need for the CVC and the risk of infection, recommended the discontinuation of unnecessary or high-risk CVCs, and suggested PICC insertion for patients requiring prolonged access. Data on age, gender, type of catheter, duration of catheter utilization, and the development of CLABSIs were obtained.

RESULTS

A total of 638 CVCs were placed for 4917 catheter-days, during which 12 patients had a CLABSI, for a rate of 2.4 per 1000 catheter-days. A total of 622 PICCs were placed for 5703 catheter-days, during which 13 patients had a CLABSI, for a rate of 2.3 per 1000 catheter-days. The median time to development of infection was significantly longer in the patients with a PICC (23 vs 13 days; P=.03).

CONCLUSION

In the presence of active surveillance and intervention to remove unnecessary or high-risk CVCs, CVCs and PICCs had similar rates of CLABSIs. Given their longer time to the development of infection, PICCs may be a safe alternative for prolonged inpatient IV access.

Improved hospital-level risk adjustment for surveillance of healthcare-associated bloodstream infections: a retrospective cohort study

BACKGROUND

To allow direct comparison of bloodstream infection (BSI) rates between hospitals for performance measurement, observed rates need to be risk adjusted according to the types of patients cared for by the hospital. However, attribute data on all individual patients are often unavailable and hospital-level risk adjustment needs to be done using indirect indicator variables of patient case mix, such as hospital level. We aimed to identify medical services associated with high or low BSI rates, and to evaluate the services provided by the hospital as indicators that can be used for more objective hospital-level risk adjustment.

METHODS

From February 2001-December 2007, 1719 monthly BSI counts were available from 18 hospitals in Queensland, Australia. BSI outcomes were stratified into four groups: overall BSI (OBSI), Staphylococcus aureus BSI (STAPH), intravascular device-related S. aureus BSI (IVD-STAPH) and methicillin-resistant S. aureus BSI (MRSA). Twelve services were considered as candidate risk-adjustment variables. For OBSI, STAPH and IVD-STAPH, we developed generalized estimating equation Poisson regression models that accounted for autocorrelation in longitudinal counts. Due to a lack of autocorrelation, a standard logistic regression model was specified for MRSA.

RESULTS

Four risk services were identified for OBSI: AIDS (IRR 2.14, 95% CI 1.20 to 3.82), infectious diseases (IRR 2.72, 95% CI 1.97 to 3.76), oncology (IRR 1.60, 95% CI 1.29 to 1.98) and bone marrow transplants (IRR 1.52, 95% CI 1.14 to 2.03). Four protective services were also found. A similar but smaller group of risk and protective services were found for the other outcomes. Acceptable agreement between observed and fitted values was found for the OBSI and STAPH models but not for the IVD-STAPH and MRSA models. However, the IVD-STAPH and MRSA models successfully discriminated between hospitals with higher and lower BSI rates.

CONCLUSION

The high model goodness-of-fit and the higher frequency of OBSI and STAPH outcomes indicated that hospital-specific risk adjustment based on medical services provided would be useful for these outcomes in Queensland. The low frequency of IVD-STAPH and MRSA outcomes indicated that development of a hospital-level risk score was a more valid method of risk adjustment for these outcomes.

Strategies to prevent central line-associated bloodstream infections in acute care hospitals

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections. The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line–associated bloodstream infection (CLABSI) prevention efforts. Refer to the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America “Compendium of Strategies to Prevent Healthcare-Associated Infections” Executive Summary and Introduction and accompanying editorial for additional discussion.

1. Patients at risk for CLABSIs in acute care facilities

a. Intensive care unit (ICU) population: The risk of CLABSI in ICU patients is high. Reasons for this include the frequent insertion of multiple catheters, the use of specific types of catheters that are almost exclusively inserted in ICU patients and associated with substantial risk (eg, arterial catheters), and the fact that catheters are frequently placed in emergency circumstances, repeatedly accessed each day, and often needed for extended periods.

b. Non-ICU population: Although the primary focus of attention over the past 2 decades has been the ICU setting, recent data suggest that the greatest numbers of patients with central lines are in hospital units outside the ICU, where there is a substantial risk of CLABSI.

2. Outcomes associated with hospital-acquired CLABSI

a. Increased length of hospital stay

b. Increased cost; the non-inflation-adjusted attributable cost of CLABSIs has been found to vary from $3,700 to $29,000 per episode