Catheter-related Bloodstream Infection Rates Research Articles

P223: The impact of reminder program on catheter-related blood stream infection rates in an intensive care unit in single center of korea

catheter-related blood stream infection rates (CR-BSIs) are a substantial problem in the intensive care unit.

Catheter Related Blood Stream Infections in ICU: A study from North India

Introduction: Central venous catheter (CVC) insertion is common in ICU practices; this can be a source of dangerous bacteremia, sepsis, multi organ failure and sometimes even death. Aim: We conducted this study to find out rate of Catheter colonization, Catheter related blood stream infections (CRBSI), their association and microbial spectrum of CRBSI in critical care unit over 1 year period. Material and methods: Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter related blood stream infections. Tip of Central venous catheter (CVC) as well as peripheral blood for culture were obtained simultaneously and processed according to pre determined protocol. Antimicrobial susceptibility testing was done for the isolated organisms. Results: CRBSI rate 10 per thousand catheter days with Staphylococcus sp. as most common organism was observed. Conclusion: Since central venous catheters are increasingly being used in the critical care, regular surveillance for infection associated with them is essential.

Risk factors for catheter-related bloodstream infection in non-critical patients with total parenteral nutrition

Catheter-related bloodstream infection (CRBSI) is one of the most important complications in patients with a central venous catheter (CVC), due to its association with increased mortality, morbidity and health care cost. The administration of total parenteral nutrition (TPN) is considered a CRBSI risk factor. The aim of our study was to determine the incidence rate and risk factors of CRBSI in patients with TPN that were hospitalized at the medical-surgical wards. This is a prospective observational study in non-critical patients who received TPN and were admitted at our hospital from January 2010 to November 2011. The clinical end point was the CRBSI. CRBSI incidence rate was calculated from episodes by every 1000 CVC-day. CRBSI independent risk factors were obtained from logistic regression analysis. A total of 331 patients were prescribed TPN during our study. The mean time of catheterization was 12.4 (DE 8.7) days and the mean TPN duration was 10.4 (DE 8.3) days. 47 cases of CRBSI were recorded, with an incidence rate of 11.4/1,000 CVC-day and of 13.7/1,000 NPT-day. Risk factors for CRBSI on univariante analysis included duration of catheterization more than 20 days (OR = 2.48; IC 95%: 1.16-5.26), TPN duration more than 2 weeks (OR= 4.63; IC 95%: 2.16-9.90) and the presence of fistulas (OR = 3.08; IC 95%: 1.24-7.63). At multivariate analysis, TPN duration (OR for a duration more than 14 days= 4.9; IC 95%: 2.2-10.9; p < 0.0001) was the only independent risk factor for CRBSI. In non-critical adult patients hospitalized at the medical-surgical wards, we have demonstrated that duration of TPN infusion increases the CRBSI risk. This risk increase is especially remarkable, being multiplied by 5, with a duration superior to 2 weeks.

Peripherally Inserted Central Catheters for Long‐term Parenteral Nutrition in Infants With Intestinal Failure

Infants with intestinal failure often require long-term central access for delivery of parenteral nutrition (PN). Traditionally, surgically placed central venous catheters (CVCs) have been used; however, the complications associated with these catheters can lead to significant morbidity. Peripherally inserted central catheters (PICCs) are potentially superior to CVCs because they tend to be smaller, and can be placed without general anesthesia. The purpose of the study is to report the use of PICCs for long-term administration of PN in infants with intestinal failure and compare with previously published catheter infection and venous thrombosis rates. A 4-year review of infants younger than 12 months with intestinal failure and a PICC for PN delivery was performed to determine the incidence of catheter-related bloodstream infections (CRBSIs) and PICC-associated venous thrombosis. The complication rates were compared with those reported for CVCs and PICCs in the pediatric literature. A total of 45 infants with intestinal failure, receiving PN through a PICC were included in the study. Data from 95 PICCs accounting for 10,189 catheter days were collected. The overall incidence of CRBSI was 5.3/1000 catheter days and the incidence of venous thrombosis was 2.0/1000 catheter days. PICCs offer an advantage over CVCs in that they can often be inserted without a general anesthesia and do not require manipulation of the vein. Given the low rate of CRBSI and venous thrombosis, we recommend PICCs for infants with intestinal failure requiring PN.

Complications of peripherally inserted central venous catheter in Japanese neonatal intensive care units

The aim of this study was to investigate the incidence and risk factors of peripherally inserted central venous catheter (PICC)-related complications using a multicenter case survey. A prospective cohort study was carried out by 19 neonatal intensive care units (NICUs) in Japan from February 2005 to March 2007. A total of 975 case records were collected. PICC-related complications including pericardial effusion/cardiac tamponade pleural effusion/ascites, catheter removal difficulties, catheter-related bloodstream infection (CR-BSI), and symptomatic catheter-related thrombosis were collected from case record forms. As for precautions during insertion, institutions were classified into three groups: those with maximum barrier precautions; standard precautions; and no specific precautions. PICC complications occurred in 27 cases (2.9%) among 946 PICC. The incidence was 1.6% for CR-BSI, and 0.1% for cardiac tamponade. CR-BSI rate per 1000 catheter-days was 1.1 with maximum barrier precautions at catheter insertion, 1.2 with standard precautions, and 1.8 with no specific precautions. Multiple logistic regression analysis showed that proximal placement (odds ratio [OR], 3.88; 95% confidence interval [CI]: 1.42-10.60, P = 0.008) and longer placement duration (OR, 1.35; 95%CI: 1.14-1.60, for each week, P = 0.0005) independently contributed to overall complications. The incidence of cardiac tamponade was rare in this multicenter prospective study. Longer duration and proximal placement may be risk factors for PICC complications. In this cohort, the CR-BSI rate was low irrespective of the degree of barrier precautions at insertion.

Project to reduce the central venous catheter-related bloodstream infection rate

Central venous catheter-related bloodstream infection (CRBSI) is an important indicator of care quality. The average CRBSI rate in our unit was 1.027% in 2009. Causes of infection included inadequate CRBSI prevention practices and outdated standard procedures. We designed a project to reduce the CRBSI rate below 0.5% in our intensive care unit. Improvement plans included providing in-service education, establishing a central venous catheter (CVC) care checklist, and updating CRBSI clinical management standards. The CRBSI rate fell to 1.43‰ after implementation. This was significantly below the reduction target of 0.5%. This project effectively reduced CRBSI. We want to share this experience to help other hospitals and units improve critical care quality and reduce healthcare costs.

Impact of transitioning to antibiotic-impregnated PICCs on blood stream infection rate at a large tertiary institution

Purpose Catheter-related blood stream infections (CRBSIs) are associated with high morbidity and mortality as well as significant economic burden. These infections increase the length of hospitalization 7-21 days while costing an extra $23, 424 ± 5,184. 1 Consequently, to reduce the risk of CRBSIs, our institution transitioned to minocycline/rifampin-impregnated PICCs in April 2012. The aim of this study is to compare the rate of BSIs associated with antibiotic-impregnated versus non-impregnated PICCs. Materials and Methods A retrospective analysis of BSIs associated with minocycline/rifampin-impregnated versus non-impregnated PICCs was performed in conjunction with our infectious disease department. The rate of BSIs associated with the new antibiotic-impregnated PICCs placed from 4/1/2012 through 8/31/2012 was compared to the rate of BSIs associated with non-impregnated PICCs placed from 1/1/2011 through 12/31/2011. Results A total of 1,515 minocycline/rifampin-impregnated PICCs were placed at our institution from 4/1/2012 through 8/31/2012. There were 12 documented BSIs associated with these PICCs (6 patients had multiple catheters). A total of 4,516 non-impregnated PICCs were placed from 1/1/2011 through 12/31/2011. There were 31 documented BSIs associated with these PICCs (7 patients had multiple catheters). Approximately 1 out of every 126 antibiotic-impregnated PICCs was associated with a BSI while approximately 1 out of every 146 non-impregnated PICCs was associated with a BSI. Conclusion The transition from non-impregnated to minocycline/rifampin-impregnated PICCs has not decreased the rate of CRBSIs at our institution. However, the cohort size is limited as this has been a recent change. This study is also limited by the high proportion of patients with multiple catheters in the antibiotic-impregnated group. Further analysis will be performed as more PICCs are placed.

Pre-filled normal saline syringes to reduce totally implantable venous access device-associated bloodstream infection: a single institution pilot study

Flushing totally implantable venous access devices (TIVADs) with manually filled saline syringes may increase contamination and catheter-related bloodstream infection (CRBSI). We used a retrospective cohort study to assess the impact of changing from manually filled syringes to manufactured pre-filled syringes on the frequency of CRBSI in 718 TIVADs. Manually filled syringes were used in 269 patients and pre-filled syringes in 449. The CRBSI rate was 2.7% in the pre-filled syringe group and 6.3% in the manually filled syringe group (P=0.016). Sex, tumour type and stage, access site and access body side were not independent risk factors for CRBSI.

Nurse understaffing and infection risk: current evidence, future research and health policy

Nurse understaffing and infection risk: current evidence, future research and health policy

PROPHYLACTIC ADMINISTRATION OF DOXYCYCLINE REDUCES CENTRAL VENOUS CATHETER INFECTIONS IN PATIENTS UNDERGOING HEMATOPOIETIC CELL TRANSPLANTATION

Hematopoietic stem cells are generally transfused through a central venous catheter (CVC), which also facilitates administration of medications and intravenous fluids. We had observed a high rate of CVC infections at our Bone Marrow Transplantation (BMT) unit. Accordingly, we evaluated the impact of administration of doxycycline as a prophylactic strategy to reduce CVC infection rates. Data was collected retrospectively on 54 consecutive patients, 26 who received doxycycline (doxycycline group), and we compared their outcomes to a previous cohort of 28 subjects who did not receive doxycycline (comparison group). The groups were comparable in regards to age, gender, transplant type, and CD34 cell dose. No (0%) CVC infection was observed in the doxycycline group, while 5 infection episodes (18%) occurred in 4 patients in the comparison group (p<0.001). Isolated organisms included: Escherichia-coli (EC)=1, coagulase-negative Staphylococcus-spp (CNSS)=2, both EC & CNSS=1. Notwithstanding the non-randomized comparative nature of our study, results suggest that CVC infection rate was reduced significantly after adding doxycycline for prophylaxis. A randomized controlled study is warranted to confirm these findings.

Central venous catheters and catheter locks in children with cancer: A prospective randomized trial of taurolidine versus heparin

To determine if the catheter lock taurolidine can reduce the number of catheter-related bloodstream infections (CRBSI) in pediatric cancer patients with tunneled central venous catheters (CVC). During a study period of 34 months, 129 newly placed tunneled CVCs in 112 patients were randomly assigned to standard lock with heparin solution or experimental lock with a taurolidine solution (ClinicalTrials.gov Identifier NCT00735813). Sixty-five CVCs were included in the standard group and 64 CVCs in the experimental group. The groups were comparable regarding patients' characteristics. A total number of 72 bloodstream infections of which 33 were CRBSIs were observed during 39,127 CVC-days. A lower rate of CRBSI (0.4 per 1,000 CVC-days) was observed in the experimental arm compared with the standard arm (1.4 per 1,000 CVC-days, incidence rate ratio (IRR) = 0.26; 95% confidence interval (CI) 0.09-0.61; P = 0.001). A lower rate of total bloodstream infections (1.2 per 1,000 CVC-days) was also observed in the experimental arm compared with the standard arm (2.5 per 1,000 CVC-days, IRR = 0.49; 95% CI 0.29-0.82; P = 0.004). Median interval from catheter insertion until first CRBSI was significantly lower in the standard group (156 days, range 12-602) compared with the experimental group (300 days, range 12-1,176; P = 0.02). Premature removal of the CVC due to infection and overall CVC survival were similar in the two study groups. Locking of long-term tunneled CVC with taurolidine significantly reduces catheter-related bloodstream infections in children with cancer.

Central venous catheter-related blood stream infections in patients receiving intravenous iloprost for pulmonary hypertension

Catheter-related blood stream infection (CR-BSI) in patients with pulmonary hypertension (PH) receiving intravenous iloprost via an indwelling central line has previously not been fully described. Recent studies have suggested a link between the pH of prostanoid infusions and the rate and nature of CR-BSI. We have investigated CR-BSI in patients receiving intravenous iloprost at our unit. Databases and hospital records were interrogated for all patients receiving intravenous iloprost between September 2007 and June 2012. Fifty-nine patients received intravenous iloprost via an indwelling central catheter with a total of 23,072 treatment days. There were 15 episodes of CR-BSI, identified using a systematic screening protocol, involving 11 patients giving an overall CR-BSI rate of 0.65/1,000 treatment days. CR-BSI rate for Gram-positive organisms was 0.26/1,000 treatment-days and for Gram-negative organisms was 0.39/1,000 treatment-days. The pH of iloprost in typical dosing regimens was comparable to the pH used in standard-diluent treprostinil and dissimilar to alkaline epoprostenol infusions. The proportion of Gram-negative CR-BSI was similar to that reported for standard-diluent treprostinil. CRP was normal on admission in 33% of cases of confirmed CR-BSI and remained normal in 13% of cases. CR-BSI rates with intravenous iloprost are comparable to those observed for other prostanoids. The high proportion of Gram-negative organisms observed and the neutral pH of iloprost infusions support the previously hypothesised link between pH and antimicrobial activity. Although usually elevated during a CR-BSI, CRP may be normal in early infection and a normal result cannot completely exclude infection.

Chlorhexidine-Gel Dressings Prevent Catheter-Related Bloodstream Infections

Rates of catheter-related bloodstream infections (CR-BSIs) have dropped dramatically with standardization of insertion and care. These interventions include use of maximal sterile barriers during placement, appropriate antiseptic skin cleansing prior to insertion, and immediate removal of central lines when no longer needed. As most CR-BSIs are …

Efficacy of Taurolidine on the Prevention of Catheter-related Bloodstream Infections in Patients on Home Parenteral Nutrition

To assess the efficacy of taurolidine (TauroLockTM) line locks on the prevention of catheter-related bloodstream infections (CRBSI) in patients on home parenteral nutrition (HPN). In our unit, any patient with ≥2 CRBSIs in six months is considered for TauroLockTM (2% taurolidine and 4% citrate) line locks. All such patients from May 2007 until January 2012 were identified, along with associated CRBSI rates. CRBSI was defined by differential time to positivity for positive blood cultures. CRBSIs were grouped into pre-taurolidine use and post-taurolidine commencement for each patient and the infection rate per 1000 catheter days calculated. Results were analyzed using Wilcoxon two-sided test. A total of nine patients were included (two men and seven women) with a median age of 51 (range 43-82) years. Infection rates after commencing taurolidine decreased markedly in all patients studied. The median CRBSI rate prior to taurolidine use was 6.39 per 1000 catheter days. This decreased to a median CRBSI rate of 0 per 1000 catheter days after commencing taurolidine. Taurolidine is no substitute for careful aseptic technique. However, it is clearly effective at preventing CRBSIs and should be used in patients with recurrent infections to reduce morbidity.

Variations in catheter-related bloodstream infections rates based on local practices

BackgroundCatheter-related bloodstream infection (CRBSI) surveillance serves as a quality improvement measure that is often used to assess performance. We reviewed the total number of microbiological samples collected in three Belgian intensive care units (ICU) in 2009–2010, and we described variations in CRBSI rates based on two factors: microbiological documentation rate and CRBSI definition which includes clinical criterion for coagulase-negative Staphylococcus (CNS) episode.FindingsCRBSI rates were 2.95, 1.13 and 1.26 per 1,000 estimated catheter-days in ICUs A, B and C, respectively. ICU B cultured fewer microbiological samples and reported the lowest CRBSI rate. ICU C had the highest documentation rate but was assisted by support available from the laboratory for processing single CNS positive blood cultures. With the exclusion of clinical criterion, CRBSI rates would be reduced by 19%, 45% and 0% in ICUs A, B and C, respectively.ConclusionCRBSI rates may be biased by differences of blood culture sampling and CRBSI definition. These observations suggest that comparisons of CRBSI rates in different ICUs remain difficult to interpret without knowledge of local practices.

Catheter related blood stream infections in the paediatric intensive care unit: A descriptive study

Context:Catheter related blood stream infections (CRBSI) contributes significantly to morbidity, mortality and costs in intensive care unit (ICU). The patient profile, infrastructure and resources in ICU are different in the developing world as compared to western countries. Studies regarding CRBSI from pediatric intensive care unit (PICU) are scanty in the Indian literature.Aims:To determine the frequency and risk factors of CRBSI in children admitted to PICU.Settings and Design:Descriptive study done in the PICU of a tertiary care teaching hospital over a period of four months.Materials and Methods:Study children were followed up from the time of catheterization till discharge. Their clinical and treatment details were recorded and blood culture was done every 72 h, starting at 48 h after catheterization. The adherence of doctors to Centre for Disease Control (CDC) guidelines for catheter insertion was assessed using a checklist.Statistical Analysis:Clinical parameters were compared between colonized and non-colonized subjects and between patients with and without CRBSI. Unpaired t-test and Chi-square test were used to test the significance of observed differences.Results:Out of the 41 children, 21 developed colonization of their central venous catheter (66.24/1000 catheter days), and two developed CRBSI (6.3/1000 catheter days). Infants had a higher risk for developing colonization (P = 0.01). There was 85% adherence to CDC guidelines for catheter insertion.Conclusions:The incidence of CRBSI and catheter colonization is high in our in spite of good catheter insertion practices. Hence further studies to establish the role of adherence to catheter maintenance practices in reducing risk of CRBSI is required. The role of a composite package of interventions including insertion and maintenance bundles specifically targeting infants needs to be studied to bring down the catheter colonization as well as CRBSI rates.

Effect of Shorter Term of Intravenous Infusion for Reduction of Catheter-Related Bloodstream Infection After Gastrectomy

After gastrectomy, a longer period of intravenous alimentation is required than for other digestive surgeries, portending a higher risk of catheter-related bloodstream infection (CRBSI). From assessment of CRBSI occurring between 2004 and 2007 (preintervention group), the duration of intravenous infusion between 2008 and 2010 (postintervention group) was changed to shorter-term (6-day) infusion. To verify the effect of changes in injection schedule on the incidence of CRBSI, the occurrence of CRBSI was studied comparatively among preintervention and postintervention cases, excluding cases requiring intravenous infusion preoperatively, and cases requiring long-term intravenous infusion postoperatively due to postoperative complications. The rate of CRBSI in the postintervention group (0%; 0 of 298) was significantly lower than that in the preintervention group (1.7%; 8 of 477; P = 0.026). There was no significant difference between preintervention and postintervention groups in postoperative complications. Six-day infusion decreased the incidence of CRBSI after gastrectomy significantly, without increasing postoperative complications.

Catheter associated blood stream infections in patients receiving parenteral nutrition: a prospective study of 850 patients.

BackgroundData was prospectively collected on 850 consecutive patients undergoing central venous catheterisation (CVC) to receive total parenteral nutrition (TPN) in a major university teaching hospital over a 46 months period.MethodsData included information about CVC insertion and clinical outcomes, most notably, suspected catheter-related blood stream infections (CRBSI).ResultsThe internal jugular vein was the most common site (n = 882, 68%), followed by the subclavian vein (n = 344, 24.6%) and femoral vein (n = 95, 6.5%). The CRBSI rate per 100 line feeding days was 0.93% in patients cared for in a non ICU setting versus 1.98% for ICU managed patients. The mean number of line days preceding a pyrexial spike was 13.1. CRBSI was commonest in patients with femoral lines (n = 21/95, 22.1%), especially those cared for in a non-ICU setting (29.6% versus 14.5% for those in the ICU group). Preference should be given to internal jugular or subclavian-sited CVCs in ICU and non-ICU patients to reduce the risk of CRBSI. If femoral catheterisation is unavoidable, strict attention to aseptic technique is mandatory.ConclusionThe aim of this study was to investigate the rate and pattern of CRBSI and to recommend changes in protocol, technique and equipment as deemed necessary from these findings.

Beyond the bundle--journey of a tertiary care medical intensive care unit to zero central line-associated bloodstream infections.

IntroductionWe set a goal to reduce the incidence rate of catheter-related bloodstream infections to rate of <1 per 1,000 central line days in a two-year period.MethodsThis is an observational cohort study with historical controls in a 25-bed intensive care unit at a tertiary academic hospital. All patients admitted to the unit from January 2008 to December 2011 (31,931 patient days) were included. A multidisciplinary team consisting of hospital epidemiologist/infectious diseases physician, infection preventionist, unit physician and nursing leadership was convened. Interventions included: central line insertion checklist, demonstration of competencies for line maintenance and access, daily line necessity checklist, and quality rounds by nursing leadership, heightened staff accountability, follow-up surveillance by epidemiology with timely unit feedback and case reviews, and identification of noncompliance with evidence-based guidelines. Molecular epidemiologic investigation of a cluster of vancomycin-resistant Enterococcus faecium (VRE) was undertaken resulting in staff education for proper acquisition of blood cultures, environmental decontamination and daily chlorhexidine gluconate (CHG) bathing for patients.ResultsCenter for Disease Control/National Health Safety Network (CDC/NHSN) definition was used to measure central line-associated bloodstream infection (CLA-BSI) rates during the following time periods: baseline (January 2008 to December 2009), intervention year (IY) 1 (January to December 2010), and IY 2 (January to December 2011). Infection rates were as follows: baseline: 2.65 infections per 1,000 catheter days; IY1: 1.97 per 1,000 catheter days; the incidence rate ratio (IRR) was 0.74 (95% CI = 0.37 to 1.65, P = 0.398); residual seven CLA-BSIs during IY1 were VRE faecium blood cultures positive from central line alone in the setting of findings explicable by noninfectious conditions. Following staff education, environmental decontamination and CHG bathing (IY2): 0.53 per 1,000 catheter days; the IRR was 0.20 (95% CI = 0.06 to 0.65, P = 0.008) with 80% reduction compared to the baseline. Over the two-year intervention period, the overall rate decreased by 53% to 1.24 per 1,000 catheter-days (IRR of 0.47 (95% CI = 0.25 to 0.88, P = 0.019) with zero CLA-BSI for a total of 15 months.ConclusionsResidual CLA-BSIs, despite strict adherence to central line bundle, may be related to blood culture contamination categorized as CLA-BSIs per CDC/NHSN definition. Efforts to reduce residual CLA-BSIs require a strategic multidisciplinary team approach focused on epidemiologic investigations of practitioner- or unit-specific etiologies.

Effective Communication Network Structures for Hospital Infection Prevention

Many hospitals are unable to successfully implement "evidence-based practices" at the unit level. For example, consistent implementation of the central line bundle (CLB), proven to prevent catheter-related bloodstream infections (CRBSIs) is often difficult. This problem has been broadly characterized as "change implementation failure" in health care organizations. Several studies have used retrospective designs to examine the problem; however, there are few prospective studies examining communication dynamics underlying successful implementation of change (eg, evidence-based practices). This prospective study will be set in 2 intensive care units at an academic medical center. At baseline, both units have low compliance with CLB and higher-than-expected CRBSIs. Periodic quality improvement (QI) interventions will be conducted over a 52-week period to promote implementation of CLB in both units. Simultaneously, the following parameters will be examined: (1) Structure and content of communication related to CLB in both units through "communication logs" completed weekly by nurses, physicians, and managers; and (2) outcomes, that is, CLB adherence in both units through weekly chart review. Catheter utilization and CRBSI (infection) rates will serve as additional unit-level outcome measures. The aim is 2-fold: (1) to examine associations between QI interventions and structure and content of communication at the unit level; and (2) to examine associations between structure and content of communication and outcomes at the unit level. The periodic QI interventions are expected to increase CLB adherence and reduce CRBSIs through their influence on structure and content of communication. The prospective design would help examine dynamics in unit-level communication structure and content related to CLB, as well as unit-level outcomes. The study has potential to make significant contributions to theory and practice, particularly if interventions are found to be effective in enabling successful practice change at the unit level. To this effect, the study has potential to provide insights into communication structure and content associated with collective learning and culture change at the unit level. Results and insights are expected to lay a foundation for generating context-sensitive "evidence-based management" strategies for successful practice change at the unit level. An ultimate expected deliverable is the development of an "action-learning framework" for successful implementation of evidence-based practices in health care organizations.