Central Catheter-associated Bloodstream Infections Research Articles

Identifying and Mitigating Disparities in Central Line–Associated Bloodstream Infections in Minoritized Racial, Ethnic, and Language Groups

Although inequitable care due to racism and bias is well documented in health care, the impact on health care-associated infections is less understood. To determine whether disparities in first central catheter-associated bloodstream infection (CLABSI) rates existed for pediatric patients of minoritized racial, ethnic, and language groups and to evaluate the outcomes associated with quality improvement initiatives for addressing these disparities. This cohort study retrospectively examined outcomes of 8269 hospitalized patients with central catheters from October 1, 2012, to September 30, 2019, at a freestanding quaternary care children's hospital. Subsequent quality improvement interventions and follow-up were studied, excluding catheter days occurring after the outcome and episodes with catheters of indeterminate age through September 2022. Patient self-reported (or parent/guardian-reported) race, ethnicity, and language for care as collected for hospital demographic purposes. Central catheter-associated bloodstream infection events identified by infection prevention surveillance according to National Healthcare Safety Network criteria were reported as events per 1000 central catheter days. Cox proportional hazards regression was used to analyze patient and central catheter characteristics, and interrupted time series was used to analyze quality improvement outcomes. Unadjusted infection rates were higher for Black patients (2.8 per 1000 central catheter days) and patients who spoke a language other than English (LOE; 2.1 per 1000 central catheter days) compared with the overall population (1.5 per 1000 central catheter days). Proportional hazard regression included 225 674 catheter days with 316 infections and represented 8269 patients. A total of 282 patients (3.4%) experienced a CLABSI (mean [IQR] age, 1.34 [0.07-8.83] years; female, 122 [43.3%]; male, 160 [56.7%]; English-speaking, 236 [83.7%]; LOE, 46 [16.3%]; American Indian or Alaska Native, 3 [1.1%]; Asian, 14 [5.0%]; Black, 26 [9.2%]; Hispanic, 61 [21.6%]; Native Hawaiian or Other Pacific Islander, 4 [1.4%]; White, 139 [49.3%]; ≥2 races, 14 [5.0%]; unknown race and ethnicity or refused to answer, 15 [5.3%]). In the adjusted model, a higher hazard ratio (HR) was observed for Black patients (adjusted HR, 1.8; 95% CI, 1.2-2.6; P = .002) and patients who spoke an LOE (adjusted HR, 1.6; 95% CI, 1.1-2.3; P = .01). Following quality improvement interventions, infection rates in both subgroups showed statistically significant level changes (Black patients: -1.77; 95% CI, -3.39 to -0.15; patients speaking an LOE: -1.25; 95% CI, -2.23 to -0.27). The study's findings show disparities in CLABSI rates for Black patients and patients who speak an LOE that persisted after adjusting for known risk factors, suggesting that systemic racism and bias may play a role in inequitable hospital care for hospital-acquired infections. Stratifying outcomes to assess for disparities prior to quality improvement efforts may inform targeted interventions to improve equity.

Association Between Hospital-Acquired Harm Outcomes and Membership in a National Patient Safety Collaborative

Hospital engagement networks supported by the US Centers for Medicare & Medicaid Services Partnership for Patients program have reported significant reductions in hospital-acquired harm, but methodological limitations and lack of peer review have led to persistent questions about the effectiveness of this approach. To evaluate associations between membership in Children's Hospitals' Solutions for Patient Safety (SPS), a federally funded hospital engagement network, and hospital-acquired harm using standardized definitions and secular trend adjustment. This prospective hospital cohort study included 99 children's hospitals. Using interrupted time series analyses with staggered intervention introduction, immediate and postimplementation changes in hospital-acquired harm rates were analyzed, with adjustment for preexisting secular trends. Outcomes were further evaluated by early-adopting (n = 73) and late-adopting (n = 26) cohorts. Hospitals implemented harm prevention bundles, reported outcomes and bundle compliance using standard definitions to the network monthly, participated in learning events, and implemented a broad safety culture program. Hospitals received regular reports on their comparative performance. Outcomes for 8 hospital-acquired conditions were evaluated over 1 year before and 3 years after intervention. In total, 99 hospitals met the inclusion criteria and were included in the analysis. A total of 73 were considered part of the early-adopting cohort (joined between 2012-2013) and 26 were considered part of the late-adopting cohort (joined between 2014-2016). A total of 42 hospitals were freestanding children's hospitals, and 57 were children's hospitals within hospital or health systems. The implementation of SPS was associated with an improvement in hospital-acquired condition rates in 3 of the 8 conditions after accounting for secular trends. Membership in the SPS was associated with an immediate reduction in central catheter-associated bloodstream infections (coefficient = -0.152; 95% CI, -0.213 to -0.019) and falls of moderate or greater severity (coefficient = -0.331; 95% CI, -0.594 to -0.069). The implementation of the SPS was associated with a reduction in the monthly rate of adverse drug events (coefficient = -0.021; 95% CI, -0.034 to -0.008) in the post-SPS period. The study team observed larger decreases for the early-adopting cohort compared with the late-adopting cohort. Through the application of rigorous methods (standard definitions and longitudinal time series analysis with adjustment for secular trends), this study provides a more thorough analysis of the association between the Partnership for Patients hospital engagement network model and reductions in hospital-acquired conditions. These findings strengthen previous claims of an association between this model and improvement. However, inconsistent observations across hospital-acquired conditions when adjusted for secular trends suggests that some caution regarding attributing all effects observed to this model is warranted.

Reducing Unnecessary Laboratory Utilization in the Medical ICU: A Fellow-Driven Quality Improvement Initiative.

OBJECTIVES:Overutilization of laboratory services is now recognized as harmful to patients and wasteful. In fact, the American Board of Internal Medicine’s Choosing Wisely campaign recommends against ordering routine testing that does not answer a clinical question. Per peer benchmarking, our institution as a whole occupied an extreme outlier position at the 100th percentile for laboratory utilization. We sought to address this problem starting in our medical ICUs with a quality improvement project.DESIGN:Quality improvement project using the design, measure, analyze, improve, and control process. The primary endpoint was a sustained reduction in laboratory utilization. Counterbalance metrics were also followed, and these included mortality, renal replacement therapy initiation rates, stat laboratory orders, and central catheter–associated blood stream infections.SETTING:The medical ICU at the Ohio State University Medical Center.PATIENTS:All patients admitted to the medical ICU from March 2019 to March 2020.INTERVENTIONS:Root causes were identified and addressed with the implementation of a wide range of interventions involving a multidisciplinary team led by trainee physicians.MEASUREMENTS AND MAIN RESULTS:There was a sustained 20% reduction in the number of tests performed per patient day, with no change in the counterbalance metrics.CONCLUSIONS:Trainees can affect positive change in the culture and processes at their institutions to safely reduce laboratory utilization.

July Effect on Mortality and Complications in Patients With ARDS in US Teaching Hospitals.

Each July, teaching hospitals in the United States experience an influx of new resident and fellow physicians. It has been theorized that this occurrence may be associated with increased patient mortality, complication rates, and health care resource use, a phenomenon known as the "July effect." To assess the existence of a July effect in clinical outcomes of patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation in the intensive care unit in US teaching hospitals. The National Inpatient Sample database was queried for all adult patients with ARDS who received mechanical ventilation from 2012 to 2014. Using a multivariate difference-in-differences (DID) model, differences in mortality, ventilator-associated pneumonia, iatrogenic pneumothorax, central catheter-associated bloodstream infection, and Clostridium difficile infection were compared between teaching and nonteaching hospitals during April-May and July-August. There were 70 535 and 43 175 hospitalizations meeting study criteria in teaching and nonteaching hospitals, respectively. Multivariate analyses revealed no differential effect on the rates of all-cause inpatient mortality (DID, 0.66; 95% CI, -0.42 to 1.75), C difficile infection (DID, 0.29; 95% CI, -0.19 to 0.78), central catheter-associated bloodstream infection (DID, 0.14; 95% CI, -0.04 to 0.33), iatrogenic pneumothorax (DID, 0.00; 95% CI, -0.25 to 0.24), ventilator-associated pneumonia (DID, 0.22; 95% CI, -0.05 to 0.49), and any complication (DID, 0.60; 95% CI, -0.01 to 1.20) for July-August versus April-May in teaching hospitals compared with nonteaching hospitals. This study did not show a differential July effect on mortality outcomes and complication rates in ARDS patients receiving mechanical ventilation in teaching hospitals compared with nonteaching hospitals.

Impact of a Peripheral Vascular Access Service on Device Use.

More than 1 billion peripheral vascular access devices are inserted annually worldwide with potential complications including infection, thrombosis, and vasculature damage. Vasculature damage can necessitate the use of central catheters, which carry additional risks such as central catheter-associated bloodstream infections. To address these concerns, one institution used expert nurses and a consult request system with algorithms embedded in the electronic medical record. To develop a uniform process for catheter insertion by means of a peripheral vascular access service dedicated to selecting, placing, and maintaining all inpatient peripheral catheters outside of the intensive care units. Descriptive analysis and χ2 analysis were done to describe the impact of the peripheral vascular access service. In 2018, 6246 consults were reviewed. Of these, 26% did not require vascular access. Similarly, in 2019, 7861 consults were reviewed, and 35.3% did not require vascular access. Use of central catheters decreased from 21% in 2017 to 17% in 2018 and 2019. The peripheral vascular access service allowed patients to receive appropriate peripheral vascular access devices and avoid unnecessary peripheral catheter placements. This may have preserved patients' peripheral vasculature and thus prevented premature central catheter placement and contributed to an overall decrease in central catheter days. With the peripheral vascular access service, peripheral vascular access devices were selected, placed, and maintained by experts with a standardized process that promoted a culture of quality and patient safety.

Specialty Certification: A Path To Improving Outcomes.

Specialty Certification: A Path To Improving Outcomes.

Health Care–Associated Infections Among Critically Ill Children in the US, 2013-2018

Central catheter-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) increase morbidity, mortality, and health care costs in pediatric patients. To examine changes over time in CLABSI and CAUTI rates between 2013 and 2018 in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) using prospective surveillance data from community hospitals, children's hospitals, and pediatric units within general hospitals. This time series study included 176 US hospitals reporting pediatric health care-associated infection surveillance data to the National Healthcare Safety Network from January 1, 2013, to June 30, 2018. Patients aged 18 years or younger admitted to PICUs or level III NICUs were included in the analysis. The primary outcomes were device-associated rates of CLABSI in NICUs and PICUs and CAUTI in PICUs (infections per 1000 device-days). Secondary outcomes included population-based rates (infections per 10 000 patient-days) and device utilization (device-days per patient-days). Regression models were fit using generalized estimating equations to assess yearly changes in CLABSI and CAUTI rates, adjusted for birth weight (≤1500 vs >1500 g) in neonatal models. Of the 176 hospitals, 132 hospitals with NICUs and 114 hospitals with PICUs contributed data. Of these, NICUs reported 6 064 172 patient-days and 1 363 700 central line-days and PICUs reported 1 999 979 patient-days, 925 956 central catheter-days, and 327 599 indwelling urinary catheter-days. In NICUs, there were no significant changes in yearly trends in device-associated (incidence rate ratio [IRR] per year, 0.99; 95% CI, 0.95-1.03) and population-based (IRR, 0.96; 95% CI, 0.92-1.00) CLABSI rates or central catheter utilization (odds ratio [OR], 0.97; 95% CI, 0.95-1.00). Results were similar in PICUs, with device-associated (IRR, 1.03; 95% CI, 0.99-1.07) and population-based (IRR, 1.03; 95% CI, 0.99-1.07) CLABSI rates and central catheter utilization (OR, 0.99; 95% CI, 0.97-1.01) remaining stable. While device-associated CAUTI rates in PICUs also remained unchanged over time (IRR, 0.97; 95% CI, 0.91-1.03), population-based CAUTI rates significantly decreased by 8% per year (IRR, 0.92; 95% CI, 0.86-0.98) and indwelling urinary catheter utilization significantly decreased by 6% per year (OR, 0.94; 95% CI, 0.91-0.96). Recent trends in CLABSI rates noted in this study among critically ill neonates and children in a large cohort of US hospitals indicate that past gains have held, without evidence of further improvements, suggesting novel approaches for CLABSI prevention are needed. Modest improvements in population-based CAUTI rates likely reflect more judicious use of urinary catheters.

Prevalence and predictors of peripherally inserted central venous catheter associated bloodstream infections in cancer patients: A multicentre cohort study.

Despite increasing use, the exact prevalence and predictors of peripherally inserted central catheter-associated bloodstream infection (PICC-CLABSI) in hospitalized patients with cancer are not elucidated.This retrospective cohort study included consecutive patients who underwent peripherally inserted central catheter (PICC) placement in 4 institutions (during 12 months in 3 hospitals and 10 months in 1 hospital). The prevalence of PICC-CLABSI was evaluated. The association between predictors and PICC-CLABSI were analyzed using Cox proportional hazards regression models and Kaplan-Meier survival analysis with log-rank tests.During the study period, 539 PICCs were inserted in 484 patients for a total of 10,841 catheter days. PICC-CLABSI occurred in 25 (5.2%) patients, with an infection rate of 2.31 per 1000 catheter days. PICC for chemotherapy (hazards ratio [HR] 11.421; 95% confidence interval (CI), 2.434–53.594; P = .019), double lumen catheter [HR 5.466; 95% CI, 1.257–23.773; P = .007], and PICC for antibiotic therapy [HR 2.854; 95% CI, 1.082–7.530; P = .019] were associated with PICC-CLABSI.PICC for chemotherapy or antibiotics, and number of catheter lumens are associated with increased risk of PICC-CLABSI in cancer patients. Careful assessment of these factors might help prevent PICC-CLABSI and improve cancer patients care.

Safety of Biweekly Chlorhexidine Gluconate Bathing in Infants 36 To 48 Weeks' Postmenstrual Age.

Little evidence supports use of chlorhexidine gluconate (CHG) baths to reduce health care-associated infections, including central catheter-associated bloodstream infections in infants less than 2 months old. To describe the safety of biweekly CHG baths in infants less than 2 months old by measuring blood levels of CHG, liver and renal function, skin reactions, and adverse events. Study participants received twice-weekly 2% CHG baths, weekly blood tests, and twice-daily skin assessments. Adverse events were monitored. Ten infants 36 to 48 weeks' postmenstrual age with central venous catheters admitted to the neonatal or cardiac intensive care unit were enrolled before the study was closed by the Food and Drug Administration. The 9 patients contributing data had 83 CHG exposures; 31 CHG levels were analyzed. All patients had evidence of CHG absorption. Seven patients had CHG levels of 100 ng/mL or greater. Findings did not support accumulation of CHG but did show evidence of higher absorption than previously reported. Results of liver and renal function studies remained within reference limits. No patient had any adverse events, including skin reactions. Although no adverse events were observed, our patients had evidence of CHG absorption. The effects of this absorption remain unknown. More research is needed to determine safe blood levels of CHG in infants less than 2 months of age.

P1.47: Evaluation of central venous catheters in hospitalized pediatric patients with intestinal failure from a brazilian gastroenterology reference center

Introduction: Intestinal Failure (IF) is a debilitating condition, defined as the need for parenteral Nutrition (PN) for more than 60 days. One of the most important IF complication is central catheter-associated bloodstream infection (CCABSI). The Taurolidine line prophylaxis seems to be a promising measure for the prevention of these infections. Materials and Methods: retrospective study, evaluating 89 catheters used by 18 pediatric patients with IF from 2015 to 2017 at a center in the Southern Brazil. Results and Discussion: Most patients (61%) had short bowel syndrome, and prevalence of CCABSI was higher in this group of patients (P=0,036). Of the 18 children studied, 14 (77,8%) had at least one CCABSI. A total of 89 catheters were used by these children – mean of 4,95/patient. CCABSI occurred in 27 catheters (30,3%). 66.3% of the total number of catheters were non-tunneled and 32,6% were tunneled. 35,6% of the non-tunneled CVC had CCABSI compared to 20,7% of the tunneled (p=0,289).34,8% of the catheters were removed due to mechanical problems and 18% were removed due to CCABSI. The frequency of CCABSI was 5.7 per 1000 catheter days. The taurolock line prophylaxis has been used in our hospital since march/2016 and this paper included patients before this period. We found a statistically significant association between CCABSI and death (p=0,01). Patients with at least one CCABSI needed to change the CVC more often (x= 4 catheters) than children that did not presented infection (x= 2 catheters) (p=0,035). The use of taurolock improved catheter survival from 20 days to 26 days (p=0,032). Conclusions: CCABSIs was the main cause of death in this group of patients and frequency of CCABSIs is still high among our population. The use of taurolock helped to increase the days that the CVC remained in the patient, but more data is necessary to correlate this lock with an improvement in infection rate in our population.

Infections on Extracorporeal Life Support in Adults and Children—A Survey of International Practice on Prevention, Diagnosis, and Treatment*

To assess nosocomial infection management practices in pediatric and adult patients supported with extracorporeal life support. A 23-question online survey was developed to assess practices related to infection prevention, surveillance, diagnosis, and treatment in patients managed on extracorporeal life support. The survey was distributed internationally to intensivists via online newsletters and e-mail from June to December 2017. Extracorporeal life support centers. Intensivists working in extracorporeal life support centers. None. We analyzed 147 responses from 25 countries. Most centers have bundles implemented as standard of care to prevent against ventilator-associated pneumonia (77%) and central catheter-associated bloodstream infections (91%). Prophylactic antibiotics beyond cannulation are at least occasionally used by 61% of respondents. Daily C-reactive protein (35%) and white cell count (80%) are the most commonly used surveillance biomarkers, and 25% of respondents reported collecting daily surveillance cultures. Participants responded that new onset of hemodynamic instability and rising C-reactive protein (49%) or rising procalcitonin (30%) are the most common triggers to commence antibiotics. There is considerable variability surrounding practices on prevention and diagnosis of infection in patients treated with extracorporeal life support. In view of the impact of infections acquired during extracorporeal life support, further research to inform recommendations on prevention, diagnosis, and management of infection on extracorporeal life support is urgently needed.

Venous Ports in Infants

PurposeTo evaluate technical success and the incidences of, and risk factors for, mechanical and infectious complications of venous port placement in infants. Materials and MethodsThis was a retrospective single-institution cohort study of port placement in infants (age < 1 y) from January 2006 through June 2016 (mean age, 7.5 mo ± 3.3; mean weight, 8.1 kg ± 1.9). Age, weight, sex, side of placement, tip position, and indication for placement (chemotherapy vs other) were recorded. Total catheter-days (CDs), mechanical complications, and central catheter–associated bloodstream infections (CCABSIs) were identified. ResultsDuring the study years, 64 ports were placed in 64 infants, with a technical success rate of 100%. The mean catheter life was 321 days (total range, 4–1,917 d; interquartile range [IQR], 107–421 d). There were 13 CCABSI events (0.63 per 1,000 CDs); of these, 8 (12.5% among 64 patients) required port removal for infection. There was an increase in CCABSIs in patients with left-sided port placement (relative risk [RR], 3.22; 95% confidence interval [CI], 1.02–10.14; P = .05). There were 8 mechanical complications of the port reservoir or catheter (0.39 per 1,000 CDs). Of these, 2 (3.1%) required removal. Patients in the lowest weight quartile were at an increased risk of mechanical complications (RR, 4.37; 95% CI, 1.09–17.48; P = .04). ConclusionsVenous ports can be placed with a high rate of technical success in infants. Left-sided ports and low weight are associated with increased infectious and mechanical complications, respectively.

Risk factors for Candida parapsilosis bloodstream infection in a neonatal intensive care unit: a case-control study

BackgroundCandida parapsilosis is increasingly responsible for invasive candidiasis in neonates. This study investigates phenotypic and genotypic features of C. parapsilosis microbial isolates and underlying clinical conditions associated with acquisition of C. parapsilosis in a neonatal intensive care unit (NICU) in Italy.MethodsIdentification of C. parapsilosis was performed by VITEK® 2 and MALDI TOF and confirmed by analysis of internal transcribed spacer ribosomal DNA sequences. Genotyping was performed by PCR fingerprinting. Antifungal susceptibility of strains was evaluated by microdilution. A case-control study was designed to identify risk factors for C. parapsilosis bloodstream infection.ResultsDuring the study period (April 2009- April 2012), C. parapsilosis was responsible for 6 umbilical catheter and 11 central catheter-associated bloodstream infection in 17 neonates in the NICU. Molecular typing identified identical fingerprinting profile in all C. parapsilosis isolates from neonates. Fifteen of 17 C. parapsilosis isolates were susceptible to all antifungal drugs, two isolates were resistant to fluconazole and intermediate susceptible to itraconazole. Low birthweight, gestational age and time to exposure to assisted ventilation were risk factors for C. parapsilosis infection in neonates in the NICU at univariate and multivariate analysis.ConclusionC. parapsilosis bloodstream infections in the NICU were caused by a single epidemic clone. Low birthweight, gestational age and time to exposure to invasive devices, with predominance of assisted ventilation, were the clinical conditions associated with C. parapsilosis bloodstream infection in the NICU.

INTERVENTIONS TO DECREASE CATHETER-ASSOCIATED BLOODSTREAM INFECTIONS IN NEWBORNS: AN INTEGRATIVE REVIEW

ABSTRACT Objective: to perform an integrative review of strategies presented in care bundles to decrease central catheter-associated bloodstream infection among newborns. . Method a search was conducted of the Cochrane Library, IBECS, PubMed, Lilacs, Medline and Scielo catalogues, using the terms "bundle", "catheter-related infection", "infection control", "prevention", "evidence-based nursing"," evidence-based medicine" and" central venous catheter". Inclusion criteria were: papers published from 2009 to April 2014; written in Portuguese, English or Spanish; addressing both neonatal and pediatric populations or just neonatal populations; describing the use and/or assessing care bundles or protocols to control central catheter-associated infection. Results fifteen studies published between 2009 and 2013 were selected. The main information extracted from the studies was systematized as: 1) measures adopted to prevent central catheter-associated bloodstream infection according to level of scientific evidence, and 2) strategies used to implement evidence into health practice. Conclusion there was a variety of practices adopted, some of which are consistent with scientific evidence and some of which are not. Systematization conducted in this study is expected to contribute to practice, facilitating the use of the best evidence in each context, and research indicating gaps in knowledge to be explored in future studies

Severe Neutropenia at the Time of Implantable Subcutaneous Chest Port Insertion Is Not a Risk Factor for Port Removal at a Tertiary Pediatric Center

PurposeTo determine if severe neutropenia at the time of chest port insertion is a risk factor for port removal and central catheter–associated bloodstream infection (CCABSI) in pediatric patients. Materials and MethodsFrom May 2007 to June 2015, 183 consecutive patients (mean age, 9.9 y; range, 0.75–21 y) had a port inserted at a single tertiary pediatric center. Seventy-two had severe neutropenia at the time of port insertion (absolute neutrophil count [ANC] range, 0–500/mm3; mean, 185/mm3). Follow-up until port removal or death and CCABSI events were recorded. ResultsWithin the first 30 days, similar incidences of CCABSI (12.5% of patients with severe neutropenia [n = 9] vs 4.5% of patients without [n = 5]), port removal for infection (2.8% [n = 2] vs 2.7% [n = 3]), and local port infection (2.8% [n = 2] vs 0.9% [n = 1]) were observed in both groups (P > .05), but the rate of CCABSI per 1,000 catheter-days was higher for patients with severe neutropenia (P = .045). Overall, similar incidences of CCABSI (18.1% [n = 13] vs 16.2% [n = 18]), port removal for infection (2.8% [n = 2] vs 7.2% [n = 8]), local port infection (2.8% [n = 2] vs 2.7% [n = 3]), and CCABSIs per 1,000 catheter-days (0.332 vs 0.400) were observed in both groups (P > .05). ConclusionsPort placement in patients with severe neutropenia can be performed without an increased incidence of port removal for infection. The majority of CCABSIs were successfully treated without port removal.

A point-prevalence survey of healthcare-associated infection in fifty-two Chinese hospitals

Healthcare-associated infection (HCAI) represents a major problem for patient safety worldwide. To demonstrate the prevalence, causative agents, and risk factors for HCAI in Chinese hospitals. A one-day point-prevalence survey was conducted in 52 Chinese hospitals between October 2014 and March 2015. A web-based software system was developed for data entry and management. Among 53,939 patients surveyed, the prevalence of patients with at least one HCAI was 3.7%. Of 2182 HCAI episodes, the most frequently occurring types were lower respiratory tract infections (47.2%), followed by urinary tract infection (12.3%), upper respiratory tract infection (11.0%), and surgical site infection (6.2%). The prevalence of patients with at least one HCAI in critical care units was highest (17.1%). Device-associated infections, including ventilator-associated pneumonia, catheter-associated urinary tract infection, and central catheter-associated bloodstream infection, accounted for only 7.9% of all HCAIs. The most frequently isolated micro-organisms were Pseudomonas aeruginosa [206 infections (9.4%)], Acinetobacter baumannii [172 infections (7.9%)], Klebsiella pneumoniae [160 infections (7.3%)], and Escherichia coli [145 infections (6.6%)]. Of the survey patients (18,206/53,939), 33.8% were receiving at least one antimicrobial agent at the time of the survey. Risk factors for HCAI included older age (≥80 years), male gender, days of hospital admission, admission into a critical care unit, and device utilization. Our study suggests that the overall prevalence of HCAI in surveyed Chinese hospitals was lower than that reported from most European countries and the USA. More attention should be given to the surveillance and prevention of non-device-associated HCAI in China.

Hyperglycemia at the Time of Acquiring Central Catheter-Associated Bloodstream Infections Is Associated With Mortality in Critically Ill Children.

Hyperglycemia is common and may be a risk factor for nosocomial infections, including central catheter-associated bloodstream infections in critically ill children. It is unknown whether hyperglycemia at the time of acquiring central catheter-associated bloodstream infections in pediatric critical illness is associated with worse outcomes. We hypothesized that hyperglycemia (blood glucose concentration > 126 mg/dL [> 7 mmol/L]) at the time of acquiring central catheter-associated bloodstream infections (from 4 d prior to the day of first positive blood culture, i.e., central catheter-associated bloodstream infections) in critically ill children is common and associated with ICU mortality. Retrospective observational cohort study. Fifty-five-bed PICU and 26-bed cardiac ICU at an academic freestanding children's hospital. One hundred sixteen consecutively admitted critically ill children from January 1, 2008, to June 30, 2012, who were 0-21 years with central catheter-associated bloodstream infections were included. We excluded children with diabetes mellitus, metabolic disorders, and those with a "do not attempt resuscitation" order. None. The study cohort had an overall ICU mortality of 23%, with 48% of subjects developing hyperglycemia at the time of acquiring central catheter-associated bloodstream infections. Compared with survivors, nonsurvivors experienced more hyperglycemia both at the time of acquiring central catheter-associated bloodstream infections and subsequently. Median blood glucose at the time of acquiring central catheter-associated bloodstream infections was higher in nonsurvivors compared with survivors (139.5 mg/dL [7.7 mmol/L] vs 111 mg/dL [6.2 mmol/L]; p < 0.001) with 70% of nonsurvivors experiencing blood glucose greater than 126 mg/dL (> 7 mmol/L) during the 7 days following central catheter-associated bloodstream infections (in comparison to 45% of survivors; p = 0.03). After controlling for severity of illness and interventions, hyperglycemia at the time of acquiring central catheter-associated bloodstream infections was independently associated with ICU mortality (adjusted odds ratio, 1.9; 95% CI, 1.1-6.4; p = 0.03), in addition to other risk factors for ICU mortality (vasopressor use and severity of organ dysfunction). Hyperglycemia at the time of acquiring central catheter-associated bloodstream infections is common and associated with ICU mortality in critically ill children. Strategies to monitor and control blood glucose to avoid hyperglycemia may improve outcomes in critically ill children experiencing central catheter-associated bloodstream infections.

Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses' hand washing.

Critically ill patients are at marked risk of hospital-acquired infections, which increase patients' morbidity and mortality. Registered nurses are the main health care providers of physical care, including hygiene to reduce and prevent hospital-acquired infections, for hospitalized critically ill patients. To investigate a new patient hand hygiene protocol designed to reduce hospital-acquired infection rates and improve nurses' hand-washing compliance in an intensive care unit. A preexperimental study design was used to compare 12-month rates of 2 common hospital-acquired infections, central catheter-associated bloodstream infection and catheter-associated urinary tract infection, and nurses' hand-washing compliance measured before and during use of the protocol. Reductions in 12-month infection rates were reported for both types of infections, but neither reduction was statistically significant. Mean 12-month nurse hand-washing compliance also improved, but not significantly. A hand hygiene protocol for patients in the intensive care unit was associated with reductions in hospital-acquired infections and improvements in nurses' hand-washing compliance. Prevention of such infections requires continuous quality improvement efforts to monitor lasting effectiveness as well as investigation of strategies to eliminate these infections.

Central catheter-associated bloodstream infection reduction with ethanol lock prophylaxis in pediatric intestinal failure: broadening quality improvement initiatives from hospital to home.

Children with intestinal failure are at high risk for developing central catheter-associated bloodstream infections (CCABSIs) owing to children's chronic dependence on central venous catheters for parenteral nutrition. To evaluate the effectiveness and safety of the addition of ethanol lock prophylaxis to a best-practice CCABSI prevention bundle on hospital and ambulatory CCABSI rates in children with intestinal failure. Quality improvement and statistical process control analysis that took place at a tertiary care pediatric hospital and patient homes. Participants included children who were 18 years or younger with intestinal failure requiring a central venous catheter. Central catheter-associated bloodstream infection prevention bundle that included daily ethanol lock prophylaxis. Central catheter-associated bloodstream infection rates and safety outcomes (central catheter insertions, repairs, and hospitalizations) before (January 1, 2011-January 31, 2012) and after (February 1, 2012-December 31, 2013) ethanol lock prophylaxis bundle implementation. Twenty-four children with intestinal failure received the ethanol lock prophylaxis CCABSI prevention bundle for a median of 266 days (range, 12-635 days). Rates of CCABSI decreased from 6.99 CCABSIs per 1000 catheter days at baseline to 0.42 CCABSI per 1000 catheter days after ethanol lock prophylaxis bundle implementation, despite an increase in the total number of catheter days. A subset of 14 children who received prolonged ethanol lock prophylaxis (≥3 months) had fewer median (range) central catheter insertions 0 (0-2) vs 3 (0-6); P = .001. The pre-ELP intervention CCABSI rates in this subset was 7.01 per 1000 catheter days vs 0.64 per 1000 catheter days for post-ELP intervention (P = .004). There were no significant differences in the total number of hospital admissions; however, there were fewer hospitalizations for fever and CCABSI (P = .003). A best-practice CCABSI prevention bundle that included ethanol lock prophylaxis in both the hospital and home was successfully implemented, well tolerated, and demonstrated a significant and sustained reduction in preventable harm in the form of CCABSIs in children with intestinal failure.

Nurse-physician collaboration and hospital-acquired infections in critical care.

Nurse-physician collaboration may be related to outcomes in health care-associated infections. OBJECTIVE To examine the relationship between nurse-physician collaboration and health care-associated infections in critically ill adults. A secondary analysis was done of 5 years of nurses' perception data from 671 surveys from 4 intensive care units. Ventilator-associated pneumonia and central catheter-associated bloodstream infections were examined. Multilevel modeling was used to examine relationships between nurse-physician collaboration and the 2 infections. Nurse-physician collaboration was significantly related to both infections. For every 0.5 unit increase in collaboration, the rate of the bloodstream infections decreased by 2.98 (P= .005) and that of pneumonia by 1.13 (P= .005). Intensive care units with a higher proportion of certified nurses were associated with a 0.43 lower incidence of bloodstream infections (P= .02) and a 0.17 lower rate of the pneumonia (P= .01). With nursing hours per patient day as a covariate, units with more nursing hours per patient day were associated with a 0.42 decrease in the rate of bloodstream infections (P= .05). Nurse-physician collaboration was significantly related to health care-associated infections.