Central Line-associated Bloodstream Infection In Patients Research Articles

Incidence, Risk Factors, and Outcomes of Central Line-Associated Bloodstream Infections in Trauma Patients.

Introduction: Central line-associated blood stream infection (CLABSI) is a hospital-acquired infection (HAI) associated with increased morbidity and mortality among the general patient population. However, few studies have evaluated the incidence, outcomes, and risk factors for CLABSI in trauma patients. This study aimed to identify the rate of positive (+)CLABSI in trauma patients and risk factors associated with (+)CLABSI. Methods: The 2017-2021 Trauma Quality Improvement Program database was queried for trauma patients aged ≥18 years undergoing central-line placement. We compared patients with (+)CLABSI vs. (-)CLABSI patients. Bivariate and multivariable logistic regression analyses were performed. Results: From 175,538 patients undergoing central-line placement, 469 (<0.1%) developed CLABSI. The (+)CLABSI patients had higher rates of cirrhosis (3.9% vs. 2.0%, p = 0.003) and chronic kidney disease (CKD) (4.3% vs. 2.6%, p = 0.02). The (+)CLABSI group had increased injury severity score (median: 25 vs. 13, p < 0.001), length of stay (LOS) (median 33.5 vs. 8 days, p < 0.001), intensive care unit LOS (median 21 vs. 6 days, p < 0.001), and mortality (23.7% vs. 19.6%, p = 0.03). Independent associated risk factors for (+)CLABSI included catheter-associated urinary tract infection (CAUTI) (odds ratio [OR] = 5.52, confidence interval [CI] = 3.81-8.01), ventilator-associated pneumonia (VAP) (OR = 4.43, CI = 3.42-5.75), surgical site infection (SSI) (OR = 3.66, CI = 2.55-5.25), small intestine injury (OR = 1.91, CI = 1.29-2.84), CKD (OR = 2.08, CI = 1.25-3.47), and cirrhosis (OR = 1.81, CI = 1.08-3.02) (all p < 0.05). Conclusion: Although CLABSI occurs in <0.1% of trauma patients with central-lines, it significantly impacts LOS and morbidity/mortality. The strongest associated risk factors for (+)CLABSI included HAIs (CAUTI/VAP/SSI), specific injuries (small intestine), and comorbidities. Providers should be aware of these risk factors with efforts made to prevent CLABSI in these patients.

1680. Characterization of Ethanol Lock Use and Line Infections in Pediatric Patients with Intestinal Failure Requiring Central Venous Access

Abstract Background Pediatric patients with intestinal failure often require central venous line access for administration of parenteral nutrition and/or fluids, which leads to increased risk for central line associated-bloodstream infections (CLABSI). Ethanol lock therapy (ELT) has been used to reduce the risk of CLABSI in this patient population, but recent significant increases in the price of ethanol have prompted healthcare systems to explore cost-saving measures such as decreasing ELT frequency from daily to thrice weekly (TIW) or using antibiotic lock therapy as an alternative to ELT. The objective of this study was to compare the incidence and microbiology of CLABSI in pediatric patients with intestinal failure who received different lock therapies. Methods This was a single-center, retrospective, descriptive study that included pediatric patients who were followed by the Michigan Medicine Children’s Intestinal Rehabilitation Program between July 1, 2020 and June 30, 2022. Data were collected via the electronic health record. Incidence of CLABSI and microbiology were compared based on the type of lock therapy patients received (daily ELT, TIW ELT, or no ELT). Results A total of 46 patients were analyzed in this study, including 13 on daily ELT, 23 on TIW ELT, and 10 on no ELT. During the study period, 69% (9/13) of patients on daily ELT, 35% (8/23) of patients on TIW ELT, and 60% (6/10) of patients on no ELT had at least one CLABSI (for comparison between daily and TIW ELT, p = 0.0819). Of 75 episodes of CLABSI identified during the study period, the most commonly isolated pathogens were Staphylococcus epidermidis (n = 33), S. aureus (n = 19), S. hominis (n = 17), and Escherichia coli (n = 8). Almost half (44%, 33/75) of CLABSI reported were polymicrobial (see Table 1 for comparison of microbiology by type of lock therapy).Table 1:Number of monomicrobial vs. polymicrobial CLABSI by Gram stain results and type of lock therapy. Conclusion There was no statistically significant difference in the incidence of CLABSI between pediatric patients with intestinal failure who received TIW ELT and those who received either daily ELT or no ELT. TIW ELT appears to be an effective and cost-efficient option compared to daily ELT in this patient population. Disclosures All Authors: No reported disclosures

Central Line-Associated Bloodstream Infection in Patients With Hematologic Malignancy Receiving Parenteral Nutrition.

Parenteral nutrition (PN) has been shown to be a safe method of feeding in the intensive care unit with modern infection prevention practices, but similar analysis in the hematology-oncology setting is lacking. A retrospective analysis of 1,617 patients with hematologic malignancies admitted and discharged from the Hospital of the University of Pennsylvania during 3,629 encounters from 2017 to 2019 was undertaken to evaluate the association of PN administration with risk of central line-associated bloodstream infection (CLABSI). Proportions of mucosal barrier injury (MBI)-CLABSI and non-MBI-CLABSI were also compared between groups. Risk of CLABSI was associated with cancer type and duration of neutropenia but not with PN administration (odds ratio, 1.015; 95% CI, 0.986 to 1.045; P = .305) in a multivariable analysis. MBI-CLABSI comprised 73% of CLABSI in patients exposed to and 70% in patients not exposed to PN, and there was no significant difference between groups (χ2 = 0.06, P = .800). PN was not associated with increased risk of CLABSI in a sample of patients with hematologic malignancy with central venous catheters when adjusting for cancer type, duration of neutropenia, and catheter days. The high proportion of MBI-CLABSI highlights the effect of gut permeability within this population.

Risk factors associated with increased incidences of catheter-related bloodstream infection.

We have implemented several preventive measures to reduce central line-associated bloodstream infection (CLABSI) in the general intensive care unit (ICU) of a university hospital in Japan. Here, we analyzed the factors associated with CLABSI in patients with central venous catheter (CVC) insertions and evaluated the effects of our implemented preventive measures. From July 2013 to June 2018, data was collected from the medical records of 1472 patients with 1635 CVC insertions, including age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, duration of ICU stay, duration of catheter insertion, insertion site, and mechanical ventilation status. During weekly conferences, a surveillance team comprising intensive care and infection control doctors and nurses determined the patients’ CLABSI status. The analyzed factors were compared between CLABSI and central line patients without bloodstream infection. Multivariate analysis revealed three factors associated with CLABSI. Adjusted odds ratios with 95% confidence intervals were as follows: duration of ICU stay, 1.032 (1.019–1.044); duration of catheter insertion, 1.041 (1.015–1.066); and APACHE II score, 1.051 (1.000–1.105). The prominent risk factors were associated with the severity of the initial condition and exacerbation of the clinical condition of the patients during their stays in the ICU. Further strategies to reduce CLABSI must be developed.

771. COVID-19 on the Line: A Significant Increase in CLABSI in Hospitalized Patients with COVID-19 at a Major Teaching Hospital

BackgroundWe observed an increase in central line associated bloodstream infections (CLABSI) associated with the 2020 COVID-19 pandemic and performed a retrospective analysis to better understand the impact of COVID-19 on CLABSI rates.Figure 1. CLABSI rate in 2019 vs CLABSI rate in 2020 A comparison of CLABSI rates (displayed in infections/1000 catheter days) in all adult inpatients at our institution for calendar-years 2019 and 2020MethodsRetrospective review was done for all CLABSI in adults meeting National Healthcare Safety Network (NHSN) criteria in 2020 at an 889-bed teaching hospital. CLABSIs in encounters with PCR-confirmed COVID-19 (COVID CLABSI) were compared with CLABSIs in encounters without a COVID diagnosis (non-COVID CLABSI). As a secondary analysis, we also reviewed all CLABSI occurrence in 2019. Characteristics were compared using Mid-P Exact (Poisson) and Chi Squared (categorical) Tests. Subjective data collected by infection preventionists during real-time case reviews with clinical staff of each CLABSI was also reviewed.ResultsIn 2020, the rate of COVID CLABSI (CLABSI/1000 catheter days) was 6.6 times greater than the rate of non-COVID CLABSI (5.47 vs. 0.83, p< 0.001). In the COVID CLABSI group we observed higher rates of occurrence in the ICU setting (94% vs 28%, p< 0.001), in house mortality (53% vs 26% P=0.0187), presence of arterial lines (91% vs 20%, p< 0.001) and increased number of catheter lumens (4 vs 3, p< 0.001). No significant difference was observed in the distribution of pathogens. No significant differences were observed between 2019 CLABSI and 2020 non-COVID CLABSI. Real-time case reviews identified changes in nurse staffing, increased nurse: patient ratios, delays in routine central line dressing changes, and inconsistent use of alcohol-impregnated port protectors as possible contributing factors. Table 1. 2020 COVID CLABSI vs 2020 non-COVID CLABSI A comparison of selected patient and catheter characteristics in COVID CLABSI vs non-COVID CLABSI in 2020Table 2. 2019 CLABSI vs 2020 non-COVID CLABSI A comparison of selected patient and catheter characteristics in CLABSI in 2019 vs non-COVID CLABSI in 2020Figure 2. CLABSI rate in 2019 vs COVID CLABSI and non-COVID CLABSI in 2020 A comparison of CLABSI rates (displayed in infections/1000 catheter days) in all adult inpatients at our institution for calendar years 2019 and 2020, with the infections in 2020 divided into those that occurred during an encounter with a PCR -confirmed diagnosis of COVID-19 and those without.ConclusionWe observed a dramatically higher rate of CLABSI in patients with COVID-19 in 2020, while the rate of CLABSI in patients without COVID-19 remained unchanged from the year prior. Higher rates of ICU admission, critical illness, increased numbers of lumens, increased presence of arterial lines, nurse staffing changes, and gaps in routine line prevention processes associated with emergency measures in the COVID-19 cohort ICU may have contributed to this finding. Further work is needed to better understand how to minimize process-related disruptions in central line care during a hospital response to a pandemic. Disclosures Jonathan Grein, MD, Gilead (Other Financial or Material Support, Speakers fees)

777. Implementation of Antimicrobial Impregnated Catheters to Reduce Central Line Associated Bloodstream Infections (CLABSI) in a Pediatric Setting

BackgroundAntimicrobial impregnated catheters (AIC) are one strategy to prevent CLABSI with existing data for central lines required for short duration, however, the strength of evidence, particularly for children, is lacking. Recent 3-year CLABSI data at our institution show 60 (51%) infections occurred in central lines within 8 weeks of insertion, suggesting an opportunity for evaluation of an intervention targeting this time frame. We implemented AIC to evaluate their effectiveness in reducing CLABSI standardized infection ratio (SIR) in patients requiring central venous access for less than 8 weeks. We also monitored for complications (malfunction, line exchange, fungal infection).MethodsA stepped wedge observational design was used to implement Minocycline + Rifampin impregnated catheters in a rolling fashion across the institution. Children > 3kg were eligible if admitted to a participating unit and required central venous access through a peripherally inserted central catheter (PICC), non-tunneled catheter, or tunneled non-cuffed femoral catheter for < 8 weeks. Units, prioritized based on CLABSI SIR, were added to the intervention monthly until AIC were used throughout the institution. A multidisciplinary team (infectious diseases and infection control experts, CLABSI leaders, unit-based physicians and nurses, proceduralists, supply chain) met weekly to facilitate implementation, assess for CLABSI and monitor for complications.Figure 1. Study design. This figure describes the stepped wedge study design where units were phased into the invention on a rolling monthly basis allowing for comparison between and within units. The shaded boxes represent time periods when units were using antimicrobial impregnated catheters and the white boxes represent time periods when units were using standard non-impregnated catheters.ResultsAIC were systematically implemented over a 7-month period. The institution’s CLABSI SIR decreased from 0.80 to 0.59 during this timeframe. There were no NHSH defined CLABSI in patients with an AIC during the intervention. Obstacles included shortage of catheters due to supply chain disruption, adjustment of technique for line insertion and cracked/broken lines. Infections and complications were reviewed by the multidisciplinary team and compared to historical rates with non-impregnated lines. This figure shows the institution’s rolling 12-month SIR during the intervention period.ConclusionCLABSI SIR decreased at our institution during the intervention period. While many efforts likely led to this reduction (optimizing maintenance bundle, unit based CLABSI initiatives), we believe the use of AIC contributed to this improvement. There were no pediatric-specific safety events identified during implementation.Disclosures Ravi Jhaveri, MD, AstraZeneca (Consultant)Dynavax (Consultant)Elsevier (Other Financial or Material Support, Editorial stipend as Co-EiC, Clinical Therapeutics)Hologic (Consultant)Seqirus (Consultant)

Central Venous Catheter Salvage in Ambulatory Central Line-Associated Bloodstream Infections.

Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.

Central Line Associated Bloodstream Infection Rate Among Hematologic Malignant Patients Who Received Antimicrobial Prophylaxis in the Inpatient Setting

Introduction:Patients with hematological malignancies are at increased risk of infections which leads to increased morbidity and mortality. Particularly, they are at an increased risk of developing central line associated bloodstream infection (CLABSI) since they frequently require central venous catheters for various essential reasons including chemotherapy, blood transfusions, and parenteral nutrition. Prophylaxis with antibiotics is the key in the management for these patients but is not always effective and sometimes associated with complications. Hence, the main objective of the study is to examine the rate of developing CLABSI in patients with hematological malignancies receiving antimicrobial prophylaxis and in those who did not receive prophylaxis.MethodsWe conducted a retrospective study involving patients diagnosed with a hematological malignancy admitted to the Augusta University Medical Center from 2002 to 2019. IRB approval was obtained to review the patients' charts. Patients who developed CLABSI are defined as those who had positive blood cultures after central venous catheter had been placed. Percentage of patients who received prophylaxis and those who didn't get antimicrobial prophylaxis were calculated. The difference between the two percentages was examined to determine whether or not it is statistically significant.ResultsThe charts of 268 patients admitted for hematological malignancies were reviewed. Among 173 patients receiving antibiotic prophylaxis (65.0%), 78 (45.1%) developed CLABSI. Among the patients who didn't receive prophylaxis, 64 (68.8%) developed CLABSI. The difference between the two groups was statistically significant (p<0.01), and the relative risk of developing CLABSI in patients who did not receive prophylaxis is 0.57 (95% confidence interval 0.41 - 0.79).ConclusionPatients who had been diagnosed with a hematologic malignancy and admitted at the academic institution from 2002 to 2019 were analyzed for the risk of developing CLABSI that was associated with the use of antibiotic prophylaxis. We found that the non-prophylactic group has statistically significant higher risk of developing CLABSI than the prophylactic group. Thus prophylaxis with antibiotics may play a major role in decreasing the rate of CLABSI in patients admitted with hematological malignancy. DisclosuresNo relevant conflicts of interest to declare.

1375. Characterization of Recurrent Central Line-associated Bloodstream Infections at Texas Children’s Hospital

BackgroundRecurrent central line-associated bloodstream infections (CLABSI) in children present a unique challenge to infection prevention efforts but guidelines for management are lacking.MethodsWe reviewed CLABSI data at Texas Children’s Hospital (TCH) from fiscal years (FY) 2017-2019. A chart review to characterize clinical features, risk factors, and outcomes of patients with recurrent CLABSIs in FY2019 was performed. Descriptive statistics and Fisher’s exact test were used.ResultsRecurrent CLABSIs increased from FY 2017-2019 [20% (26/126) to 33% (44/131)] (P=0.03). In FY2019, 15 patients accounted for 44 CLABSIs (Figure 1). Underlying conditions included aplastic anemia (4), hemophagocytic lymphohistiocytosis (3), malignancy (4), genetic disease (2), congenital heart disease (1) and biliary atresia (1). Two-thirds of the CLABSIs occurred in the setting of severe neutropenia (ANC < 100 cells/mm3) though only 16 (36%) were classified as mucosal barrier injury. The median time between line insertion and date of infection was 41 days (range 1-105). Line type included central venous catheters (25, 57%), peripherally inserted central catheters (17, 39%) and implantable ports (2, 5%). Most lines (80%) had double lumens. The most common organisms included: Gram-negative bacilli (15), coagulase negative staphylococci (14), viridans group streptococci (6) Candida spp. (5), Enterococcus faecalis (3) and Staphylococcus aureus (3). Four CLABSIs were polymicrobial. Patients with >2 CLABSIs were more likely to have subsequent infections with the same organism as compared to patients with only 2 CLABSIs (P=0.01). Lines were removed promptly (19, 43%), had delayed removal (removal >72 hours from infection date) (10, 23%) or remained in place (15, 34%). Lines were removed for all episodes of fungemia (5/44) and for most Gram-negative infections (10/12). Six of 7 Escherichia coli CLABSIs were breakthrough fluoroquinolone-resistant infections in patients on levofloxacin.Single Episode and Recurrent CLABSIs at Texas Children’s Hospital for Fiscal Year 2019 ConclusionRecurrent CLABSI accounted for a third of CLABSIs in FY2019. Line mismanagement was not a key contributor to recurrent CLABSI. Breakthrough CLABSIs in patients on levofloxacin prophylaxis need further investigation. For patients with CLABSIs due to Staphylococci decolonization may be considered.Disclosures All Authors: No reported disclosures

Development of a Risk Prediction Model for Central-Line–Associated Bloodstream Infection (CLABSI) in Patients With Continuous Renal Replacement Therapy

Background: The number of patients with end-stage renal disease and acute kidney injury in China is large and increasing year by year. Continuous renal replacement therapy (CRRT) is one of the important treatment methods. However, long-time CRRT would inevitably lead to CLABSI, which would seriously affect the treatment and prognosis of the patient. Although CLABSIs can be prevented and controlled, the rate of CLABSI in China is still higher than in other countries. Therefore, it is urgent to find new intervention methods on the basis of existing methods. Surveillance is the prerequisite of infection prevention and control. We sought to develop a risk prediction model for CLABSI in patients with CRRT according to uncontrollable risk factors, which could be used for early assessment and screening of high-risk infection groups. Such a tool would bring the supervision and infection control to the forefront in addressing these issues. Methods: We selected 3,103 CRRT patients in the West China Hospital of Sichuan University from January 2013 to December 2018 using the hospital infection and infectious disease monitoring module of electronic medical records (EMR) system with the integration and elimination criteria. Data mining and feature selection were performed using Weka software. Separately, prediction models developed by Weka software and SPSS software were compared with each other using the area under the curve (AUC) method to assess the performance of the forecasting models. Result: The incidence of CLABSI in CRRT patients was 8.01 per 1,000 catheter days (238 of 29,711). According to the multifactor regression analysis by SPSS software, the retaining time of dialysis catheter, C-reactive protein levels, total bilirubin, acute pancreatitis, and systemic inflammation reaction syndrome were the risk factors. According to the Youden’s index, the cutoff point of the retaining time of dialysis catheter was 5.5 days; the cutoff point of CRP was 112.5mg/L; and the cutoff point of total bilirubin was 14.15 μmol/L. The prediction models of CLABSI for CRRT patients were developed: The AUC of the prediction model developed by SPSS software was 0.763 (95% CI, 0.717–0.809). The receiver operating characteristic (ROC) curve analysis showed that the AUCs of the prediction models developed separately by Weka software using Bayes, logistic regression analysis, multiple layer Perceptron and J48, and SPSS software through logistic regression analysis were between 0.6 and 0.8. Using the down-sampling technique, the AUC ranged between 0.7 and 0.9, and the sensitivity, precision, and &amp;kappa; value increased. Thus, these models had definite clinical significance. Conclusion: The prediction models of CLABSI for CRRT patients, developed based on the big healthcare data, not only had good judgment ability, but also had good application value for individual evaluations and the target population.Funding: This study was supported by the Health Commission of Sichuan Province.Disclosures: None

Knowledge Based Approach to Solving CLABSIs in Patients Receiving Total Parenteral Nutrition...Improving Nursing Best Practice Through Direct Observation & Education

<h3>Background</h3> Total parental nutrition (TPN) administered via a central line has been identified as an independent risk factor for central line-associated bloodstream infection (CLABSI). Our institution experienced a large increase in CLABSI from 8 for December 2017- July 2018 to 15 for August 2018 - March 2019; SIR = 0.614 vs 1.270; p=0.0958. Likewise, the percentage of CLABSI associated with TPN administration via peripherally inserted catheter (PICC) increased from zero to 60% (9/15). We propose there is a TPN set-up and maintenance knowledge deficit among nursing that is contributing to the increase in CLABSI. <h3>Methods</h3> An intervention was conducted from April to July 2019 to evaluate nursing knowledge and practice of TPN administration. A multidisciplinary group of infection prevention, nursing, pharmacy, and education rounded on xx of patients receiving TPN to conduct audits of best practice and provide real-time feedback as an educational intervention. In addition, a voluntary anonymous 12-question survey addressing TPN administration and central line care was distributed to nursing. <h3>Results</h3> 70 nurses participated in the intervention by completing the survey. 37% indicated awareness of proper TPN setup, 50% reported scrubbing the hub prior to connecting the patient, 71% were aware to stop TPN infusion if line became disconnected, 57% were aware of appropriate TPN indications, and 43% of direct observations included proper hand hygiene. 3 CLABSI have been identified April to October 2019 (SIR = 0.513); zero associated with TPN administration via PICC. <h3>Conclusions</h3> Many opportunities for improvement were discovered through direct observation. Our group utilized results from rounding and the knowledge assessment to tailor educational opportunities for all disciplines involved. Clinical lessons learned were incorporated into mandatory nursing competencies and six additional knowledge based sessions. Periodic audits to assess TPN practice combined with knowledge assessments may be needed to improve and sustain compliance with TPN administration standards of care.

A hospital-wide reduction in central line–associated bloodstream infections through systematic quality improvement initiative and multidisciplinary teamwork

Few data are available on hospital-wide incidence of central line-associated bloodstream infection (CLABSI) rates in patients with central venous catheter (CVC) in China, where many systemic obstacles holding back evidence-based guidelines implementation exist. This study was conducted prospectively in 2 phases. The baseline and intervention phases were performed in a teaching hospital in China, between January 2017 and October 2018. A systematic quality improvement (SQI) and multidisciplinary teamwork (MDT) CLABSI infection control program was introduced in the intervention phase. In the intensive care units (ICUs) and non-ICUs, CLABSIs were continuously monitored, data collected, then analyzed. After intervention, the CLABSI rate decreased from 2.84-0.56 per 1,000 CVC days in ICUs (P < .001), and from 0.82-0.47 per 1,000 CVC days in non-ICUs (P = .003). The length of time until CLABSI occurrence increased from 8.72-13.60 days in ICUs (P = .046), and from 10.00-12.00 days in non-ICUs (P = .048). The number of multidrug-resistant bacteria isolated from CLABSI episodes decreased both in ICUs and in non-ICUs. The SQI and MDT CLABSI infection control program is effective in reducing hospital-wide CLABSI in patients with CVC, both in ICUs and in non-ICUs.

The risk of bloodstream infection associated with totally implantable venous access ports in cancer patient: a systematic review and meta-analysis.

This systematic review and meta-analysis aimed to provide evidence-based guidance to better understand the risk of central line-associated bloodstream infection (CLABSI) in cancer patients who received totally implantable venous access ports (TIVAPs) compared with those who received external central venous catheters (CVCs). A systematic search of PubMed, Web of science, Embase, and the Cochrane Library was carried out from inception through Oct 2018, with no language restrictions. Trials examining the risk of CLABSI in cancer patients who received TIVAPs compared with those who received external CVCs were included. Two reviewers independently reviewed, extracted data, and assessed the risk of bias of each study. A random-effect model was used to estimate relative risks (RRs) with 95% CIs. In all, 26 studies involving 27 cohorts and 5575 patients reporting the incidence of CLABSI in patients with TIVAPs compared with external CVCs were included. Pooled meta-analysis of these trials revealed that TIVAPs were associated with a significant lower risk of CLABSI than were external CVCs (relative risk [RR], 0.44; 95% confidence interval [CI], 0.31-0.62; P < 0.00001), which was confirmed by trial sequential analysis for the cumulative z curve entered the futility area. Subgroup analyses demonstrated that CLABSI reduction was greatest in adult patients (RR [95% CI], 0.35 [0.22-0.56]) compared with pediatric patients who received TIVAPs (RR [95% CI], 0.55 [0.38-0.79]). TIVAP can significantly reduce the risk of CLABSI compared with external CVCs.

Abstract 16813: Epidemiology and Microbiology of Central Line-Associated Bloodstream Infections in the Cardiac Intensive Care Unit

Introduction: Extensive literature exists on the incidence, risk factors and impact of Central Line-Associated Bloodstream Infections (CLABSI) in the general ICU, but is lacking for the Cardiac Intensive Care Unit (CICU). Hypothesis: We describe the epidemiology and microbiology of CLABSI in patients admitted to a CICU. Methods: We retrospectively reviewed all critically-ill cardiac patients who met the definition for CLABSI while admitted at a Quaternary CICU between May-10 to Feb-18. Data on CLABSI rate per 1000 line days was only available since Jan 13. CLABSI data were collected prospectively by the Infectious Diseases Nurse Specialist. Patient demographics and clinical data were retrospectively collected using a predefined collection tool. Results: Out of approximately 21,070 individual CICU admissions within the study period, 46 patients met criteria for CLABSI with an average of 1.4 CLABSI per 1000 line days. The mean age was 67±11 years, 59% male with an observed in-hospital mortality of 39%. Most patients who developed CLABSI sustained a cardiac arrest (34%), cardiogenic shock (28%) or acute decompensated heart failure (24%). Line burden prior to CLABSI was estimated as a median of 2 (2-3 Q 1-3 ) lines per patient. Most central lines were venous (86%) with jugular access predominance (76.5%) over femoral (22.5%). Inotropic, vasopressor and mechanical circulatory support was commonly encountered in this population. (Figure 1) Gram-positive cocci (64%) were the most common organism detected in blood cultures, but gram-negative bacilli represented a significant proportion (26%) of the implicated microbiology. Conclusion: A definition of CLABSI is met in the CICU mainly in the setting of cardiac arrest, cardiogenic shock and/or decompensated heart failure. The emergent placement of lines in hemodynamically unstable patients and the potential for gut translocation in this population may play a potential role and deserves further exploration.

Defining Incidence and Risk Factors for Catheter-Associated Bloodstream Infections in an Outpatient Adult Hematopoietic Cell Transplantation Program

Allogeneic hematopoietic cell transplantation (HCT) patients are at an increased risk of developing central line–associated bloodstream infections (CLABSIs) due to prolonged periods of myelosuppression, immunosuppression, and indwelling catheter days. CLABSIs are among the most serious complications in HCT recipients and can lead to prolonged hospitalizations, intensive care unit admissions, lengthy antimicrobial therapies, and increased mortality. There is a lack of data regarding the incidence and risk factors associated with the development of CLABSIs in the HCT population undergoing outpatient transplantation. This was a single-center, retrospective analysis of adult patients who underwent allogeneic HCT between July 2012 and July 2016 in an outpatient transplant unit at a tertiary academic medical center. The primary outcome was the cumulative incidence of CLABSIs from the date of central line placement through the first 100 days post-transplantation. Secondary outcomes included risk factors for CLABSI, number of hospitalizations due to CLABSI, mortality rate at 6 months post-transplantation, and the cumulative incidence, speciation, and presence of multidrug resistance in identified microorganisms. Three hundred fifty-nine patients underwent allogeneic HCT at Vanderbilt University Medical Center and 352 were included for analysis. The cumulative incidence of CLABSIs was 9%, with the majority occurring within the first 30 days post HCT (67%). The use of a matched unrelated donor (MUD) and/or haploidentical donor (odds ratio, 3.993; 95% confidence interval [CI], 1.329 to 12.001; P = .0136) and use of an ablative conditioning regimen (odds ratio, 2.394; 95% CI, 1.052 to 5.446; P = .0374) were independently associated with development of a CLABSI on multivariate analysis. The most common organism implicated in CLABSI was Staphylococcus epidermidis (34%). Patients who developed a CLABSI had an almost 5 times higher risk of mortality at 6 months post-transplantation compared with patients who did not develop a CLABSI (hazard ratio, 4.932; 95% CI, 2.463 to 9.878; P < .001). There is a low incidence of CLABSIs in patients undergoing HCT in the outpatient setting. Patients who underwent HCT using a MUD or haploidentical donor and received ablative conditioning were at higher risk for developing CLABSIs. Overall mortality at 6 months post-transplantation was higher in patients who developed a CLABSI. Additional prospective studies are needed to confirm these observations.

Mucosal Barrier Injury Laboratory Confirmed Bloodstream Infections

To increase the awareness of the new CDC survey definition of Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infection (MBI-LCBI). We included a comparison of the definition of Central Line-Associated Bloodstream Infection (CLABSI), with a high sensitivity but low specificity and Catheter-Related Bloodstream Infection (CRBSI). There are other parameters like the difference between the size of the inoculum (catheter lumen vs peripheral), that increased specificity and is useful for research and clinical decisions. Also, MBI-LCBI secondary to bacterial translocation in patients who had received myeloablative chemotherapy with severe neutropenia is not related to central venous catheter care. This new survey definition is useful for better classification of nosocomial bloodstream infections among patients receiving myeloablative chemotherapy and has impacted diminishing the incidence of CLABSI, which has probably has been overestimated in patients with hematological malignancies. The concept of MBI-LCBI should not be limited to survey purposes; it is also useful for clinical decisions. We propose to incorporate a second set of blood cultures obtained 48 hours after antibiotic treatment onset, one through the line of the CVC and another one at a peripheral site; if negative, it avoids unnecessary removal of the catheter in patients with severe neutropenia or, on the contrary, if positive blood cultures persist after 48 hours of antimicrobial therapy, there is a clear indication for central venous catheter removal. The definition of MBI-LCBI avoids over-diagnosis of CLABSI in patients receiving myeloablative chemotherapy with severe neutropenia.

Strategies to Reduce the Risk of Central Line–Associated Bloodstream Infections in Parenteral Nutrition

Parenteral nutrition (PN) is a lifesaving or life-sustaining treatment, but complications from its use, including central line–associated bloodstream infections (CLABSIs), necessitate that care be taken to ensure its safety. Our institution developed strategies that aim to incorporate evidence-based practices to reduce the risk of CLABSIs in patients receiving PN. A retrospective evaluation was conducted to assess the implementation of these strategies. Overall, adherence to the risk-reduction strategies was high, and no patients receiving PN experienced CLABSI during the time of the study.

Are antimicrobial peripherally inserted central catheters associated with reduction in central line-associated bloodstream infection? A systematic review and meta-analysis.

Antimicrobial peripherally inserted central catheters (PICCs) may reduce the risk of central line-associated bloodstream infection (CLABSI). However, data regarding efficacy are limited. We aimed to evaluate whether antimicrobial PICCs are associated with CLABSI reduction. MEDLINE, EMBASE, CINHAL, and Web of Science were searched from inception to July 2016; conference proceedings were searched to identify additional studies. Study selection and data extraction were performed independently by 2 authors. Of 597 citations identified, 8 studies involving 12,879 patients met eligibility criteria. Studies included adult and pediatric patients from intensive care, long-term care, and general ward settings. The incidence of CLABSI in patients with antimicrobial PICCs was 0.2% (95% confidence interval [CI], 0.0%-0.5%), and the incidence among nonantimicrobial catheters was 5.3% (95% CI, 2.6%-8.8%). Compared with noncoated PICCs, antimicrobial PICCs were associated with a significant reduction in CLABSI (relative risk [RR], 0.29; 95% CI, 0.10-0.78). Statistical heterogeneity (I2, 71.6%; T2 = 1.07) was resolved by publication type, with peer-reviewed articles showing greater reduction in CLABSI (RR, 0.21; 95% CI, 0.06-0.74). Twenty-six patients (95% CI, 21-75) need to be treated with antimicrobial PICCs to prevent 1 CLABSI. Studies of adults at greater baseline risk of CLABSI experienced greater reduction in CLABSI (RR, 0.20; P = .003). Available evidence suggests that antimicrobial PICCs may reduce CLABSI, especially in high-risk subgroups. Randomized trials are needed to assess efficacy across patient populations.

Reduction in Inpatient Central Line Associated Blood Stream Infection Post Implementation of Bundled Care Measures in Patients with Benign and Malignant Hematological Conditions in a Single Pediatric Institution

Background:Central line associated blood stream infections (CLABSIs) are a significant source of morbidity, mortality and cost for pediatric hematology/oncology patients. In response to increasing CLABSI rates, the Hematology/Oncology division at Primary Children's Hospital (PCH) initiated a quality improvement project to reduce CLABSIs in January 2011. This effort included participation in the Children's Hospital Association (CHA) quality improvement initiative targeted at reducing CLABSIs in hematology/oncology patients from 2011 through 2015, implementation of best practice central line maintenance bundles, and ongoing monitoring of staff adherence to the maintenance care bundles.Objective:The objective of this study was to study the relationship and impact of implementation of a comprehensive central line care quality improvement program on CLABSI rates and bloodstream pathogens in children admitted to our hospital with benign and malignant hematological conditions.Methods:We retrospectively identified CLABSIs in children with a hematology/oncology diagnosis admitted to the 32 bed immunocompromised unit at Primary Children's Hospital from January 2006 through July 2015. We used the National Health Safety Network and Center for Disease Control's definition for CLABSI. The pre-intervention period was from January 2006 through December 2010. The post-intervention period was from January 2011 through July 2015. We calculated CLABSI events per 1000 line days for both the pre- and post-intervention groups. In January 2011, our hospital implemented a central line quality improvement initiative, which includedCDC-based guidelines on: daily central line assessment, hand hygiene, sterile/non-sterile gloves and mask depending on procedure, specific central line site care protocols with scrub and dressing change schedule, specific hub/cap/tubing care and parental fluid/medication administration.Results:More than 75% of CLABSIs in hospitalized children with a hematology/oncology diagnosis, in both the pre- and post-intervention periods occurred in patients with benign and malignant hematological conditions. From 2006-2010, there were 156 infections [4.84/1,000 line days (32,229 line days)] documented in hospitalized hematology/oncology patients of which 123 infections were in patients with any hematological condition. This decreased to 80 infections [2.86/1,000 line days (28,003 line days)] in all hospitalized hematology/oncology patients, and to 65 in patients with any hematological conditions from 2010-2015 (Fig 1). Viridans group Streptococci was the leading cause of CLABSIs in both pre- and post-intervention periods (27% and 20%, respectively), but we observed post-intervention notable decreases among Viridans group Streptococci, coagulase-negative Staphylococci, and Candida species. Gram negative and Enterococcus spp. infections appeared to remain similar in the pre- and post-intervention period (Fig 2).Conclusion:In both pre- and post-implementation periods, patients with benign and malignant hematological conditions comprise the majority (75%) of all hematology/oncology patients who experience CLABSI events.After implementation of a central line care quality improvement initiative in 2011, CLABSI events decreased among all hematology/oncology patients, with apparent decreases noted in infections involving Viridans group Streptococci, coagulase-negative Staphylococci and Candida spp. It appears as though CLABSIs due to organisms common to the lower gastrointestinal tract, i.e. gram negative organisms and Enterococcus spp., were similar in both study periods. This may indicate that infections involving these organisms may be less amenable to reduction with current best practice central line maintenance care bundles. Continuing to evaluate these data will not only further our understanding of CLABSIs in patients with benign and malignant hematological conditions but also bloodstream infections (BSI) in general in the hematology/oncology population. This information will guide ongoing refinements of interventions to reduce BSI in this population. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Meta-analysis on central line–associated bloodstream infections associated with a needleless intravenous connector with a new engineering design

Intravenous needleless connectors (NCs) with a desired patient safety design may facilitate effective intravenous line care and reduce the risk for central line-associated bloodstream infection (CLA-BSI). We conducted a meta-analysis to determine the risk for CLA-BSI associated with the use of a new NC with an improved engineering design. We reviewed MEDLINE, Cochrane Database of Systematic Reviews, Embase, ClinicalTrials.gov, and studies presented in 2010-2012 at infection control and infectious diseases meetings. Studies reporting the CLA-BSIs in patients using the positive-displacement NC (study NC) compared with negative- or neutral-displacement NCs were analyzed. We estimated the relative risk of CLA-BSIs with the study NC for the pooled effect using the random effects method. Seven studies met the inclusion criteria: 4 were conducted in intensive care units, 1 in a home health setting, and 2 in long-term acute care settings. In the comparator period, total central venous line (CL) days were 111,255; the CLA-BSI rate was 1.5 events per 1,000 CL days. In the study NC period, total CL days were 95,383; the CLA-BSI rate was 0.5 events per 1,000 CL days. The pooled CLA-BSI relative risk associated with the study NC was 0.37 (95% confidence interval, 0.16-0.90). The NC with an improved engineering design is associated with lower CLA-BSI risk.