Central Line-associated Bloodstream Infection Rates Research Articles

2018. Comparison of Trends in Hospital-Onset Bloodstream Infections (HOBSIs) and Central Line Associated Bloodstream Infections (CLABSIs) across a Three-Hospital Health System in the COVID Era

Abstract Background Hospital-onset bloodstream infection (HOBSI) incidence has been proposed as a complementary quality metric to central line-associated bloodstream infection (CLABSI) surveillance. Several recent studies have detailed increases in median HOBSI and CLABSI rates during the COVID-19 pandemic. We sought to understand trends in HOBSI and CLABSI rates at a single health system in the context of COVID-19. Methods We conducted a retrospective analysis of HOBSIs and CLABSIs at a three-hospital health system from 2017 to 2021 (Figure 1). We compared counts, denominators, and demographic data for HOBSIs and CLABSIs between the pre-pandemic (1/1/2017-3/30/2020) and pandemic period (4/1/2020-12/31/2021) (Table 1). We applied Poisson or negative binomial regression models to estimate the monthly change in incidence of HO-BSI and CLABSI rates over the study period. Figure 1:Definitions applied for hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs). Potentially contaminated blood cultures were identified by microbiology laboratory technicians as any set of blood culture in which a single bottle was positive for organisms typically considered as skin contaminants. Uncertain cases undergo secondary review by senior lab technicians. Table 1:Count, denominator, and device utilization ratio data for hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs)Note that central line utilization increased upon regression analysis (p<0.001). Results The median monthly HOBSI rate per 1,000 patient days increased from 1.0 in the pre-pandemic to 1.3 (p< 0.01) in the pandemic period, whereas the median monthly CLABSI rate per central line days was stable (1.01 to 0.88; p=0.1; Table 2). Our regression analysis found that monthly rates of HO-BSIs increased throughout the study, but the increase was not associated with the onset of the COVID-19 pandemic based on comparisons of model fit (Figure 2; Table 3). Despite an increase in central line utilization, regression modelling found no changes in monthly CLABSIs rates with respect to time and the COVID-19 pandemic. Incidence of HOBSIs and CLABSIs by common nosocomial organisms generally increased over this time period, though time to infection onset remained unchanged in our studied population (Table 2). Table 2:Epidemiology and demographic characteristics of hospital-onset bloodstream infections (HO-BSIs) and central line-associated bloodstream infections (CLABSIs).Figure 2:Regression analysis of monthly rates of HO-BSIs and CLABSIs over time per patient days (left) and CLABSIs per central line days (right). Gray areas denote COVID-19 pandemic period (April 2020 to December 2021). Provided p values refer to the statistical significance of the coefficient of the time variable in each model. Table 3:Likelihood ratio tests comparing regression models.No statistical significance was noted between models that included COVID-19 variables (including a time-trended post-pandemic variable) and models that were only time-dependent. Conclusion HOBSIs rates did not correlate with CLABSI incidence across a three-hospital health system from 2017 and 2021, as rates of HOBSI increased but CLABSI rates remained flat. Our observed increase in HOBSI rates did not correlate with the onset of the COVID-19 pandemic, and caution should be used in modeling the effects of COVID-19 without time-trended analysis. Further evaluation is needed to understand the etiology, epidemiology, and preventability of HO-BSI. Disclosures All Authors: No reported disclosures.

2037. Epidemiology and Preventability of Hospital Onset Bacteremia and Fungemia in two Hospitals in India

Abstract Background The National Healthcare Safety Network (NHSN) central line-associated bloodstream infection (CLABSI) is a widely accepted quality measure. However, studies from the United States indicate that NHSN reportable CLABSIs account for less than 20% of all hospital-onset bacteremia and fungemia (HOB, i.e., any positive blood culture obtained at least 3 calendar days after hospital admission) events and about 66% of all HOB events are potentially preventable. The incidence and overall preventability of HOB is unknown in low and middle-income countries (LMICs). This study evaluated the epidemiology and preventability of HOB in two hospitals in India. Methods Six months data on all consecutive blood cultures processed in two hospitals (Hospital A- 8.16.2020 to 2.15.2021; Hospital B- 1.1.2021 to 6.30.2021) were collected prospectively to calculate HOB and CLABSI incidence. Correlation between HOB and CLABSI rates was assessed using Spearman’s rank correlation. Medical records of 300 consecutive HOB events were retrospectively reviewed to determine the source and preventability of HOB utilizing a structured guide developed for the study. Results Among 3,558 hospitalized patients from whom blood cultures were obtained, 10.4% developed HOB with 409 unique HOB events (HOB incidence: 2.87 per 1000 patient-days). Only 15% (59 of 409) of HOB events were reported as CLABSI as per hospital CLABSI surveillance programs. The CLABSI rate was 4.4 per 1000 central line-days. There was a moderation correlation (r=0.51; p=0.07) between HOB and CLABSI rates. Among the 300 HOB events for which medical records were reviewed, the most common organism isolated was Klebsiella pneumoniae and 75% of K. pneumoniae were carbapenem resistant (Figure 1). The most common source of HOB was CLABSI (26.3%) (Figure 2). Fifty-two percent of all HOB events and 45% of HOB events not attributable to contaminants were potentially preventable (Figure 3). CLABSIs accounted for 69% of non-contaminant HOB preventable events. Conclusion We found that 69% of the non-contaminant related HOB preventable events were due to CLABSI. Prevention efforts in these hospitals could focus on CLABSI to reduce HOB rates while additional studies are performed to better understand the epidemiology of HOB in LMICs. Microorganisms identified from 300 Hospital Onset Bacteremia and Fungemia Events in Two Hospitals in India. Source of Hospital Onset Bacteremia and Fungemia Events in Two Hospitals in India (n=300). Preventability Rating Source of Hospital Onset Bacteremia and Fungemia events in Two Hospitals in India (n=300). Disclosures All Authors: No reported disclosures.

2016. CLABSIs in the Time of COVID

Abstract Background With the COVID-19 pandemic, acute care facilities experienced an initial increase in hospital-acquired infections, most notably Central Line-Associated Bloodstream Infections (CLABSIs). Interestingly, the positive correlation between COVID-19 and CLABSIs appeared to wane post surge. We sought to define the pre and post-pandemic CLABSI rates. Methods Single-center, retrospective review of the CLABSIs reported to the National Healthcare Safety Network (NHSN) for the five years previous to COVID and through to the First Quarter of 2022. Our center is a quaternary care, level 1 trauma center in New York, which serves a highly ill critical care population, including solid organ and bone marrow transplants, acute leukemias, and patients requiring extracorporeal membrane oxygenation (ECMO). Results Between January 2015 and December 2019, our Medical Intensive Care Unit (MICU) reported 15 CLABSIs with an overall Standardized Infection Ratio (SIR) of 1.007. During the second winter surge of COVID, we saw a sharp rise in CLABSIs. Between October 2020 and March 2021, our MICU reported eight CLABSIs, with an overall SIR of 4.601 and a p-value of 0.0005 (CI 2.137 – 8.737), representing a statistically significant increase (p-value 0.0019) in comparison to prior years. Of these patients, seven had COVID. All patients received high-dose steroids. The average number of days between hospital admission to CLABSI was 16.38 days, and mortality was 87.5%. Since that spike in CLABSI, we have reported seven CLABSIs in NHSN for a SIR of 2.026. After 2019 patients with CLABSI tended to be younger and had a higher Body Mass Index. Conclusion We reported a spike in CLABSIs in our adult medical Intensive Care during the second wave of COVID-19 that affected the Northeast United States in the winter of 2020/2021. Despite experiencing a sharp rise, our CLABSI rates are returning to pre-pandemic low levels even during subsequent surges in COVID-19, including the recent Omicron surge. It remains to be determined if the improvements in infection control measures, differences in the patient illness severity, and/or variations of COVID management have contributed to the stabilization of the CLABSI rate. Disclosures All Authors: No reported disclosures.

1049: IMPROVING CENTRAL LINE-ASSOCIATED BLOODSTREAM INFECTION RATES VIA RISK SCREENING AND INTERVENTION

Introduction: Central venous lines are essential tools in the pediatric ICU (PICU). However, Central-line-associated bloodstream infections (CLABSI) cause significant morbidity and mortality. There are well-described CLABSI risk factors and mitigation strategies. Our smart aim was to decrease the CLABSI rate in the PICU by 30% in 1 year through the development of a risk screening and mitigation tool deployed by a quality improvement (QI) team embedded in daily rounds. Methods: All patients with central venous access were screened daily by the QI team, for the following risk factors: acute behavioral health need, > 72 hours of central access, permanent line, ≥ 25 line accesses per day, impaired skin integrity, immunologic dysfunction, parental nutrition use, extracorporeal support. Any risk factor triggered a CLABSI huddle focused on line necessity, enteral medication conversion, and access reduction. Simultaneous nursing interventions involved prevention education and bundle performance audits. Process measures were followed for the first four months with the primary outcome followed for one year. Results: In the first four months, 19.1% (N=121) patients screened positive for high CLABSI risk, most commonly due to ≥25 line accesses per day (41.7%, n=73). Median total criteria met on initial positive screen was 1 (IQR 1-2). Among positive screens, percutaneous central venous lines (40.5%) and femoral vein location (25.6%) were most prevalent. The most common admitting diagnosis was respiratory failure (22%). Of the 614 positive screens, huddle compliance was 95.9% with ≥ 1 mitigation intervention applied following 20.2% of the huddles. Interventions included line removal (35.7%, n=45), lab modifications (33.3%, n=42), and enteral medication conversion (30.9%, n=39). The annual CLABSI rate decreased from 1.88/1000 line days to 1.18/1000 line days (37.2% decrease). Conclusions: Targeted screening and risk factor mitigation, implemented by dedicated QI team members embedded in rounds, led to a 37.2% reduction in the CLABSI rate in this single center. While this is a promising improvement, sustainability and external validity need to be investigated. Multidisciplinary commitment to reduction of this important complication of critical illness is paramount.

2041. Impact of Coronavirus Disease 2019 pandemic on healthcare-associated infections at intensive care unit in South Korea: Data from Korean National Healthcare-associated Infections Surveillance System (KONIS)

Abstract Background Coronavirus Disease 2019 (COVID-19) pandemic has influenced hospital infection control practices. We evaluated the impact of the COVID-19 pandemic on healthcare-associated infections (HAIs) in the intensive care unit. Methods We conducted a retrospective analysis using data from the Korean National Healthcare-Associated Infections Surveillance System (KONIS). KONIS has conducted nationwide prospective surveillance of HAIs in intensive care units. Comparisons of incidence rates of bloodstream infection (BSI), central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), and ventilator-associated pneumonia (VAP) before (Jan 2018-Dec 2019) and during the COVID-19 pandemic (Jan 2020-Jun 2021) were performed according to hospital size. The microorganism distributions in BSI, urinary tract infection, and pneumonia were compared between the period before and during the COVID-19 pandemic. Results The incidence rate of BSI significantly decreased during the COVID-19 pandemic than in the pre-COVID-19 period (1.38 vs. 1.19 per 10,000 patient-days; P < 0.001) [Table 1]. Incidence rates of CLABSI (2.30 vs. 2.17 per 1,000 device-days; P = 0.03) and VAP (1.03 vs. 0.81 per 1,000 device-days; P < 0.001) decreased significantly during the COVID-19 pandemic than in the pre-COVID-19 period, whereas that rate of CAUTI was similar between the two periods. The annual trends of incidence rate of CLABSI and VAP also has decreased (Figure 1). According to the hospital size, the incidence rate per 1,000 device-days of CLABSI significantly decreased during the COVID-19 pandemic than in the pre-COVID-19 period in small to medium-sized hospitals (300-699 beds). The incidence rate per 1,000 device-days of VAP significantly decreased only in small-sized hospitals (200-449 beds). The microorganism distributions in HAIs did not change significantly. Conclusion The incidence rates of CLABSI and VAP decreased during the COVID-19 pandemic than in the pre-COVID-19 period, which was attributable to the changes in small to medium-sized hospitals. Disclosures All Authors: No reported disclosures.

2020. Disinfection of Needle-less Connectors Using UVC Light

Abstract Background Nearly 50% of post-insertion catheter-related infections are due to microbial ingress from needleless connectors (NC), widely used devices which connect to the end of catheters or infusion sets and enable access for injection of medications and attachment of infusions. Infections arising from NC could result in central line associated bloodstream infection (CLABSI). The clinical guideline for disinfecting NC is to wipe the hub of the NC with a 70% alcohol and to manually scrub the connector surface for at least 15 seconds. Unfortunately, multiple studies have found low compliance with the 15 second disinfection scrub. Methods In this study, we investigated the efficacy of 1 second of ultraviolet light-C exposure in the reduction of the 3 most common CLABSI associated organisms: Staphylococcus aureus, Candida albicans, Candida auris, and Methicillin-resistant Staphylococcus aureus (MRSA). We tested a total of 30 NC samples for each organism with 3 positive controls and 1 negative control. Results The log reductions were 5.68, 5.05, 4.41, and 6.38 for S. aureus, C. albicans, C. auris and MRSA, respectively. Growth of Candida albicans with and without UV-C exposure for 1 second. The figure shows the observed growth of Candida albicans from the surface of the connector with and without UV-C exposure for 1 second, displaying no growth on the agar plate for samples that were exposed to 1 second of UV-C disinfection. Log reduction of tested organisms after exposure of UV-C for 1 second. Table 1 displays the overall log reduction of tested organisms after 1 second of UV-C exposure. The results are shown for positive control concentration and log reduction for the test organisms Staphylococcus aureus, Candida albicans, Candida auras, and Methicillin-resistant Staphylococcus aureus. Conclusion Our findings demonstrate greater than 4 log reduction of common CLABSI-associated organisms with 1 second of UV-C exposure, which we believe would decrease CLABSI rates, increase aseptic technique compliance, and reduce disruption in hospital workflow. Disclosures Julia Rasooly, MS, Puracath Medical, Inc: Board Member|Puracath Medical, Inc: Stocks/Bonds Michael Fourkas, MS, Puracath Medical, Inc: Grant/Research Support Gregory Schears, MD, Puracath Medical, Inc: Advisor/Consultant|Puracath Medical, Inc: Stocks/Bonds.

Care of patients on home parenteral nutrition during the first year of the COVID-19 pandemic: Management of central line-associated bloodstream infections

The aim of this study was to analyze central line-associated bloodstream infections (CLABSI) in home parenteral nutrition (HPN) patients assisted by an interdisciplinary team during the first year of the COVID-19 pandemic in Argentina. Longitudinal, retrospective and analytical study of patients on HPN for ≥90 days during 2020. Data collection included age (adults >18 years, pediatric ≤18 years), gender, diagnosis, type of catheter, number of lumens, venous access, days on HPN, infusion modality and number of CLABSI-associated events. In COVID-19 cases, number of patients, disease progression, mortality rate and microorganisms involved were analyzed. A total of 380 patients were included, 120 (31.6%) pediatric and 260 (68.4%) adult patients. Median age was 44.50 years (10; 62.25). Twelve patients (3.15% of the total) had COVID-19; of these, two pediatric and seven adult patients had no complications, and three adults died of COVID-19 pneumonia. The diagnoses observed were benign chronic intestinal failure (CIF, n=311), grouped into short bowel (n=214, 56.3%), intestinal dysmotility (n=56, 14.7%), intestinal fistula (n=20, 5.3%), and extensive small bowel mucosal disease (n=21, 5.5%); malignant tumors (n=52, 13.7%); other (n=17, 4.4%). Total catheter days were 103,702. Median days of PN duration per patient were 366 (176.2, 366). The types of catheters used were tunneled (317 patients, 83.4%); peripherally inserted central (PICC) line (55 patients, 14.5%) and ports (8 patients; 2.1%). A total of 111 CLABSI was registered, with a prevalence of 1.09/1000 catheter days (adult, 0.86/1000 days; pediatric, 1.51/1000 days). The microorganisms identified in infectious events were Gram+bacteria (38, 34.5%); Gram-bacteria (36, 32%); mycotic (10, 9%); polymicrobial (4, 3.6%); negative culture and signs/symptoms of CLABSI (23, 20.3%). The odds ratio between pediatric and adult patients was 2.29 (1.35, 3.90). The rate of CLABSI during the COVID-19 pandemic was within the ranges reported by international scientific societies. The risk of CLABSI was higher in pediatric patients, and mortality rate in COVID-19 infected patients was higher than in the general population.

Does the antimicrobial-impregnated peripherally inserted central catheter decrease the CLABSI rate in neonates? Results from a retrospective cohort study.

The use of antimicrobial-impregnated peripherally inserted central catheters (PICCs) has been introduced in the last few years to neonatal units aiming to reduce central line-associated bloodstream infection (CLABSI). This retrospective observational study aimed to compare the CLABSI rates and other catheter-related parameters including the insertion success rates and catheter-related complications in the antimicrobial-impregnated and conventional (ordinary) PICCs in NICU between 2017 and 2020. Our dedicated PICC team including physicians and nurses inserted 1,242 conventional (PremiCath and NutriLine) and 791 antimicrobial-impregnated PICCs (PremiStar) over the study period from 2017 to 2020. Of those 1,242 conventional PICCs, 1,171 (94.3%) were 1 Fr single lumen and only 71 (5.7%) were 2 Fr double lumen. The mean ± SD [median (IQR)] for the birth weight in all babies who had a PICC line was 1,343.3 ± 686.75 [1,200 (900, 1,500)] g, while the mean ± SD for the gestational age was 29.6 ± 4.03 [29 (27, 31)] weeks. The mean ± SD [median (IQR)] age at the time of insertion for all catheters was 9.3 ± 21.47 [2 (1, 9)] days, while the mean ± SD [median (IQR)] dwell time was 15.7 ± 14.03 [12 (8, 17)] days. The overall success rate of the PICC insertion is 1,815/2,033 (89.3%), while the first attempt success rate is 1,290/2,033 (63.5%). The mean ± SD [median (IQR)] gestational age, birth weight, age at catheter insertion, and catheter dwell time were 28.8 ± 3.24 [29, (26, 31)] weeks, 1,192.1 ± 410.3 [1,150, (900, 1,450)] g, 6.3 ± 10.85 [2, (1, 8)] days, and 17.73 ± 17.532 [13, (9, 18)] days in the antimicrobial-impregnated catheter compared with 30.1 ± 4.39 [29, (27, 32)] weeks (P < 0.001), 1,439.5 ± 800.8 [1,240, (920, 1,520)] g (P < 0.001), 11.1 ± 25.9 [1, (1, 9)] days (P < 0.001), and 14.30 ± 10.964 [12, (8, 17)] days (P < 0.001), respectively, in the conventional PICCs. The use of the antimicrobial-impregnated catheter was not associated with any significant reduction in the CLABSI rate (per 1,000 days dwell time), either the overall [P = 0.11, risk ratio (RR) (95% CI): 0.60 (0.32, 1.13)] or the yearly CLABSI rates. The use of miconazole and rifampicin-impregnated PICCs did not reduce the CLABSI rate in neonates compared with conventional PICCs. However, it has a higher overall rate of elective removal after completion of therapy and less extravasation/infiltration, occlusion, and phlebitis compared with the conventional PICCs. Further large RCTs are recommended to enrich the current paucity of evidence and to reduce the risk of bias. Neonatal PICCs impregnation by other antimicrobials is a recommendation for vascular access device manufacturers.

Changes in Central Line-Associated Bloodstream Infection (CLABSI) Rates Following Implementation of Levofloxacin Prophylaxis for Children and Adolescents With High-Risk Leukemia.

Background: Despite initiatives to reduce central line-associated bloodstream infection (CLABSI), children and adolescents with hematologic malignancies, as well as those with relapsed disease, remain at the greatest risk for infection. This single-institution project evaluated changes in CLABSI rates following implementation of antibacterial prophylaxis with levofloxacin for patients with high-risk hematologic malignancies. Methods: Positive blood culture events meeting National Health Safety Network surveillance criteria to be classified as CLABSIs from January 1, 2006, to December 31, 2019, were included. Data were organized into four time periods for comparison based on implementation of CLABSI-reduction interventions. Conditional Poisson regression models were used to evaluate the effect of time (intervention period) on CLABSI rates with post hoc Tukey pairwise comparisons between each of the four time periods. Results: From 2006 and 2019, 227 patients experienced 310 CLABSIs. Clinically important decreases in CLABSI rates from baseline (4.84 per 1,000 line days) occurred with implementation of Children's Hospital Association (CHA) bundles (3.29 per 1,000 line days); however, this difference was not significant (p = .16). CLABSI rates decreased from baseline with the addition of formalized supportive cares (2.66 per 1,000 line days; incidence rate ratio [IRR] = 0.60; p < .01), and with the use of antibacterial prophylaxis (1.66 per 1,000 line days; IRR = 0.35; p < .01). Post hoc comparisons indicated decreased CLABSI rates with the use of antibacterial prophylaxis compared with CHA bundles alone (IRR = 0.49; p = .011) and CHA bundles plus formalized supportive cares (IRR = 0.58; p = .046). Discussion: Results demonstrate sustained success using a practice-based evidence approach to guide CLABSI-reduction interventions. Follow-up research, applying machine learning algorithms, may identify additional risk factors and inform future interventions.

Lower risk of bloodstream infections for peripherally inserted central catheters compared to central venous catheters in critically ill patients

BackgroundPeripherally inserted central venous catheters (PICCs) serve as an alternative to short-term central venous catheters (CVCs) for providing intravenous access in hospitalized patients. Although a number of studies suggest that PICCs are associated with a lower risk of central line-associated bloodstream infections (CLABSIs) than CVCs, recent data concerning specific patient groups support the contrary. In this regard, we are comparing CVC- and PICC-related CLABSI rates developed in a selected group of critically ill inpatients and evaluating the CLABSI microbiological distribution.MethodsThe study was conducted at a tertiary care hospital in Greece between May 2017 and May 2019. We performed a two-year retrospective analysis of the data collected from medical records of consecutive adult patients who underwent PICC or CVC placement.ResultsA total of 1187 CVCs placed for 9774 catheter-days and 639 PICCs placed for 11,110 catheter-days, were reported and analyzed during the study period. Among CVCs, a total of 59 (4.9%) CLABSIs were identified, while among PICCs, 18 (2.8%) cases presented CLABSI (p = 0.029). The CLABSI incidence rate per 1,000 catheter-days was 6.03 for CVC group and 1.62 for PICC group (p < 0.001). The CLABSI rate due to multidrug-resistant organisms (MDROs) among the two groups was 3.17 in CVC group and 0.36 in PICC group (p < 0.001). Within CLABSI-CVC group, the most common microorganism detected was MDR Acinetobacter baumannii (27.1%) followed by MDR Klebsiella pneumoniae (22%). In CLABSI-PICC group, the predominant microorganism was Candida spp. (33.3%) followed by non-MDR gram-negative pathogens (22.2%).ConclusionsPICC lines were associated with significantly lower CLABSI rates comparing to CVC although they were in place longer than CVC lines. Given their longer time to the development of infection, PICCs may be a safer alternative for prolonged inpatient IV access. The high prevalence of CLABSI-MDROs depicts the local microbial ecology, emphasizing the need of public health awareness.

CLABSI in Hemodialysis– New Face to an Old Foe; A Look at Current Trends and a Review of Literature

Background: Bloodstream infections are a potentially devastating complication of hemodialysis. This study aimed to elucidate the rates of CLABSI (Central Line Associated Blood Stream Infections)in a south Indian dialysis cohort and determine the catheter care and hygiene practices in the dialysis unit which might contribute to CLABSI Methods: A prospective observational study involving in-center dialysis patients with temporary access was conducted from June 2019 to December 2019. The catheter insertion and line handling techniques were monitored using a proforma adapted from the CDC (Center for Disease Control) guidelines. Adherence to infection control practices, rates of CLABSI identified using CDC surveillance definitions, and organisms identified were reported. Results and Discussion: The median rate of CLABSI in this dialysis unit was 1.68 per 1000 catheter days. Gram-positive organisms were the majority – 69.2% and 72.27% were drug-resistant pathogens. The adherence to infection control practices in hand sterility, use of barriers, and sterile insertion technique were 100% with respect to existing CDC guidelines. The use of sterile semi-transparent dressings, however, was 98.2%. 65% of all patients had soiled dressings on arrival to the hospital. Line handling protocols were followed in accordance with CDC guidelines in 97.1% of cases Conclusion: CLABSI rates in this institute are in keeping with those around the world. There is a predominance of gram-positive organisms causing CLABSI. Drug-resistant organisms represent an alarming 72.27%of all infections. Soiled dressing and home care of the dialysis catheters represent a neglected aspect of catheter care and should be addressed.

Reduction of Central-line-Associated Bloodstream Infections in a Tertiary Neonatal Intensive Care Unit through Simulation Education.

Critically ill neonates and those with complex medical conditions frequently require the use of central venous lines. Unfortunately, central line-associated bloodstream infections (CLABSIs) result in significant morbidity and mortality, and the cost and increased length of stay burden the healthcare system. Previous studies have demonstrated that standardized care bundles can decrease CLABSI rates, but achieving sustained improvement has proven difficult. All patients admitted to the Neonatal Intensive Care Unit between 2014 and 2020 who had a CVL were included in this study. First, we recorded all CLABSI events and total CVL days according to defined criteria. Then, in late 2016, we instituted simulation-based nursing training for CVL care. Job Instruction Sheets were initially introduced to Neonatal Intensive Care Unit nursing staff simultaneously with one-on-one teaching sessions between instructors and bedside nurses. Intermittent performance audits and re-education for identified deficiencies did not improve the CLABSI rate per 1000 line days. After instituting simulation-based CVL training in 2016, there was a decreased rate of CLABSI events per 1000 line days sustained over time (x = 0.692). Standardized care bundles and Hospital-acquired Condition interactor audits were insufficient to reduce the CLABSI rate. However, combining care bundles and education with simulation-based training significantly decreased CLABSI rates. One-on-one intensive training and continued ongoing monitoring were critical to producing a sustained reduction. This experience demonstrates that supervised, interactive education combined with simulation can significantly impact patient outcomes.

Reducing Central-Line-Associated Bloodstream Infections (CLABSI): An Improvement Project in a Specialized Tertiary Hospital.

Central-line-associated bloodstream infections (CLABSI) are preventable hospital-acquired infections that harm and prolong a patient's hospital stay and increase unnecessary hospital expenditure. In collaboration with infection control and hospital epidemiology, the quality management department initiated a performance improvement project to address 144 CLABSI events in 2017. The performance improvement project team used brainstorming to create change ideas presented in a driver diagram. The team then applied plan-do-study-act (PDSA) cycles to implement and monitor the improvements. Finally, the team applied a bundle of interventions that included the following: (a) policies and procedures for central line insertion, maintenance and removal processes standardization, (b) physicians training for line insertion by simulation, (c) an awareness campaign that included recognizing healthcare workers and enhancing patient engagement, (d) performing root cause analysis for the CLABSI events, and (e) automation of central line insertion, and (f) maintenance bundles documentation in the hospital information system. The CLABSI rate per 1000 patient days dropped from 1.5 per 1000 device days to 1.03 per 1000 device days. In addition, CLABSI events reduction was 24% by 2018. Then further reduction of 15% occurred by the end of 2019. Thus, the overall decrease in CLABSI events was 35% from the baseline number of events (i.e., 144 events) in 2017. Another achievement of the project is that 10 units reported zero CLABSI events in 2018 and 2019, of which four units had a high central line utilization rate, more than 40%. The implemented interventions effectively reduced the CLABSI events in the hospital. The project team will continue implementing more interventions with monitoring, aiming to achieve zero CLABSIs over time in all the hospital units.

Reducing central-line associated bloodstream infections (CLABSIs) through patient accountability contracts: A pilot project for patients on Weill Cornell Medicine (WCM) bone marrow transplant (BMT) service.

283 Background: Patients with cancer whom develop Central Line Associated Blood Stream Infections (CLABSIs) have increased mortality rates ranging from 12% to 40%. Transplant patients are particularly at risk due to cytotoxic chemotherapy regimens and/or graft-versus-host disease with risk for translocation of oral and gut flora to the bloodstream. At Weill Cornell Medicine, we had 102 CLABSIs in 2021, 25 (25%) of which attributed to patients in oncology units. The Bone Marrow Transplant (BMT) Unit, had 10 of the 25 (40%), 2.05 CLABSIs per 1000 central line inpatient days with a CLABSI standardized infection ratio (SIR) of 1.26 (above goal of 1). Methods: Our SMART aim was to reduce the number and rate of CLABSI events on the BMT unit by 10% from February 1, 2022 – June 30, 2022 by educating patients on preventive strategies and implementing a patient central-line maintenance “contract.” We had previously optimized evidence-based nursing interventions for CLABSI prevention which included adherence to central line maintenance best practices, weekly device rounds with Infection, Protection &amp; Control to monitor compliance with dressing changes and IV tubing, annual CLABSI prevention competencies, peer-to-peer validation of blood culture lab draws, weekly quality-improvement huddles and interdisciplinary root cause analysis discussions for CLABSI events. Patient noncompliance with daily recommendations for central line care was identified as a possible CLABSI risk factor that was not previously addressed in the bundle. Newly-developed patient education and a “contract” was incorporated into the BMT admission process. Results: The BMT CLABSI patient education and contract was initiated with all new patients admitted to unit in February 1, 2022. Since starting, the BMT unit CLABSI SIR has decreased from 1.26 to 0.6, and from a CLABSI rate per 1000 central lines days of 2.05 to 0.97. Conclusions: Engaging patients in their own care of the central lines can significantly reduce overall risk of central line infections. Patients have positively responded to this pilot project. We have translated educational materials and contracts to other languages and are considering expansion into other units.

Device-associated healthcare-associated infections surveillance in an intensive care unit of a tertiary care hospital in COVID-19 patients

Background: Surveillance for healthcare-associated infections has a major role in hospital infection prevention and control programmes. In the present study, we estimated the impact of the COVID-19 pandemic on device-associated healthcare-associated infections (DA-HAI) ventilator-associated events (VAE), central line-associated bloodstream infection (CLABSI) and catheter-associated urinary tract infections (CAUTI). Methods: This was a prospective surveillance study from January 2021 to June 2021 conducted in a 30-bed intensive care unit (ICU) of tertiary care, and academic healthcare organisations. Targeted surveillance was carried out by the National Healthcare Safety Network surveillance requirements of the Centers for Disease Control and Prevention. Results: A total of 249 patients admitted to the ICU with 2920 patient days of surveillance data were included during the study. A DA-HAIs attack rate of 17.67/100 admissions was seen during the study. The device utilisation ratios of central line, ventilator and urinary catheters were 0.49, 0.60 and 0.83, respectively. VAE, CLABSI and CAUTI rates were 12.44, 6.91 and 9.01/1000 device days, respectively. Among 54 DA-HAIs reported, pathogens could be identified for 41 DA-HAI cases. The most common organisms causing VAE, CAUTI and CLABSI were Acinetobacter baumannii (42.1%), Escherichia coli (30%) and Pseudomonas aeruginosa (41.7%), respectively. Of the Gram-negative organisms 61.7% were carbapenem resistant and 50% of Staphylococcus aureuswere methicillin resistant. Conclusions: The present study shows high rates of ICU-acquired DA-HAIs and moderately high resistance patterns of the organisms causing HAIs, which poses a great risk to patient safety.

A longitudinal analysis of nosocomial bloodstream infections among preterm neonates

Nosocomial bloodstream infections (NBSIs), commonly due to central-line associated bloodstream infections (CLABSI), contribute substantially to neonatal morbidity and mortality. We aimed to identify longitudinal changes in incidence of NBSI, microbiological-spectrum, and antibiotic exposure in a large cohort of preterm neonates admitted to the neonatal intensive care unit. We retrospectively assessed differences in annual rates of NBSI (per 1000 patient-days), CLABSI (per 1000 central-line days), and antibiotic consumption (per 1000 patient-days) among preterm neonates (< 32 weeks’ gestation) hospitalized between January 2012 and December 2020. Multi-state Markov models were created to model states of progression of NBSI and infection risk given a central-line on days 0, 3, 7, and 10 of admission. Of 1547 preterm infants, 292 (19%) neonates acquired 310 NBSI episodes, 99 (32%) of which were attributed to a central-line. Over the years, a significant reduction in central-line use was observed (p < 0.001), although median dwell-time increased (p = 0.002). CLABSI incidence varied from 8.83 to 25.3 per 1000 central-line days, with no significant difference between years (p = 0.27). Coagulase-negative staphylococci accounted for 66% of infections. A significant decrease was found in antibiotic consumption (p < 0.001). Probability of NBSI decreased from 16% on day 3 to 6% on day 10. NBSI remains a common problem in preterm neonates. Overall antibiotic consumption decreased over time despite the absence of a significant reduction in infection rates. Further research aimed at reducing NBSI, in particular CLABSI, is warranted, particularly with regard to limiting central-line dwell-time and fine-tuning insertion and maintenance practices.

Does COVID-19 Increase the Risk of Central-Line-Associated Bloodstream Infections?

Objectives: All over the world, there has been a rapid and significant increase in the number of critically ill patients requiring mechanical ventilation, which was over the capacity of the intensive care units (ICU). This resulted in an increased risk of healthcare-associated infections. The most significant increase was in central-line-associated bloodstream infections (CLABSI). Our study aimed to determine the effect of COVID-19 infection on CLABSI rates in patients in the COVID-ICU and the factors affecting it. Methods: Adult patients hospitalized in the ICU between January 01, 2021, and December 31, 2021, and diagnosed with CLABSI were evaluated retrospectively. Only the first infection data of patients diagnosed with more than one CLABSI during hospitalization were included in the study. The patients were divided into two groups COVID-ICU and general ICU patients and were compared in terms of infection rate, risk factors, and agent distributions. Results: Twenty-two patients in the COVID-ICU and 32 patients in the general ICUs were diagnosed with CLABSI, and the infection rates were 2.05 and 1.03, respectively. The patients in the COVID-ICU had a shorter length of stay in the ICU and a significantly shorter time from ICU admission to CLABSI diagnosis. There was no difference in mortality between the two groups. Infections caused by Gram-negative microorganisms developed most frequently in both groups, and Acinetobacter baumannii was the most frequent among them. Conclusion: CLABSI is seen more frequently and earlier in patients followed in the COVID-ICU. According to our study, this situation did not significantly affect mortality. To prevent CLABSI in COVID-ICUs and improve health care quality, additional management strategies must be determined, and close data monitoring is needed. Keywords: bloodstream infection, intensive care unit, COVID-19, central venous catheter, etiologic microorganisms

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

Strategies to Sustain Quality Interventions: Case Examples of Chlorhexidine Gluconate Bathing.

Subcutaneous tunnelling versus conventional insertion of peripherally inserted central catheters in hospitalized patients (TUNNEL-PICC): a study protocol for a randomized controlled trial

BackgroundPeripherally inserted central catheters (PICCs) are now widely used in modern medicine, and associated complications have also increased. Central line-associated bloodstream infection (CLABSI) is the most serious complication because it can cause extended hospital stays and increase costs. Furthermore, it can contribute to dire consequences for critically ill patients. Subcutaneous tunnelling for central venous catheters is an accepted method to reduce the risk of CLABSI. However, it is not generally adopted for PICC placement in most hospitals because its safety and efficacy have not been thoroughly evaluated.MethodsIn this multi-institutional, prospective, non-blinded pragmatic randomized controlled trial, 1694 patients treated at five referral hospitals will be assigned to one of two parallel arms (conventional and tunnelled PICC groups) using computer-generated stratified randomization. The conventional group will undergo PICC placement by routine practice. In the tunnelled PICC (tPICC) group, additional subcutaneous tunnelling will be applied. Patients will be followed until PICC removal or the end of this study. The primary endpoint is whether subcutaneous tunnelling reduced the rate of CLABSI compared to the conventional method. The secondary endpoints are technical success rates, complications including exit-site bleeding or infection, and the procedure time between the groups.DiscussionSubcutaneous tunnelling is a widely used method to reduce catheter-associated infection. However, it has not been thoroughly applied for PICC. A randomized trial is needed to objectively assess the effects of the subcutaneous tunnel in PICC placement. This TUNNEL-PICC trial will provide evidence for the effectiveness of subcutaneous tunnelling in decreasing the risk of CLABSI.Trial registrationClinical Research Information Service (CRiS) KCT0005521

CLABSI Reduction Strategy: Utilizing Weekly Rounds with an Interdisciplinary Team.

Introduction: Central line-associated bloodstream infections (CLABSIs) in pediatric ICU patients lead to a wide variety of adverse outcomes, including increased mortality and morbidity, longer length of stay in the hospital, and greater healthcare costs.1 Pediatric cardiac ICU patients are at a significantly higher risk for these healthcare-associated infections because of an increase in risk factors, such as congenital anomalies, presence of surgical wounds, compromised immune function post cardiopulmonary bypass, and the presence of multiple invasive medical devices.2 After noting an increase in the pediatric cardiac ICU CLABSI rate, an interdisciplinary team was formed to approach the problem. Objectives: The primary aim was to decrease the pediatric cardiac ICU’s CLABSI rate by 25% in 8 months by engaging an interdisciplinary team with identifying and addressing CLABSI maintenance bundle concerns in real time on the unit. Methods: An interdisciplinary team with representatives from nursing, unit leadership, intensive care physicians, infection prevention, nurse practitioners, vascular access team, and quality improvement utilized initial Plan-Do-Study-Act (PDSA) cycles to develop a rounding tool that identified threats to the CLABSI prevention bundle with patient-specific interventions to consider implementing. Weekly interdisciplinary rounds were then conducted on all central lines. Additional PDSA cycles focused on addressing unit-specific gaps in education and increasing awareness of best practices for central line care and maintenance. These included addition and delineation of space to separate clean and dirty supplies, hygiene supplementations to the care bundle, eRecord handoff updates, and both in-person and online educational offerings. Results: Preliminary data suggested a decrease in CLABSI rate during the initial 4-month intervention period (Fig. 1). The focus on central line care has also led to more consistent and robust observations for bundle compliance. In 2021, zero CLABSIs were noted for the initial 4 months after intervention contributing to a unit record of 243 days CLABSI-free. We would like to call attention to 2 points in Figure 1. Point two represents the initiation of weekly interdisciplinary CLABSI rounds. Point three represents 2 premature infants, atypical for unit census, on extracorporeal membrane oxygenation with hemodialysis catheters that required off-label use of Prismaflex. Conclusions: Engagement of a microsystem’s interdisciplinary team to focus efforts on identifying and addressing real-time concerns to central lines has led to a short-term decrease in CLABSI rate. Sustaining this decrease in CLABSIs will require continual reassessment of the effectiveness of strategies utilized. Additional PDSA interventions as a result of the weekly rounds are being investigated, including the use of antimicrobial sheets for high-risk patients, the creation of unit-specific prepackaged sterile central line dressing kits, and transitioning from alcohol to chlorohexidine scrubs for hub accessing.Fig