Central Line-associated Bloodstream Infections Research Articles

Evaluation of Candidemia Cases Developed in the Intensive Care Unit: A Ten-Year Analysis

Objective: Fungal infections have been a major health problem for many years. They constitute a major cause of increased mortality and morbidity, especially in immunocompromised patients and intensive care unit (ICU) patients. In this study, we aimed to evaluate the epidemiologic characteristics, mortality and causative agent distribution of cases of healthcare-associated candidemia (HCA) in intensive care units of our hospital and to contribute to the literature. Methods: Our study included patients diagnosed with healthcare-associated candidemia who were hospitalized in 3rd level ICUs with various complaints between November 2011 and August 2021 in Meram State Hospital. Results: In our study, the mean age of patients who developed candida infection during intensive care unit hospitalization was 67.2±20.5 years. Of these patients, 59.5% (n:103) were men and 40.5% (n:70) women. Mean duration of hospitalization in the intensive care unit was 38.2±29.5 (min:1, max:231) days. Grouping of candida related HCAIs developed in patients according to Centers for Disease Control and Prevention (CDC) criteria shows that the most common candida related healthcare-associated infection (HCAI) was central line-associated bloodstream infection (CLABSI) at 52% and the second most common was laboratory-confirmed bloodstream infection (LCBI) at 31.2%. Cumulatively, candidemia are significantly higher to other candida related HCAIs. Conclusion: To prevent and empirically treat candidemia, which has a very high mortality rate, the causative agent distribution of the center should be well understood. Large-scale, high-quality studies using various biomarkers in addition to clinical findings for the correct antifungal selection and to reduce mortality due to invasive candidiasis in line with these selections are warranted.

Incidence of Central Line-Associated Bloodstream Infections (CLA-BSIs) in the Intensive Care Unit (ICU) at Benghazi Medical Centre

Incidence of Central Line-Associated Bloodstream Infections (CLA-BSIs) in the Intensive Care Unit (ICU) at Benghazi Medical Centre

Mitigating risks in central line-associated bloodstream infection: a comprehensive insight into critical care nurses’ knowledge, attitudes, barriers, and compliance

BackgroundCentral venous catheter-related bloodstream infections (CLABSIs) are a significant concern in intensive care units (ICUs) as they lead to increased morbidity, mortality, and healthcare costs. Fortunately, these infections are largely preventable through strict adherence to CLABSI prevention guidelines. Nurses play a critical role in preventing CLABSIs.AimThis study aimed to investigate factors affecting critical care nurses' knowledge, attitudes, and perceived barriers related to implementing CLABSI prevention guidelines, and to predict factors influencing compliance with these guidelines.MethodsThis cross-sectional study was conducted from April to May 30, 2023, with a convenience sample of 470 critical care nurses from ICUs across eight hospitals in Sana’a, Yemen. Data were collected using an observational checklist and self-administered questionnaire. Descriptive statistics, Independent Student’s t-test, one-way ANOVA, Pearson’s correlation coefficient, multiple linear regression, and multilayer perceptron neural networks were performed.ResultsCritical care nurses exhibited low knowledge of CLABSI prevention guidelines, with compliance reaching an acceptable level. Despite the higher perceived barriers, the nurses demonstrated a positive attitude. Nurses with greater knowledge and positive attitudes displayed higher compliance levels. However, perceived barriers were negatively associated with knowledge and compliance. Notably, multilayer neural network analysis identified knowledge and perceived barriers as the strongest predictors of nurses' compliance.ConclusionThe current findings emphasize the need for multifaceted strategies to implement the CLABSI prevention guidelines. These strategies should address knowledge gaps, support positive attitudes, and address practical barriers faced by nurses to ensure successful implementation of CLABSI prevention.

Cost-effectiveness of a new multi-lumen infusion device to reduce central-venous-line-associated bloodstream infections in neonates

A new medical device was developed for multi-infusion in neonatal intensive care units (NICUs) with the aim of addressing issues related to drug incompatibilities and central-line-associated bloodstream infections (CLABSIs). To assess the cost-effectiveness of implementing this new perfusion system in an NICU setting. This single-centre, observational study was conducted in all infants admitted to the NICU within 3 days of birth, and who required a central venous line, to evaluate the cost and effectiveness before (2019) and after (2020) implementation of the new perfusion system. Costs were calculated from the hospital perspective, and the incidence of CLABSIs was examined over a time horizon from NICU admission to discharge. Resource utilization was measured (infusion device, infection-treating drugs and biological analyses), and corresponding costs were valued using tariffs for 2019. The incremental cost-effectiveness ratio (ICER) was calculated, expressed as Euros per CLABSI avoided, and one-way and multi-variate sensitivity analyses were conducted. Among 609 infants selected, clinical characteristics were similar across both periods. The CLABSI rate decreased significantly (rate ratio 0.22, 95% confidence interval 0.07-0.56), and total costs reduced from €65,666 to €63,932 per 1000 catheter-days (P<0.001) after implementation of the new perfusion system, giving an ICER of €251 saved per CLABSI avoided. The majority of sensitivity analyses showed that the new intervention remained economically dominant. This single-centre study showed a significant decrease in the incidence of CLABSIs after implementation of the new perfusion system, without incurring additional costs. Further prospective multi-centre randomized studies are needed to confirm these results in other NICUs.

Should I stay or should I go? A case of central line-associated bloodstream infection (CLABSI) differential diagnosis.

Should I stay or should I go? A case of central line-associated bloodstream infection (CLABSI) differential diagnosis.

Central lines, aseptic batching services, and infection rates: A pharmacy-led initiative of intravenous tube priming within a NICU.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Central line-associated bloodstream infections (CLABSIs) are hospital-acquired, serious complications that greatly affect many vulnerable neonates throughout their hospital stay. This article describes the implementation of a unique practice in which pharmacy primes continuous infusions through medication tubing for neonatal central lines in a cleanroom at Children's Hospital Colorado - Colorado Springs (CHCO-CSH). This institution is a freestanding children's hospital with a level III neonatal intensive care unit (NICU) that opened in April 2019. Since then, the pharmacy department has been priming central line tubing for continuous infusions for all patients in the NICU. Neonates are at increased risk for developing CLABSIs due to their immature immune systems and frequent need for central line placement. With that in mind, the pharmacy department decided to focus efforts on this population. Pharmacists and pharmacy technicians received training on how to properly prime tubing, document when a patient received a new central line, document if a central line was removed, and record when new tubing was due based on a department policy. This novel, pharmacy-led priming procedure resulted in a low CLABSI incidence, offering a promising strategy to reduce CLABSIs in a NICU.

Differences in the Dwell Time of Peripherally Inserted Central Catheters between Patients with Catheter Colonization and Those Developing Central Line-Associated Bloodstream Infection: A Single Centre Retrospective Cohort Study.

Substantial knowledge gaps exist concerning the varying durations of peripherally inserted central catheter (PICC) placements that lead to either central line-associated bloodstream infection (CLABSI) or catheter colonization. We aimed to compare PICCs dwell time between patients who developed CLABSIs due to multidrug-resistant microorganisms (MDROs) and patients with catheter colonization by MDROs. Data from 86 patients admitted consecutively to a tertiary-care hospital from 2017 to 2020 were retrospectively analyzed. The mean dwell time was 25.73 ± 16.19 days in the PICC-CLABSI group and 16.36 ± 10.28 days in the PICC-colonization group (p = 0.002). The mean dwell time was 17.38 ± 9.5 days in the PICC-MDRO group and 22.48 ± 15.64 days in the PICC-non-MDRO group (p = 0.005). Within the PICC-CLABSI group, the mean dwell time for CLABSIs caused by MDROs was 21.50 ± 12.31 days, compared to 27.73 ± 16.98 days for CLABSIs caused by non-MDROs (p = 0.417). Within the PICC-colonization group, the mean dwell time was 15.55 ± 7.73 days in PICCs colonized by MDROs and 16.92 ± 11.85 days in PICCs colonized by non-MDROs (p = 0.124). The findings of the present study suggest that CLABSIs caused by MDROs in PICCs are associated with a shorter mean catheter dwell time compared to those caused by non-MDROs, underscoring the importance of considering infections by MDROs when evaluating PICC dwell times.

Development of best evidence-based practice protocols for central venous catheter placement and maintenance to reduce CLABSI.

Although evidence-based interventions can reduce the incidence of central line-associated bloodstream infection (CLABSI), there is a large gap between evidence-based interventions and the actual practice of central venous catheter (CVC) care. Evidence-based interventions are needed to reduce the incidence of CLABSI in intensive care units (ICU) in China. Professional association, guidelines, and database websites were searched for data relevant to CLABSI in the adult ICUs from inception to February 2020. Checklists were developed for both CVC placement and maintenance. Based on the Integrated Promoting Action on Research Implementation in Health Services framework, a questionnaire collected the cognition and practice of ICU nursing and medical staff on the CLABSI evidence-based prevention guidelines. From January 2018 to December 2021, ICU CLABSI rates were collected monthly. Ten clinical guidelines were included after the screening and evaluation process and used to develop the best evidence-based protocols for CVC placement and maintenance. The CLABSI rates in 2018, 2019, and 2020 were 2.98‰ (9/3021), 1.83‰ (6/3276), and 1.69‰ (4/2364), respectively. Notably, the CLABSI rate in 2021 was 0.38‰ (1/2607). In other words, the ICU CLABSI rate decreased from 1.69‰ to 0.38‰ after implementation of the new protocols. Additionally, our data suggested that the use of ultrasound-guidance for catheter insertion, chlorhexidine body wash, and the use of a checklist for CVC placement and maintenance were important measures for reducing the CLABSI rate. The evidence-based processes developed for CVC placement and maintenance were effective at reducing the CLABSI rate in the ICU.

The Next Target for Readmission Reporting? Exploring Readmission Rates of Patients with CLABSI

Background: Multi-drug resistant organisms (MDROs) are a common cause of healthcare-associated infections, particularly central line-associated bloodstream infections (CLABSIs). Prior research has shown that MDROs cause up to 67% of CLABSIs and have up to a 37% increase in 30 day readmission, which is higher than readmission rates for other conditions reported to the Centers for Medicare and Medicaid Services (CMS). The objective of the study was to determine overall 90-day readmission rates, and if there was a difference in readmission rate within 90 days post discharge for patients who had a MDRO as the causative pathogen of their CLABSI compared to patients who did not have an MDRO. Methods: A retrospective analysis of patient data from a nine-hospital system was performed on patients who had a CLABSI and were discharged alive between January 1st, 2018, and December 31st, 2019. Basic descriptive statistics were performed, and the potential differences in readmission rates were examined using Chi-square analyses. Results: The overall readmission rate for all CLABSIs was 46.9%. The chi-square analysis determined there was not a significant difference in readmission rates in patients who had a MDRO CLABSI compared to patients with a non-MDRO CLABSI (59.1% vs. 44.6%, x2= 1.564 , p= 0.211). Conclusion: There was not a significant difference in readmission rates between patients with an MDRO CLABSI compared to a non-MDRO CLABSI. However, the overall readmission rate for this patient population was much higher than seen in previous literature and other publicly reported readmission rates. Additional research is recommended to explore if the increased CLABSI readmission rates seen are a unique finding to this health system.

Successful practices to reduce central line–associated bloodstream infections post pandemic: A qualitative study

Central Line-Associated Bloodstream Infections (CLABSIs) decreased in U.S. hospitals over the last decade, but CLABSI rates increased during the COVID-19 pandemic disrupting the downward trend. This study explored factors contributing to the reduction of CLABSI, identifying deviations in infection prevention and control protocol during the pandemic, actions taken to address the increase in CLABSI, and factors promoting sustained progress. This qualitative study used the National Healthcare Safety Network data. The Centers for Disease Control and Prevention identified hospitals with elevated CLABSI standardized infection ratios (SIR) >1 between Q1 2019 - Q4 2021 followed by four quarters of sustained reduction (CLABSI SIR <1). Joint Commission researchers conducted semi-structured phone interviews with infection preventionist professionals from six hospitals representing these performance patterns. Interview themes suggested that staffing shortages (83%) and less vigilant central line practices (100%) contributed to increased CLABSI SIR during the pandemic. Organizations described evidence-based interventions, such as using chlorhexidine gluconate for skin preparation, along with other innovative strategies they used to establish reduced CLABSI rates. Despite challenges faced during the COVID-19 pandemic, some health care organizations have excelled in their efforts to reduce and sustain low rates of CLABSI by implementing evidence-based practices, innovative solutions, and education.

Implementing an Internal CLABSI Validation Program

Background: The National Healthcare Safety Network (NHSN) provides detailed surveillance case definitions for healthcare-associated infections (HAI), including central line-associated bloodstream infections (CLABSI). CLABSI data are used for several purposes, including improving patient safety, value-based purchasing, and comparing hospitals’ performance. Our Infection Prevention (IP) team conducts house-wide HAI surveillance. To ensure that our hospital CLABSI reporting is accurate and that staff are implementing case definitions consistently and systematically, we conducted an internal validation of CLABSI. This undertaking allowed us to identify educational opportunities for IPs and improve surveillance data consistency. Methods: At UNC Hospitals, data on all positive blood cultures collected in the inpatient setting from July 2022 – June 2023 were obtained from electronic medical records. A random number generator was used to select 16 records per quarter. Each record was then randomly assigned to two different IPs (out of 8 total inpatient IPs) for review. Concordance of CLABSI classification was summarized across the two reviews and compared to the initial review. Discordant cases were then reviewed by the Associate IP Director (a certified IP with 15 years of experience) for final adjudication. A summary of findings and discordant cases details were discussed at regular IP educational meetings. Results: From July 2022-June 2023, there were 1658 positive blood cultures collected in the inpatient setting. Of the 64 randomly selected blood cultures, total concordance amongst all reviewers occurred 65.6% of the time. Concordance improved in the 2nd half of FY23 compared to the 1st half (72% vs, 59%, p&gt;0.05). Amongst the 33% of blood culture results with reviewer discrepancy, the most common reasons were related to distinction of a bloodstream infection secondary to another infection site (32%) and application of the repeat infection timeframe (18%). Importantly, there was only one instance where a blood culture result was categorized by all 3 reviewers as present on admission, but upon Associate Director review, actually represented a CLABSI (i.e., false negative). Conclusions: Standardized case definitions remain open to interpretation. At our hospital, we experienced discordance in approximately one-third of instances during review of blood culture data amongst trained infection preventionists. Reviewing all blood culture data is key for validation so that both false positives and false negative CLABSIs can be identified. Identifying the most common reasons for discordance and using specific examples when case disagreement occurred for educational purposes may lead to improved reliability and accuracy of application of the NHSN surveillance defintions.

Iterative Health Equity Analyses of Central Line-Associated Bloodstream Infection (CLABSI) Events at a Pediatric Hospital

Background: Per the Centers for Disease Control and Prevention, health equity stipulates all have a fair, just opportunity to attain their highest level of health. Limited evidence exists for disparities in health equity and healthcare-associated infections (HAI), with no evidence on language or primary insurance payor. While reviewing quality metrics, a disparity signal in central line-associated bloodstream infections (CLABSIs) prompted a multidisciplinary deep dive, with iterative analyses to understand potential inequities to identify improvement opportunities. Methods: CLABSI data was stratified and analyzed for evidence of disparity by race/ethnicity, primary insurance payor, and preferred spoken language utilizing an internal methodology. Subsequent analyses included a root cause analysis (RCA), case mix index (CMI) analysis, analysis of CLABSI Kamishibai card (K-card) rounding to monitor maintenance bundle reliability, and comparison of distribution of central venous catheter (CVC) line days to K-card audits [Figure 1]. Chi-square tests were used to test for significant differences for categorical variables in RCA and K-card analyses. ANOVA was used to compare CMI between demographic groups. Multiple logistic regression was used to compare K-card compliance rates by demographic groups. Results: When stratifying CLABSI rate by primary payor, pairwise comparisons indicated patients with a public payor had a statistically higher rate of CLABSI compared to private (p=0.02) [Figure 2A]. RCA analysis revealed when compared to patients with private payors, those with public had significantly higher rates of overdue needless connector changes (p = 0.03) and increased number of daily CVC entries (p = 0.05), while patients speaking another language (p = 0.02) were significantly more likely to have CVC contamination events. CMI analyses on CLABSI cases did not show patient acuity to vary significantly between demographics. Bivariate analysis of K-card data revealed minor differences in reliability with 7 Core Maintenance Bundle Elements by demographics; adjusting for all demographics and accounting for unit, pairwise comparisons indicated public payors had significantly higher compliance than international [Figure 2B]. We found no major differences in demographic distribution of CVC line days compared to K-card audits, suggesting we representatively audit maintenance bundle process measures. Conclusions: Our review of health equity in CLABSI events ultimately led to subsequent questions requiring analysis of other data sets. Utilizing an exploratory approach and assembling a multidisciplinary team to identify potential drivers of identified disparities adds value to health equity analyses. This is the first description of HAI data beyond race and ethnicity and can assist other institutions in their process of evaluating healthcare disparities and HAIs.

Contributing Factors to Central Line-associated Bloodstream Infections and Catheter-associated Urinary Tract Infections

Background: Central line-associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI) are key healthcare-associated infection (HAI) quality metrics. In this qualitative analysis, we aimed to identify common issues contributing to CLABSIs and CAUTIs occurring during the COVID-19 pandemic. Methods: In an academic healthcare network in Atlanta, GA, four hospitals perform real-time, apparent cause analyses (ACAs) for all CLABSIs and CAUTIs. Contributing factors are entered as free text into an electronic database. We analyzed data from 8/2020–8/2022. We first performed a qualitative open card sort of all reported contributing factors to CLABSI and created a novel framework based on mutually defined critical tasks (e.g., line insertion) and cross-cutting issues (e.g., communication breakdown). Contributing factors could describe ≥1 critical task and/or ≥1 cross-cutting issue. After establishing interrater reliability, a multidisciplinary group applied this framework to classify each contributing factor. For CAUTI, we used the same set of cross-cutting issues but identified new critical tasks via open card sorting. We then used the framework to classify each CAUTI contributing factor. We used descriptive statistics to identify frequent critical tasks and cross-cutting issues. Results: We reviewed 350 CLABSI ACAs with 602 contributing factors and 240 CAUTI ACAs with 405 contributing factors (Figure 1). Our classification framework comprised 11 cross-cutting issues and 9 critical tasks for CLABSI and 7 critical tasks for CAUTI (Figure 2). CLABSI: The critical tasks most often reported were bathing (19%), central line dressing maintenance (15%), and assessing central line indication (8%; Figure 3). Within these tasks, the most frequent issues described for bathing were the task not being performed (20%) and unclear documentation (18%); for dressing maintenance, the task was not performed (15%), not documented (15%), or poorly performed due to lack of competency (15%); and for assessing line indication, there was frequent communication breakdown (33%). CAUTI: The critical tasks most often reported were urinary catheter care (26%) and assessing the indication for urinary catheter (22%; Figure 4). Within these tasks, urinary catheter care was frequently not documented (38%) or not performed (16%); assessing urinary catheter necessity was often not documented (29%) or involved breakdown of communication (19%). Conclusion: We created a novel framework to evaluate common causes of HAIs in an academic healthcare network. This framework can be used to identify and track gaps over time and to develop quality improvement initiatives targeting key tasks and associated factors, such as communication difficulties when assessing device indications.Disclosure: Colleen Kraft: Consultant - REbiotix/Ferring; Scientific Advisory Board - Seres, LLC

The CATERPILLAR study: an assessor-blinded randomized controlled trial comparing a taurolidine–citrate–heparin lock solution to a heparin-only lock solution for the prevention of central-line-associated bloodstream infections in paediatric oncology patients

Taurolidine-citrate(-heparin) lock solutions (TCHL) are suggested as a promising and safe method for the prevention of central-line-associated bloodstream infections (CLABSI). To investigate the efficacy of TCHL for the prevention of CLABSI in paediatric oncology patients. An assessor-blinded randomized controlled trial at the Princess Máxima Centre for paediatric oncology, the Netherlands, was performed from 2020 to 2023. Paediatric oncology patients receiving a tunnelled central venous access device (CVAD) were eligible. A total of 462 patients were required to compare the TCHL to the heparin-only lock (HL). Patients were followed-up for the first 90 days after CVAD insertion. The primary outcome was the incidence of the first CLABSI from CVAD insertion until the end of follow-up. Intention-to-treat and per-protocol analyses were performed. In total, 232 were randomized in the HL and 231 in the TCHL group. A total of 47 CLABSIs were observed. The intention-to-treat analysis showed that a CLABSI was observed in 26 (11.2%) of the HL group patients versus 21 (9.1%) of the TCHL group patients; incidence rate ratio (IRR) of 0.81 (95% confidence interval (CI): 0.46-1.45) in favour of the TCHL group. The per-protocol analysis showed that a CLABSI was observed in 10 (7.9%) of the HL group patients versus 6 (4.8%) of the TCHL group patients; IRR of 0.59 (95% CI: 0.21-1.62) in favour of the TCHL group. Adverse events were more common in the TCHL group but rarely reported. No difference was detected between the TCHL and HL in the incidence of CLABSI in paediatric oncology patients.

Health Equity Factors and Healthcare-Associated Infections in Louisiana Facilities, 2022

Background: Health equity is a critical consideration in public health research, emphasizing the importance of fair and just access to healthcare resources. This study explores the impact of health equity factors on the incidence rates of Central Line-Associated Bloodstream Infections (CLABSI) and Methicillin-Resistant Staphylococcus aureus (MRSA) across diverse healthcare facilities in Louisiana. Methods: We conducted a comprehensive analysis utilizing 2022 data from the National Healthcare Safety Network (NHSN). Fourteen healthcare facilities were randomly selected from nine regions in Louisiana, with guidance from the 2022 NHSN external validation toolkit. Key health equity factors from Health Resources and Service Administration (HRSA) were assessed, including urbanicity, MUA/P, and HPSA_Primary Care. Risk ratios were calculated to quantify the association between these health equity factors and the incidence rates of CLABSI and MRSA. Results: The findings reveal intriguing insights into the relationship between health equity factors and infection rates. In urban settings, the risk of CLABSI was lower (Risk Ratio: 0.634, 95% CI: 0.2442–1.646), contrasting with a significantly higher risk of MRSA (Risk Ratio: 1.7, 95% CI: 1.119–2.582). This suggests a complex interplay between urbanicity and the specific infection types. For MUA/P, no significant impact on CLABSI rates was observed (Risk Ratio: 0.963, 95% CI: 0.4225–2.195), but an increased risk of MRSA emerged (Risk Ratio: 1.652, 95% CI: 1.029–2.652). In healthcare professional shortage areas for primary care (HPSA_Primary Care), both CLABSI (Risk Ratio: 1.37, 95% CI: 0.5854–3.204) and MRSA (Risk Ratio: 2.098, 95% CI: 1.305–3.372) exhibited elevated risks, though only MRSA risk was statistically significant. Conclusions: This research underscores the nuanced relationship between health equity factors and infection rates in healthcare facilities. Urban settings may contribute to a lower risk of CLABSI but a higher risk of MRSA, emphasizing the need for tailored preventive strategies. Living in medically underserved areas appears to heighten the risk of MRSA, warranting targeted interventions. Additionally, healthcare professional shortage areas for primary care demonstrate potential associations with increased risks for both CLABSI and MRSA. These findings provide valuable insights for public health practitioners, policymakers, and healthcare administrators aiming to address health disparities and enhance infection control measures in diverse healthcare settings. Further research is encouraged to unravel the multifaceted dynamics influencing infection rates and to inform targeted interventions for improved health outcomes.

Antimicrobial bathing of the critically ill for the prevention of healthcare-associated infection at a hospital in California

Background: Patients in the intensive care unit (ICU) have invasive lines increasing their risk for healthcare-associated infections (HAIs). Our objective was to determine if antimicrobial bathing with 2% chlorhexidine gluconate (CHG) compared to the colloidal silver-based antimicrobial product would reduce the incidents of central line–associated bloodstream infections (CLABSI) and catheter-associated urinary tract infections (CAUTI). Methods: We performed a before-and-after study in four adult ICUs at a two-hospital facility in California. Prospective surveillance of CLABSI and CAUTI prevention bundles monitoring was established. The intervention consisted of daily bathing with CHG for all patients in the ICUs. A baseline period of one year was followed by an intervention period of one year. The incidence rates of CLABSIs and CAUTIs were compared between the baseline and intervention periods utilizing a t-test analysis. Results: A total of 10103 patients were included. At Facility A, a mean CLABSI rate of 2.43/1000 central line catheter days (CL) with 2149 patients days (Mean differences 95% CI -0.5–3.1; P&gt;0.0975), during the baseline period followed by 1.11/1000 CL days with 2193 patient days in the intervention period. At Facility B, the mean CLABSI rate of 1.82/1000 CL days with 2976 patient days (Mean differences 95% CI -0.6–2.31; P&gt;0.161) during the baseline period was followed by 1.01/1000 CL days with 2785 patient days in the intervention period. At Facility A, the mean CAUTI rate of 1.37/1000 indwelling catheter days (IUC) with 2149 ICU patient days (Mean difference 95% CI is 0.28–1.97; P 0.2160) was noted in the baseline period, followed by 0.45/1000 IUC days with 2785 in the intervention period. Conclusion: Daily bathing with CHG significantly reduced the incidence of CAUTI at Facility A. It is unclear why Facility A saw a statistically significant reduction in CAUTI, but Facility B did not. The difference in outcomes may be related to hospital size, service lines, supply constraints, and discrepancies in staffing. CHG bathing was not directly associated with a reduced risk of CLABSI at Facility A and B during our limited study, but it was encouraging enough that our organization will continue this intervention to obtain additional data to determine if bathing with CHG will reduce CLABSI and CAUTI.

Infection prevention making a difference on statewide standardized infection ratios for device-associated HAIs from 2015-2022

Background: Central line-associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) cause significant morbidity and mortality among hospitalized patients. Over the last 10 to 20 years, hospital accountability for the prevention of device-associated infections increased at the state and national levels. For example, the Centers for Medicare &amp; Medicaid Services implemented the Hospital Inpatient Quality Reporting Program in 2015. The objective of this study was to assess the impact of increased federal attention on infection prevention using longitudinal data from the National Healthcare Safety Network (NHSN). We hypothesize that there was a significant decrease in statewide standardized infection ratios (SIRs) for CLABSI and CAUTI over the last 8 years. Methods: We collected SIRs for CLABSI and CAUTI in acute care hospitals for all 50 states and Washington D.C. from the NHSN database from 2015 to 2022. For CLABSI, we performed unique analyses for critical care units, wards, and neonatal intensive care (NICU) locations. For CAUTI, we stratified by critical care units and wards. We included all states with more than 5 hospitals reporting data. Those with fewer than 5 were excluded by listwise deletion in the corresponding analysis. We tested trends over time using linear mixed effect models with year as fixed effect and state as random effect. We also included an indicator variable representing the influence of SARS-CoV-2 (Covid-19) on healthcare-associated infections (HAIs). We elected an alpha of 0.05 as the threshold for statistical significance. Results: Overall, CLABSI and CAUTI SIRs exhibited significant negative slopes (Figures 1-5) after controlling for the influence of Covid-19. Each analysis revealed progressively lower SIRs compared to the previous year except for the 2019-2020 interval. Interestingly, the linear trend resumed after 2020 with subsequently lower SIRs in 2021 and 2022. Covid-19 had a greater influence on CLABSI SIRs in critical care settings compared to ward or NICU locations. The slope of CAUTI SIRs were impacted less by Covid-19 in wards compared to critical care settings. Conclusion: The results of the analysis demonstrate that CLABSI and CAUTI are trending in the desired direction despite the HAI spike during Covid-19. Government and hospital stakeholders in the United States should be encouraged by the reported trends and continue to prioritize the funding and use of resources for evidence-based device-associated infection prevention.

The Mechanics, Art, and Value of Central Line Stewardship

Background: Central venous catheter (CVC) utilization and central-line associated bloodstream infection (CLABSI) have increased nationwide. Busy providers can easily overlook the recommended practice of daily assessment of the ongoing indication for CVC. Prospective audit and feedback (PAF) is widely used and the gold standard for antibiotic stewardship programs (ASP), but reports involving PAF for device use are scarce. Therefore, we decided to evaluate the usefulness and feasibility of PAF for reducing device utilization and ultimately CLABSI rates at our 528-bed tertiary care hospital. Methods: A PAF-based Central Line Stewardship (CLS) initiative was launched in February 2023, with a team of hospitalists, infectious diseases physicians, health informatics, vascular access nurses, and infection preventionists. On business days, CVC line-lists were exported from the electronic medical record (EMR), into a REDCap (Research Electronic Data Capture) database for team members to evaluate, in real-time, all non-ICU CVCs in place for more &gt;72 hours (Figures 1 and 2). For CVCs eligible for stewardship, CLS members placed Legal-approved note into the patient’s EMR, advising CVC removal or alternative IV access (Figure 3). CVCs continued to be audited until removal or patient discharge. Recommendation outcomes were tracked over the subsequent 72 hours for acceptance. Standardized Utilization Rates (SUR) and Infection Rates (SIR) were calculated and compared using the National Healthcare Safety Network. Results: Between February and August 2023, the CLS team reviewed 861 CVCs, representing 581 unique patient encounters, and made 622 recommendations. Recommendations to remove or replace the CVC represented 23.5% (146) of reviews, and 57% of these CVCs were removed within 3 days. 95% of removed lines had no adverse outcomes and did not require reinsertion. Hospital-wide CVC utilization decreased 18.7% from a SUR of 1.006 in the previous year, to 0.818 during the 7-month pilot period (p &lt; 0 .001). In the 4 months following the pilot period, decreased CVC utilization was sustained with an SUR of 0.797. Non-ICU CLABSI SIR decreased from 1.282 in 2022 to 1.024 in 2023 (p=0.36). Average time physician required for CLS review approximated a 0.4 full-time equivalent a week. The intervention was well received, with requests for expansion to urinary catheters. Conclusion: CLS safely and significantly reduced device-utilization; directly via documentation and recommendation, and indirectly through increased awareness and the Hawthorne Effect. Examples of the “art” of CLS include when to leave a discoverable note and how to determine ongoing need for CVC in a fragile patient.

Impacts of Hospital Acquired Bloodstream Infections in Patients Undergoing Hemodialysis Through a Central Venous Catheter

Background: Hospital acquired infections (HAI) are of interest given their resultant morbidity, mortality, and hospital utilization. Among HAIs, central line associated bloodstream infections result in the highest rates of mortality and additional costs. While all central venous catheters (CVC) carry risk for BSI, long-term catheter use is at increased risk. One population that utilize CVCs for extended durations are those undergoing hemodialysis. While data are available characterizing BSI impacts on outpatient hemodialysis patients, little data exist describing inpatients. The purpose of this study was to characterize the demographics, outcomes, and economics associated with the development of hospital acquired BSI (HA-BSI) in patients undergoing hemodialysis through a CVC (HD-CVC). Methods: All admissions of adult patients in the Premier Healthcare Database with hospital stays including HD-CVC with discharge dates during 2020-2022 were retrospectively evaluated. BSIs were identified by ICD-10 codes and blood culture collection dates. A BSI was deemed hospital acquired if the blood culture date was ≥3 calendar days after admission. Descriptive analyses were undertaken for HA-BSI patients including: baseline demographics, clinical characteristics, and outcomes. Length of stay (LOS), ICU utilization, and estimated costs were evaluated for HAI-BSI and non-BSI populations. Results: 166,394 admissions from 91,448 patients were identified. Of these, 5,722 patients (6.3%) had 5,842 admissions with a HA-BSI. These patients were 58.9% white, 28.3% black, 56.8% male, and 62.9% were aged ≥60years. Patients had considerable comorbidities at baseline with 88.9% having ≥2 Charlson comorbid conditions and 46.9% with ≥6. During the study period, all-cause mortality was 27.8% for HA-BSI patients with 85.5% of deaths occurring while inpatient. Median LOS for patients with HA-BSI was 25 days compared with 6 days for HD-CVC without BSI; patients with HA-BSI were also more likely to require the ICU (65.6% vs. 27.6%). The median ICU LOS was 12 days for HA-BSI versus 34 days for HD-CVC without BSI. Greater intensity of healthcare utilization was reflected in median costs of $402K for HA-BSI, compared with $43K for HD-CVC without BSI. Discussion: We described the characteristics of HD-CVC patients that developed HA-BSI. These patients had many comorbidities and relatively high rates of all-cause in-hospital mortality. Patients were likely to have long LOS, both in-hospital and within the ICU. Collectively, care of these patients was associated with considerable healthcare costs, particularly as compared with HD-CVC patients not developing a HA-BSI. Future studies should characterize risk factors and evaluate potential prevention strategies for this high-risk population.

Impact of Vascular Access Teams on Central Line Associated Bloodstream Infections

Background: During the COVID-19 pandemic, rates of central line bloodstream infections (CLABSI) increased nationally. Studies pre-pandemic showed improved CLABSI rates with implementation of a standardized vascular access team (VAT).[PL1] [PL2] [mi3] Varying VAT resources and coverage existed in our 10 acute care facilities (ACF) prior to and during the pandemic. VAT scope also varied in 1) process for line selection during initial placement, 2) ability to place a peripherally inserted central catheter (PICC), midline or ultrasound-guided peripheral IV in patients with difficult vascular access, 3) ownership of daily assessment of central line (CL) necessity, and 4) routine CL dressing changes. We aimed to define and implement the ideal VAT structure and evaluate the impact on CLABSI standardized infection ratios (SIR) and rates prior to and during the pandemic. Methods: A multidisciplinary workgroup including representatives from nursing, infection prevention, and vascular access was formed to understand the current state of VAT responsibilities across all ACFs. The group identified key responsibilities a VAT should conduct to aid in CLABSI prevention. Complete VAT coverage[mi4] was defined as the ability to conduct the identified responsibilities daily. We compared the SIR and CLABSI rates between hospitals who had complete VAT (CVAT) coverage to hospitals with incomplete VAT (IVAT) coverage. Given this work occurred during the pandemic, we further stratified our analysis based on a time frame prior to the pandemic (1/2015 – 12/2019) and intra-pandemic (1/2020 - 12/2022). Results: The multidisciplinary team identified 6 key components of complete VAT coverage: Assessment for appropriate line selection prior to insertion, ability to insert PICC and midlines, daily CL and midline care and maintenance assessments, daily assessment of necessity for CL, and weekly dressing changes for CL and midlines[NA5] . A cross walk of VAT scope (Figure 1) was performed in October 2022 which revealed two facilities (A and E) which met CVAT criteria. Pre-pandemic, while IVAT CLABSI rates and SIR were higher than in CVAT units, the difference was not statistically significant. During the pandemic, however, CLABSI rates and SIR were 40-50% higher in IVAT compared to CVAT facilities (Incident Rate Ratio 1.5, 95% CI 1.1-2.0 and SIR Relative Ratio 1.4, 95% CI1.1-1.9 respectively) (Table 1). Conclusions: CLABSI rates were lower in facilities with complete VAT coverage prior to and during the COVID-19 pandemic suggesting a highly functioning VAT can aid in preventing CLABSIs, especially when a healthcare system is stressed and resources are limited.