Central Venous Catheter-related Bloodstream Infection Research Articles

Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicator Rates Among Veteran Dual Users

This study compares rates of 11 Agency for Healthcare Research and Quality Patient Safety Indicators (PSIs) among 266 203 veteran dual users (ie, those with hospitalizations in both the Veterans Health Administration [VA] and the private sector through Medicare fee-for-service coverage) during 2002 to 2007. PSI risk-adjusted rates were calculated using the PSI software (version 3.1a). Rates of pressure ulcer, central venous catheter-related bloodstream infections, and postoperative sepsis, areas in which the VA has focused quality improvement efforts, were found to be significantly lower in the VA than in the private sector. VA had significantly higher rates for 7 of the remaining 8 PSIs, although the rates of only 2 PSIs (postoperative hemorrhage/hematoma and accidental puncture or laceration) remained higher in the VA after sensitivity analyses were conducted. A better understanding of system-level differences in coding practices and patient severity, poorly documented in administrative data, is needed before conclusions about differences in quality can be drawn.

Microbiological screening for earlier detection of central venous catheter-related bloodstream infections

Catheter-related bloodstream infections (CRBSIs) are currently detected with a reactive diagnostic policy, that is, application of tests to patients with clinically suspected CRBSI. The aim of our study was to evaluate whether CRBSIs could be anticipated in an earlier stage by microbiological screening using peptide nucleic acid fluorescence in situ hybridization (PNA FISH) with universal hybridization probes or acridine-orange leucocyte cytospin (AOLC) tests in haemodialysis and haematological patients with CVCs in situ compared with routine test. Peptide nucleic acid fluorescence in situ hybridization (PNA FISH) and AOLC tests using blood samples from both CVC lines in patients undergoing haemodialysis were performed three times a week and from one CVC line in haematological patients were performed daily. Results were compared with those obtained from routinely performed CRBSI diagnostic tests. One hundred fifteen patients with 139 catheter periods were investigated. The mean observation time per catheter period was 25 days (IQR 13.5-43.5), resulting in 5615 CVC days with a total of 4839 tested blood samples. Five CRBSI cases were detected by routine measures resulting in a CRBSI rate of 0.9/1000 catheter days. Four of five CRBSIs could be anticipated by positive PNA FISH and AOLC tests 2-8 days before the diagnosis was established with routine measures. The proactive anticipative strategy using microscopic examination of CVC blood samples to anticipate CRBSI in an earlier stage compared with routine measures is a new diagnostic approach in patients with CVCs and a high risk of developing CRBSI.

O083: Prohibit (preventing hospital-acquired infections by intervention and training): preliminary results of a European multi-center study on the effectiveness of a hand hygiene campaign and a central venous catheter bundle

Differences in the incidence of hospital-acquired infections among European hospitals are due to a range of factors such as case mix, variable infection control policies and practices, and culture. The PROHIBIT study aims at inventorying and analysing national and local infection prevention policies and practices in Europe. The aim of this study is to test two interventions of proven efficacy, a hand hygiene (HH) improvement campaign and an extensive central venous catheter (CVC) bundle, in reducing CVC-related bloodstream infection (CRBSI).

Parenteral nutrition mixtures prepared at home by trained parents are as safe as pharmacy-made mixtures: A 3-y prospective study

ObjectivesHome parenteral nutrition (HPN) prevents malnutrition in children with intestinal failure improving chances for the best possible physical development and quality of life. For organizational reasons, in Poland the majority of children on HPN receive nutrition mixtures prepared at home by their parents. The aim of this study was to evaluate whether this method influences the frequency of catheter-related bloodstream infections (CRBSIs). MethodsThe aim of this prospective study was to assess the incidence of CRBSIs from January 2008 to December 2010 in 181 children on HPN and to compare the incidence in two subgroups of these children: group Ph (pharmacy) consisting of 43 patients receiving mixtures prepared in the hospital pharmacy weekly, and group H (home)—138 patients receiving nutrition mixtures prepared daily at home by their caregivers. Central venous CRBSIs were diagnosed by the presence of clinical signs (such as fever, chills, malaise, vomiting) associated with positive blood culture from the central catheter. ResultsFrom 2008 to 2010 parenteral nutrition was administrated during 128 905 catheter-days in 181 patients, and CRBSIs occurred 129 times (1 episode per 1000 catheter-days) in 65 patients. There were 42 bloodstream infections in group Ph during 29 225 catheter-days (i.e., 1.43 per 1000 catheter-days), whereas 87 bloodstream infections occurred in group H during 100 775 catheter-days (i.e., 0.86 per 1000 catheter-days; P = 0.0516). ConclusionsPreparing parenteral nutrition mixtures at home by trained parents is a safe method of HPN with a slightly (however insignificantly) lower incidence of CRBSIs compared with hospital pharmacy-prepared parenteral nutrition mixtures.

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

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

Disparity in Race-Specific Comorbidities Associated With Central Venous Catheter–Related Bloodstream Infection (AHRQ-PSI7)

Studies of racial disparities in hospital-level patient safety outcomes typically apply a race-common approach to risk adjustment. Risk factors specific to a minority population may not be identified in a race-common analysis if they represent only a small percentage of total cases. This study identified patient comorbidities and characteristics associated with the likelihood of a venous catheter-related bloodstream infection (Agency for Healthcare Research and Quality Patient Safety Indicator 7 [PSI7]) separately for blacks and whites using race-specific logistic regression models. Hospitals were ranked by the racial disparity in PSI7 and segmented into 4 groups. The analysis identified both black- and white-specific risk factors associated with PSI7. Age showed race-specific reverse association, with younger blacks and older whites more likely to have a PSI7 event. These findings suggest the need for race-specific covariate adjustments in patient outcomes and provide a new context for examining racial disparities.

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

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

Patient- and Device-Specific Risk Factors for Peripherally Inserted Central Venous Catheter—Related Bloodstream Infections

To determine the patient- and device-specific risk factors for hospital-acquired peripherally inserted central venous catheter-related bloodstream infections (PICC BSIs) in adult patients. Nested case-control study. Barnes-Jewish Hospital, a 1,252-bed tertiary care teaching hospital. Adult patients with PICCs placed from January 1, 2006, through July 31, 2008. PICC BSI cases were identified using the National Healthcare Safety Network definition. Uninfected control patients with PICCs in place were randomly selected at a 3∶1 ratio. Patient- and device-related variables were examined using multivariate analysis. The overall PICC BSI rate was 3.13 per 1,000 catheter-days. Independent risk factors for PICC BSIs included congestive heart failure (odds ratio [OR], 2.0 [95% confidence interval (CI), 1.26-3.17]; P = .003), intra-abdominal perforation (OR, 5.66 [95% CI, 1.76-18.19]; P = .004), Clostidium difficile infection (OR, 2.25 [95% CI, 1.17-4.33]; P = .02), recent chemotherapy (OR, 3.36 [95% CI, 1.15-9.78]; P = .03), presence of tracheostomy (OR, 5.88 [95% CI, 2.99-11.55]; P < .001), and type of catheter (OR for double lumen, 1.89 [95% CI, 1.15-3.10]; P = .01 ; OR for triple lumen, 2.87 [95% CI, 1.39-5.92]; P = .004). Underlying chronic obstructive pulmonary disease (OR, 0.48 [95% CI, 0.29-0.78]; P = .03) and admission to surgical (OR, 0.43 [95% CI, 0.24-0.79]; P = .006) or oncology and orthopedic (OR, 0.35 [95% CI, 0.13-0.99]; P = .05) services were less likely to be associated with having a PICC BSI. We identified several novel factors related to PICC BSIs. These factors may inform preventive measures.

Needleless Closed System Does Not Reduce Central Venous Catheter-Related Bloodstream Infection: A Retrospective Study

The needleless closed system (NCS) has been disseminated in several clinical fields to prevent central venous catheter-related bloodstream infection (CVC-RBSI), in place of the conventional Luer cap system (LCS). The purpose of this study is to examine whether NCS is really superior to conventional LCS for prevention of CVC-RBSI. Between May 2002 and December 2008, 1767 patients received CVC in our department. The time interval from insertion to development of CVC-RBSI was compared retrospectively between selected patients who were treated using the conventional LCS (group 1, n = 89, before June 2006) and the NCS (group 2, n = 406, June 2006 and after). Kaplan-Meier analysis revealed no significant difference in the time interval from insertion to development of CVC-RBSI between the two groups. NCS does not reduce CVC-RBSI in adult colorectal cancer patients who undergo CVC insertion.

Clinical epidemiology of central venous catheter–related bloodstream infections in an intensive care unit in China

BackgroundCentral venous catheters (CVCs) are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk. At present, there are few studies on catheter-related bloodstream infections (CRBSIs) that are comparable with international similar research. The aim of this study was to determine the rate, risk factors, and outcomes of CRBSIs in patients of an intensive care unit (ICU) in China. MethodsA prospective study was performed in the Affiliated Shengjing Hospital of China Medical University. All patients admitted to the ICU from June 2007 to May 2008 who had a central line placed were monitored for the development of BSI from insertion until 48 hours after removal. One hundred seventy-four patients with 178 admissions to the ICU, 219 CVCs and 1913 CVC days, 21 episodes of CRBSI in 21 patients were enrolled. ResultsThe mean rate of CRBSI was 11.0 per 1000 CVC days with a catheter utilization rate of 72.8%. Analyses of the pathogens showed that gram-negative organisms were predominant. The univariate analysis showed that 3 things seemed to directly impact the occurrences of CRBSI. These were the number of lines insertion, the applications of antibiotics before CRBSI, and the duration of catheter. In a multiple logistic regression analysis of the risk factors, patients with multiple central lines (odds ratio = 5.981; 95% confidence intervals, 1.660-21.547; P = .006) and with the applications of multiple antibiotics before CRBSI (odds ratio = 6.335; 95% confidence interval, 2.001-20.054; P = .002) were more likely to develop CRBSI. ConclusionsThe CRBSI rate in our ICU is higher compared with that reported by the National Nosocomial Infection Surveillance and was associated with the applications of antibiotics before CRBSI and with the number of placed CVCs. Catheter-related bloodstream infections may be associated with a higher mortality rate and a higher incidence of ventilator-associated pulmonitis, which might lead to an increase in the total costs and medicine expenditures.

Propensity score analysis confirms the independent effect of parenteral nutrition on the risk of central venous catheter-related bloodstream infection in oncological patients

Parenteral nutrition is known as a high-risk factor for central venous catheter-related bloodstream infection (CVC-RBSI) in cancer patients. Owing to ethical and technical problems, the studies in the literature have nonrandomized designs and are therefore often confounded by biases. We performed a propensity score analysis to estimate the effect of parenteral nutrition on CVC-RBSI in digestive cancer patients who underwent chemotherapy. Data were collected prospectively. A logistic regression model was used to calculate a propensity score, which was the probability of receiving parenteral nutrition. Kaplan-Meier survival and Cox regression model were used to estimate the effect of the parenteral nutrition on CVC-RBSI after adjustment for the propensity score. Before the propensity score analysis, the differences between patients with (n = 113) and without (n = 312) parenteral nutrition were identified including: male gender, body weight, weight loss, performance status, location of primary cancer, FOLFIRI, and previous long-term corticotherapy. After propensity score stratification, all of the covariates were balanced within each stratum. After adjustment, patients with parenteral nutrition were at a higher risk for CVC-RBSI. By using the propensity score analysis, this study confirmed that parenteral nutrition was an independent risk factor for CVC-RBSI in digestive cancer patients.

Prevention of central venous catheter-related bloodstream infections: is it time to add simulation training to the prevention bundle?

Study ObjectiveTo study the impact of adding simulation-based education to the pre-intervention mandatory hospital efforts aimed at decreasing central venous catheter-related blood stream infections (CRBSI) in intensive care units (ICU). DesignPre- and post-intervention retrospective observational investigation. Setting24-bed ICU and a 562-bed university-affiliated, urban teaching hospital. PatientsICU patients July 2004-June 2008 were studied for the development of central venous catheter related blood stream infections (CRBSI). MeasurementsICU patients from July 2004-June 2008 were studied for the development of central venous catheter-related blood stream infections (CRBSI). Pre-Interventionmandatory staff and physician education began in 2004 to reduce CRBSI. The CRBSI-prevention program included online and didactic courses, and a pre- and post-test. Elements in the pre-intervention efforts included hand hygiene, full barrier precautions, use of Chlorhexidine skin preparation, and mask, gown, gloves, and hat protection for operators. A catheter-insertion cart containing all supplies and checklist were was a mandatory element of this program; a nurse was empowered to stop the procedure for non-performance of checklist items. InterventionAs of July 1, 2006, a mandatory simulation-based program for all intern, resident, and fellow physicians was added to teach central venous catheter (CVC) insertion. MeasurementsData collected pre- and post-intervention were CRBSI incidence, number of ICU catheter days, mortality, laboratory pathogen results, and costs. Main ResultsThe pre-intervention CRBSI incidence of 6.47/1,000 catheter days was reduced significantly to 2.44/1,000 catheter days post-intervention (58%; P < 0.05), resulting in a $539,902 savings (USD; 47%), and was attributed to shorter ICU and hospital lengths of stay. ConclusionsFollowing simulation-based CVC program implementation, CRBSI incidence and costs were significantly reduced for two years post-intervention.

Significant Reduction in Central Venous Catheter–related Bloodstream Infections in Children on HPN After Starting Treatment With Taurolidine Line Lock

The aim of this study was to review the incidence and type of central venous catheter-related bloodstream infection in children on treatment with home parenteral nutrition (PN) before and after the introduction of taurolidine. Taurolidine is a catheter lock solution that prevents biofilm formation and has broad-spectrum bactericidal and antifungal action. Its use in pediatric patients on PN has only been reported in case studies. A total of 19 children were reviewed, with the diagnoses of enteropathy (8 cases), short bowel syndrome (7 cases), and gastrointestinal dysmotility (4 cases). Incidence and type of sepsis were reviewed for 8 to 12 months pre- (when heparin was used) and 2 to 33 months postintroduction of the taurolidine catheter lock. There were 8.6 episodes of catheter-related bloodstream infections per 1000 catheter days with heparin and 1.1 episodes per 1000 catheter days with taurolidine (P=0.002). A total of 14 of the 19 patients (74%) had no infections for up to 33 months after changing to taurolidine. No reports of multiresistant organisms or adverse effects with taurolidine were found. Taurolidine line lock was associated with a decreased incidence of catheter-related bloodstream infections. This finding supports its use in patients with a history of septicemia on treatment with cyclical PN.

Central and peripheral venous lines-associated blood stream infections in the critically ill surgical patients.

Critically ill surgical patients are always at increased risk of actual or potentially life-threatening health complications. Central/peripheral venous lines form a key part of their care. We review the current evidence on incidence of central and peripheral venous catheter-related bloodstream infections in critically ill surgical patients, and outline pathways for prevention and intervention. An extensive systematic electronic search was carried out on the relevant databases. Articles were considered suitable for inclusion if they investigated catheter colonisation and catheter-related bloodstream infection. Two independent reviewers engaged in selecting the appropriate articles in line with our protocol retrieved 8 articles published from 1999 to 2011. Outcomes on CVC colonisation and infections were investigated in six studies; four of which were prospective cohort studies, one prospective longitudinal study and one retrospective cohort study. Outcomes relating only to PICCs were reported in one prospective randomised trial. We identified only one study that compared CVC- and PICC-related complications in surgical intensive care units. Although our search protocol may not have yielded an exhaustive list we have identified a key deficiency in the literature, namely a paucity of studies investigating the incidence of CVC- and PICC-related bloodstream infection in exclusively critically ill surgical populations. In summary, the diverse definitions for the diagnosis of central and peripheral venous catheter-related bloodstream infections along with the vastly different sample size and extremely small PICC population size has, predictably, yielded inconsistent findings. Our current understanding is still limited; the studies we have identified do point us towards some tentative understanding that the CVC/PICC performance remains inconclusive.

Early ultrasonographic finding of septic thrombophlebitis is the main indicator of central venous catheter removal to reduce infection-related mortality in neutropenic patients with bloodstream infection

Septic thrombophlebitis increases patient morbidity and mortality following metastatic infections, pulmonary emboli, and/or septic shock. Central venous catheter (CVC) removal for occult septic thrombophlebitis challenges current strategy in neutropenic patients. We prospectively evaluated infection-related mortality in 100 acute leukemia patients, with CVC-related bloodstream infection (CRBSI) after chemotherapy, who systematically underwent ultrasonography to identify the need for catheter removal. Their infection-related mortality was compared with that of a historical cohort of 100 acute leukemia patients, with CRBSI after chemotherapy, managed with a clinically driven strategy. Appropriate antimicrobial therapy was administered in all patients analyzed. In the prospective series, 30/100 patients required catheter removal for ultrasonography-detected septic thrombophlebitis after 1 median day from BSI onset; 70/100 patients without septic thrombophlebitis retained their CVC. In the historical cohort, 60/100 patients removed the catheter (persistent fever, 40 patients; persistent BSI, 10 patients; or clinically manifest septic thrombophlebitis, 10 patients) after 8 median days from BSI onset; 40/100 patients retained the CVC because they had not clinical findings of complicated infection. At 30 days median follow-up, one patient died for infection in the ultrasonography-assisted group versus 17 patients in the historical cohort (P<0.01). With the ultrasonography-driven strategy, early septic thrombophlebitis detection and prompt CVC removal decrease infection-related mortality, whereas clinically driven strategy leads to inappropriate number, reasons, and timeliness of CVC removal. Ultrasonography is an easy imaging diagnostic tool enabling effective and safe management of patients with acute leukemia and CRBSI.

Prevention and nursing care of central line-associated bloodstream infections in critically ill patients

Catheter-related bloodstream infections are associated with significantly increased morbidity, mortality, and expenditures. Such infections are a serious threat to patient safety in the intensive care unit. This review describes the latest protocols related to preventing and treating central venous catheter-associated bloodstream infections in critically ill patients. According to 2011 Center for Disease Control (CDC) guidelines and central line care bundles by the institute for healthcare improvement (IHI), prevention measures for catheter-related bloodstream infections include the following: hand hygiene, maximal barrier precautions insertion, chlorhexidine skin antisepsis, optimal catheter site selection, proper catheter maintenance, insertion site care, and daily review of line necessity, with prompt removal of unnecessary lines. These are important and effective infection prevention measures. Guidelines and care bundles also recommend organizing care modules based on unit characteristics; integrating resources and empirical measures; education and training to promote comprehensive implementation; and auditing and monitoring to ensure staff continue to follow procedures. Effectively preventing central venous catheter-related bloodstream infections can enhance care quality and move healthcare closer to achieving the goal of zero tolerance.

Improved diagnosis of central venous catheter-related bloodstream infections using the HB&amp;L UROQUATTRO™ system

The diagnosis of catheter-related bloodstream infections (CRBSIs) in febrile patients with indwelling central venous catheters (CVCs) needs improvement. To diagnose CRBSIs more efficiently, we have developed a novel culture approach using the catheter tips removed from febrile patients. CVCs and blood cultures from 1,070 patients with only CVC-related infections were obtained over a period of 3 years (January 2009 to December 2011). The CVCs were evaluated by a semi-quantitative catheter culture method according to Maki's method and by our novel method, which is based on the use of the HB&L UROQUATTRO™ system (Alifax, Padova, Italy). Using our new method, 571 (571/1,070) of the infections were confirmed as CRBSIs. The remaining 487 patients had infections that were associated with hematologic malignancies, neutropenia, prior exposure to antibiotics, and a decreased CVC removal rate. Twelve samples were identified as false-positives. The percentage of patients with CRBSIs confirmed using the HB&L UROQUATTRO™ system was 53.36% versus 34.95% (p-value 0.004) using Maki's method (374/1,070 CVC Maki-positive samples). Our results indicate that our new culture method allows for an improved CRBSI diagnosis rate. A significant number of tip cultures (18.41%) tested positive for CRBSIs using our system but were negative when tested using Maki's method. Moreover, the use of the HB&L UROQUATTRO™ system allowed us to significantly reduce diagnosis time; a negative CRBSI diagnosis could be made within 6h and a positive diagnosis could be made within 22-28h.

Incidence of catheter-related bloodstream infection in a general hospital using two different detection methods

IntroductionThe aim of this study was to determine the incidence of central venous catheter-related bloodstream infection (CRBSI) in a general hospital, using two different assessment methods. MethodsMethod A: One observer prospectively followed up all patients with central venous catheters (CVCs) placed in our hospital over a period of 1 year, recording all CRBSI episodes. Incidence was calculated in two ways, in relation to the total number of catheter days, and in relation to the total number of hospital days of all patients hospitalized during this period. Method B: Another observer recorded all CRBSI episodes diagnosed during the same time period using microbiology data in which blood culture and catheter culture were positive for the same microorganism. Incidence was calculated in relation to the total number of hospital days of all hospitalized patients.The patient's demographic characteristics and the catheter-related variables were recorded and analysed. Based on clinical and microbiological criteria, catheters were classified as uninfected, colonized, or CRBSI. ResultsOver the study period, 878 central venous catheters were placed in 704 patients. The total number of catheter days was 7357, and the mean duration of catheter use was 8.15 days (1–86). The total number of hospital stays in this period was 92,167.Method A: 15 episodes of CRBSI were detected, yielding an overall incidence of 2.03 episodes/1000 catheter days or 0.16 episodes/1000 hospital days. Method B: 11 episodes of CRBSI, with an incidence of 0.12 episodes/1000 hospital days. ConclusionThe two methods studied yielded different CRBSI rates, with a higher incidence reported by prospective follow-up (Method A). In addition, this method enabled a better assessment to be made of CRBSI risk as the calculation could be performed in relation to the days patients were catheterized.

Changing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of Gram-negative pathogens-authors' response

Changing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of Gram-negative pathogens-authors' response

Comment on: Changing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of Gram-negative pathogens

Comment on: Changing epidemiology of central venous catheter-related bloodstream infections: increasing prevalence of Gram-negative pathogens