Central Venous Catheter-associated Bloodstream Infections Research Articles

National influences on catheter-associated bloodstream infection rates: practices among national surveillance networks participating in the European HELICS project

This study was performed to evaluate associations between organisational characteristics, routine practices and the incidence densities of central venous catheter-associated bloodstream infections (CVC-BSI rates) in European intensive care units (ICUs) as part of the HELICS project (Hospitals in Europe Link for Infection Control through Surveillance). Questionnaires were sent to ICUs participating in the national nosocomial infection surveillance networks in 2004. The national networks were asked for the CVC-BSI rates of the ICUs participating for the time period 2003--2004. Univariate and multivariate risk factor analyses were performed to identify which practices had the greatest impact on CVC-BSI rates. A total of 526 ICUs from 10 countries sent data on organisational characteristics and practices, demonstrating wide variation in care. CVC-BSI rates were also provided for 288 ICUs from five countries. This made it possible to include 1383444 patient days, 969897 CVC days and 1935 CVC-BSI cases in the analysis. Adjusted logistic regression analysis showed that the categorical variables of country [odds ratio (OR) varying per country from OR: 2.3; 95% confidence interval (CI): 0.5-10.2; to OR: 12.8; 95% CI: 4.4-37.5; in reference to the country with the lowest CVC-BSI rates] and type of hospital 'university' (OR: 2.08; 95% CI: 1.02-4.25) were independent risk factors for high CVC-BSI rates. Substantial variation existed in CVC-BSI prevention activities, surveillance methods and estimated CVC-BSI rates among the European countries. Differences in cultural, social and legal perspectives as well as differences between healthcare systems are crucial in explaining these differences.

Improving the quality of care of the critically ill patient. Implementing the central venous line care bundle in the ICU

Intravascular (IV) access in the care of the critically ill patient is an intervention that is both life-saving and life-threatening under certain circumstances. Critically ill patients frequently require the administration of intravenous fluids, blood products, medication, nutritional replacement therapy as well as monitoring of the intravascular volume. Such invasive interventions, together with the critically ill patient's impaired immune system as a result of multiple and complex medications, co-morbid illnesses, prolonged intensive care unit (ICU) admission and multiple intravascular line insertions, make such patients at risk of developing catheter-related bloodstream infections (CRBSIs). According to the Centers for Disease Control (CDC) in the USA, 80 000 central venous catheter (CVC)-associated bloodstream infections (BSIs) occur in American ICUs each year based on an average rate of 5.3 CVC-associated BSIs per 1 000 catheter days in ICU. Southern African Journal of Critical Care Vol. 24 (1) 2008: pp. 26-31

Device-associated infection rates and mortality in intensive care units of Peruvian hospitals: findings of the International Nosocomial Infection Control Consortium

To measure device-associated infection (DAI) rates, microbiological profiles, bacterial resistance, and attributable mortality in intensive care units (ICUs) in hospitals in Peru that are members of the International Nosocomial Infection Control Consortium (INICC). Prospective cohort surveillance of DAIs was conducted in ICUs in four hospitals applying the definitions for nosocomial infections of the U.S. Centers for Disease Control and Prevention National Nosocomial Infections Surveillance System (CDC-NNIS) and National Healthcare Safety Network (NHSN). From September 2003 to October 2007 1 920 patients hospitalized in ICUs for an aggregate of 9 997 days acquired 249 DAIs, accounting for a rate of 13.0% and 24.9 DAIs per 1 000 ICU-days. The ventilator-associated pneumonia (VAP) rate was 31.3 per 1 000 ventilator-days; the central venous catheter-associated bloodstream infections (CVC-BSI) rate was 7.7 cases per 1 000 catheter-days; and the rate for catheter-associated urinary tract infections (CAUTI) was 5.1 cases per 1 000 catheter-days. Extra mortality for VAP was 24.5% (RR 2.07, P < 0.001); for CVC-BSI the rate was 15.0% (RR 2.75, P = 0.028). Methicillin-resistant strains accounted for 73.5% of all Staphylococcus aureus DAIs; 40.5% of the Enterobacteriaceae were resistant to ceftriaxone, 40.8% were resistant to ceftazidime, and 32.0% were resistant to piperacillin-tazobactam. Sixty-five percent of Pseudomonas aeruginosa isolates were resistant to ciprofloxacin, 62.0% were resistant to ceftazidime, 29.4% were resistant to piperacillin-tazobactam, and 36.1% were resistant to imipenem. The high rates of DAIs in the Peruvian hospitals in this study indicate the need for active infection control. Programs consisting of surveillance of DAIs and implementation of guidelines for infection prevention can ensure improved patient safety in the ICUs and throughout hospitals.

Answers linked to Chen C-Y, Hansen KS, Hansen LK. Rhizobium radiobacter as an opportunistic pathogen in central venous catheter-associated bloodstream infection: case report and review. J Hosp Infect 2008;68:203–207.

Answers linked to Chen C-Y, Hansen KS, Hansen LK. Rhizobium radiobacter as an opportunistic pathogen in central venous catheter-associated bloodstream infection: case report and review. J Hosp Infect 2008;68:203–207.

Questions linked to Chen C-Y, Hansen KS, Hansen LK. Rhizobium radiobacter as an opportunistic pathogen in central venous catheter-associated bloodstream infection: case report and review. J Hosp Infect 2008;68:203–207.

Questions linked to Chen C-Y, Hansen KS, Hansen LK. Rhizobium radiobacter as an opportunistic pathogen in central venous catheter-associated bloodstream infection: case report and review. J Hosp Infect 2008;68:203–207.

Investigation of an Outbreak of Central Venous Catheter–Associated Bloodstream Infection Due to Contaminated Water

An outbreak of central venous catheter-associated bloodstream infections was reported in a hospital in Ecuador. Commercially produced ampoules of water for injection were found to be contaminated with Burkholderia cepacia and Myroides odoratus. Removal of these ampoules yielded a 10-fold reduction in the incidence of catheter-associated infection.

Surveillance for Catheter-Associated Bloodstream Infection in Hematology Units: Quantifying the Characteristics of a Practical Case Definition

We evaluated 66 patients in a hematology unit, who used a total of 106 central venous catheters (CVCs), to identify CVC-associated bloodstream infections using standard and modified surveillance case definitions. Compared with the National Nosocomial Infection Surveillance system criteria, a modified case definition used by treating physicians demonstrated 100.0% sensitivity and 94.3% specificity. This case definition provides a practical method for effectively excluding CVC-associated bloodstream infection.

Rhizobium radiobacter as an opportunistic pathogen in central venous catheter-associated bloodstream infection: case report and review

Rhizobium radiobacter is an uncommon opportunistic pathogen present in soil. It has been particularly associated with indwelling intravascular devices in immunocompromised patients. In this report, we summarise the case of a patient with multiple myeloma who developed R. radiobacter bacteraemia during autologous stem cell leucopheresis. Retrospective investigation revealed exposure to soil after central venous catheter placement for chemotherapy and leucopheresis access. This is the first reported case of R. radiobacter bacteraemia following probable colonisation of the catheter from soil exposure. We further review the existing literature to delineate prevention and treatment recommendations for line-associated R. radiobacter infections.

Significant decrease of central venous catheter-associated bloodstream infection rates in 38 German intensive care units

Significant decrease of central venous catheter-associated bloodstream infection rates in 38 German intensive care units

Ethanol lock therapy to treat tunnelled central venous catheter-associated blood stream infections: Results from a prospective trial

In order to assess the efficacy of 70% ethanol locks in addition to antibiotic therapy to treat tunnelled central venous catheter-associated bloodstream infections, a pilot study of 19 patients was performed prospectively using ethanol locks for 5 d in addition to antibiotic therapy to treat tunnelled central venous catheter-associated bacteraemia. 12 patients had mono-microbial infections and 7 had polymicrobial isolates. 17 of 19 patients completed ethanol lock therapy. 15 of 17 patients completing ethanol lock therapy had no recurrence of the original organism and retained their catheter for a median of 36 and an average of 47 d following initiation of ethanol lock therapy. These results demonstrate the safety and potential efficacy of this technique against a broad range of potentially virulent organisms. The intervention was acceptable to both staff and patients with no significant side-effects. These preliminary results from our prospective pilot study suggest that ethanol lock therapy is safe and easily integrated into clinical practice, and may have utility in treating central venous catheter-associated infections, avoiding removal of catheters in patients requiring long-term venous access.

The Impact of Hospital Practice on Central Venous Catheter—Associated Bloodstream Infection Rates at the Patient and Unit Level: A Multicenter Study

Little is known about factors driving variation in bloodstream infection (BSI) rates between institutions. The objectives of this study are to (1) identify patient, process of care, and hospital factors that influence intensive care unit (ICU)-level BSI rates and (2) compare those factors to individual risk factors identified in a cohort analysis. In this multicenter prospective observational study, the authors measured the process of care for 2970 randomly sampled central venous catheter insertions over 13 months. Medical, surgical, and medical/surgical ICUs of 37 domestic and 13 international hospitals. Significant correlates of unit-level BSI rates were percentage of female patients, patients on dialysis, ICU bed size, percentage of practitioners with low numbers of previous insertions, and percentage inserted by nurses. Patient-level analysis identified gender, age, posttransplant, postsurgery, and use of the line for parenteral nutrition. Factors that influence unit-to-unit variation may differ from factors identified in studies of individual patient risk.

Catheter-associated bloodstream infections in general medical patients outside the intensive care unit: a surveillance study.

To determine the incidence of central venous catheter (CVC)-associated bloodstream infection (CA-BSI) among patients admitted to general medical wards outside the intensive care unit (ICU). Prospective cohort study performed over a 13-month period, from April 1, 2002, through April 30, 2003. Four selected general medical wards at Barnes-Jewish Hospital, a 1,250-bed teaching hospital in Saint Louis, Missouri. PATIENTS; All patients admitted to 4 general medical wards. A total of 7,337 catheter-days were observed during 33,174 patient-days. The device utilization ratio (defined as the number of catheter-days divided by the number of patient-days) was 0.22 overall and was similar among the 4 wards (0.21, 0.25, 0.19, and 0.24). Forty-two episodes of CA-BSI were identified (rate, 5.7 infections per 1,000 catheter-days). Twenty-four (57%) of the 42 cases of CA-BSI were caused by gram-positive bacteria: 10 isolates (24%) were coagulase-negative staphylococci, 10 (24%) were Enterococcus species, and 3 (7%) were Staphylococcus aureus. Gram-negative bacteria caused 7 infections (17%). Five CA-BSIs (12%) were caused by Candida albicans, and 5 infections (12%) had a polymicrobial etiology. Thirty-five patients (83%) with CA-BSI had nontunneled CVCs in place. Non-ICU medical wards in the study hospital had device utilization rates that were considerably lower than those of medical ICUs, but CA-BSI rates were similar to CA-BSI rates in medical ICUs in the United States. Studies of catheter utilization and on CVC insertion and care should be performed on medical wards. CA-BSI prevention strategies that have been used in ICUs should be studied on medical wards.

Attributable Cost and Length of Stay for Patients With Central Venous Catheter—Associated Bloodstream Infection in Mexico City Intensive Care Units A Prospective, Matched Analysis

No information is available about the financial impact of central venous catheter (CVC)-associated bloodstream infection (BSI) in Mexico. To calculate the costs associated with BSI in intensive care units (ICUs) in Mexico City. An 18-month (June 2002 through November 2003), prospective, nested case-control study of patients with and patients without BSI. Adult ICUs in 3 hospitals in Mexico City. A total of 55 patients with BSI (case patients) and 55 patients without BSI (control patients) were compared with respect to hospital, type of ICU, year of hospital admission, length of ICU stay, sex, age, and mean severity of illness score. Information about the length of ICU stay was obtained prospectively during daily rounds. The daily cost of ICU stay was provided by the finance department of each hospital. The cost of antibiotics prescribed for BSI was provided by the hospitals' pharmacy departments. For case patients, the mean extra length of stay was 6.1 days, the mean extra cost of antibiotics was US dollars 598, the mean extra hospital cost was US dollars 11,591, and the attributable extra mortality was 20%. In this study, the duration of ICU stay for patients with central venous catheter-associated BSI was significantly longer than that for control patients, resulting in increased healthcare costs and a higher attributable mortality. These conclusions support the need to implement preventive measures for hospitalized patients with central venous catheters in Mexico.

Device-Associated Nosocomial Infections in 55 Intensive Care Units of 8 Developing Countries

Health care-associated infections from invasive medical devices in the intensive care unit (ICU) are a major threat to patient safety. Most published studies of ICU-acquired infections have come from industrialized western countries. In a Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance (NNIS) System report, the U.S. pooled mean rates of central venous catheter (CVC)-related bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections were 4.0 per 1000 CVC days, 5.4 per 1000 mechanical ventilator days, and 3.9 per Foley catheter days, respectively. To ascertain the incidence of device-associated infections in the ICUs of developing countries. Multicenter, prospective cohort surveillance of device-associated infection by using the CDC NNIS System definitions. 55 ICUs of 46 hospitals in Argentina, Brazil, Colombia, India, Mexico, Morocco, Peru, and Turkey that are members of the International Nosocomial Infection Control Consortium (INICC). Rates of device-associated infection per 100 patients and per 1000 device days. During 2002-2005, 21,069 patients who were hospitalized in ICUs for an aggregate 137,740 days acquired 3095 device-associated infections for an overall rate of 14.7% or 22.5 infections per 1000 ICU days. Ventilator-associated pneumonia posed the greatest risk (41% of all device-associated infections or 24.1 cases [range, 10.0 to 52.7 cases] per 1000 ventilator days), followed by CVC-related bloodstream infections (30% of all device-associated infections or 12.5 cases [range, 7.8 to 18.5 cases] per 1000 catheter days) and catheter-associated urinary tract infections (29% of all device-associated infections or 8.9 cases [range, 1.7 to 12.8 cases] per 1000 catheter days). Notably, 84% of Staphylococcus aureus infections were caused by methicillin-resistant strains, 51% of Enterobacteriaceae isolates were resistant to ceftriaxone, and 59% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones. The crude mortality rate for patients with device-associated infections ranged from 35.2% (for CVC-associated bloodstream infection) to 44.9% (for ventilator-associated pneumonia). These initial data are not adequate to represent any entire country, and likely variations in the efficiency of surveillance and institutional resources may have affected the rates that were detected. Device-associated infections in the ICUs of these developing countries pose greater threats to patient safety than in U.S. ICUs. Active infection control programs that perform surveillance of infection and implement guidelines for prevention can improve patient safety and must become a priority in every country.

Translating evidence into practice to prevent central venous catheter-associated bloodstream infections: A systems-based intervention

The central venous catheter (CVC) is a necessary, yet inherently risky, modern medical device. We aimed to carry out a systems-based intervention designed to facilitate the use of maximal sterile barrier precautions and the use of chlorhexidine for skin antisepsis during insertion of CVC. All patients in whom a CVC was inserted at a medical-surgical intensive care unit at a university-affiliated public hospital were included in a before-after trial. The standard CVC kit in routine use before the intervention included a small sterile drape (24" by 36") and 10% povidone-iodine for skin antisepsis. We special ordered a customized kit that, instead, included a large sterile drape (41" by 55") and 2% chlorhexidine gluconate in 70% isopropyl alcohol. Both the standard kit in use before the intervention and the customized kit included identical CVCs. Baseline data included the quarterly CVC-associated bloodstream infection (BSI) rates during the 15 months before the intervention. Comparison data included the quarterly CVC-associated BSI rates during the 15 months after we instituted exclusive use of the customized kit. The mean quarterly CVC-associated BSI rate decreased from a baseline of 11.3 per 1000 CVC-days before the intervention to 3.7 per 1000 CVC-days after the intervention (P < .01). Assuming direct costs of at least 10,000 dollars per CVC-associated BSI, we calculated resultant annualized savings to the hospital of approximately 350,000 dollars. Infection control interventions that rely on voluntary changes in human behavior, despite the best intentions of us all, are often unsuccessful. We have demonstrated that a systems-based intervention led to a sustained decrease in the CVC-associated BSI rate, thereby resulting in improved patient safety and decreased cost of care.

Risk Factors for Nosocomial Infection in a Neonatal Intensive Care Unit

To determine risk factors for nosocomial infection in a neonatal intensive care unit (NICU). A prospective, open cohort study. A 22-bed NICU. Neonates admitted to a single NICU during 1994-1998 were included in the study. Outcome variables included central venous catheter (CVC)-associated primary bloodstream infection (BSI), non-CVC-associated primary BSI, pneumonia, and overall nosocomial infection. Independent variables included birth weight, use of mechanical ventilation (MV), duration of MV, use of a CVC, duration of CVC use, duration of NICU stay, gestational age, congenital malformation, maximum (ie, worst) base excess, and maximum and minimum fraction of inspired oxygen (FIO(2)) for maintaining appropriate blood saturation levels during the first 12 hours after NICU admission. A total of 1051 neonates were admitted to the NICU. Overall, 358 NIs were diagnosed. Non-CVC-associated primary BSI was the most frequent nosocomial infection (in 195 neonates [54.5%]), followed by pneumonia (46 [12.8%]), and CVC-associated primary BSI (35 [9.8%]). The mortality rate was 16%. In the final logistic regression model, the following 5 risk factors were found to be predictive of nosocomial infection development: use of MV, longer duration of MV, longer duration of CVC use, longer duration of NICU stay, and low maximum appropriate Fio(2). Invasive device use and duration of use continue to greatly influence the development of nosocomial infection in NICUs. In our cohort, birth weight showed no influence on the development of nosocomial infection. Low maximum Fio(2) influenced the occurrence of overall nosocomial infection.

The Attributable Cost, and Length of Hospital Stay of Central Line Associated Blood Stream Infection in Intensive Care Units in Brazil. A Prospective, Matched Analysis

BACKGROUND/OBJECTIVES: Limited information is available on the financial impact of central venous catheter (CVC)-associated bloodstream infection (BSI) in Brazil. In order to calculate the cost of BSI in intensive care units, a 2 - year prospective nested case-control study was undertaken at three ICUS of one hospital in Brazil. METHODS: This study was performed in three adult intensive care units (ICUs) from 1 Brazilian hospital. 70 patients with BSI (cases) and 140 patients without BSI (controls) were matched for gender, age, severity illness score, medical or surgical stays, diabetes, hypertension, angina pectoris, COPD, renal impairment, abdominal surgery, trauma, and presence of previous infection. Patient's length of stay (LOS) in the ICU was obtained prospectively on daily rounds; the estimated cost of each ICU day was provided by the hospital's finance department; the average estimated cost of antibiotics prescribed for BSIs was provided by the hospital's pharmacy department. RESULTS: The mean LOS of patients with BSI was 30.58 days. The mean LOS of patients without BSI was 6.95. The mean extra LOS for cases (compared to the controls) was 23.63 days. The mean cost of patients with BSI was US$ 9,843.35. The mean cost of patients without BSI was US$ 1,937.18. The mean extra cost for cases (compared to the controls) was US$ 7,906.17. CONCLUSIONS: CVC-associated BSI results in significant patient morbidity and is associated with considerable increased utilization of health care resources. In the present study, patients with BSI had significant prolongation of hospitalization, and cost. The present study supports the need for routine utilization of preventative interventions to reduce CVC-associated BSIs as a means of reducing health care costs.

Device-Associated Infection Rate and Mortality in Intensive Care Units of 9 Colombian Hospitals: Findings of the International Nosocomial Infection Control Consortium

To perform active targeted prospective surveillance to measure device-associated infection (DAI) rates, attributable mortality due to DAI, and the microbiological and antibiotic resistance profiles of infecting pathogens at 10 intensive care units (ICUs) in 9 hospitals in Colombia, all of which are members of the International Infection Control Consortium. We conducted prospective surveillance of healthcare-associated infection in 9 hospitals by using the definitions of the US Centers for Disease Control and Prevention National Nosocomial Surveillance System (NNIS). DAI rates were calculated as the number of infections per 100 ICU patients and per 1,000 device-days. During the 3-year study, 2,172 patients hospitalized in an ICU for an aggregate duration of 14,603 days acquired 266 DAIs, for an overall DAI rate of 12.2%, or 18.2 DAIs per 1,000 patient-days. Central venous catheter (CVC)-related bloodstream infection (BSI) (47.4% of DAIs; 11.3 cases per 1,000 catheter-days) was the most common DAI, followed by ventilator-associated pneumonia (VAP) (32.3% of DAIs; 10.0 cases per 1,000 ventilator-days) and catheter-associated urinary tract infection (CAUTI) (20.3% of DAIs; 4.3 cases per 1,000 catheter-days). Overall, 65.4% of all Staphylococcus aureus infections were caused by methicillin-resistant strains; 40.0% of Enterobacteriaceae isolates were resistant to ceftriaxone and 28.3% were resistant to ceftazidime; and 40.0% of Pseudomonas aeruginosa isolates were resistant to fluoroquinolones, 50.0% were resistant to ceftazidime, 33.3% were resistant to piperacillin-tazobactam, and 19.0% were resistant to imipenem. The crude unadjusted attributable mortality was 16.9% among patients with VAP (relative risk [RR], 1.93; 95% confidence interval [CI], 1.24-3.00; P=.002); 18.5 among those with CVC-associated BSI (RR, 2.02; 95% CI, 1.42-2.87; P<.001); and 10.5% among those with CAUTI (RR, 1.58; 95% CI, 0.78-3.18; P=.19). The rates of DAI in the Colombian ICUs were lower than those published in some reports from other Latin American countries and were higher than those reported in US ICUs by the NNIS. These data show the need for more-effective infection control interventions in Colombia.

Device-Associated Infection Rates for Non–Intensive Care Unit Patients

Reference data from intensive care units (ICUs) are not applicable to non-ICU patients because of the differences in device use rates, length of stay, and severity of underlying diseases among the patient populations. In contrast to the huge amount of data available for ICU patients, appropriate surveillance data for non-ICU patients have been missing in Germany. To establish a new module ("DEVICE-KISS") of the German Nosocomial Infection Surveillance System for generating stratified reference data for non-ICU wards. Non-ICU patients from 42 German hospitals. Monthly patient-days, device-days and nosocomial infections (NIs) (using Centers for Disease Control and Prevention definitions) were counted. Device use rates were calculated, and NI rates were stratified by different medical specialities. From July 2002 through June 2004, among the 77 wards, there were a total of 536,955 patient-days and 74,188 device-days (for CVC-associated primary bloodstream infections, there were 181,401 patient-days and 8,317 central vascular catheter [CVC]-days in 29 wards; for urinary catheter-associated urinary tract infections, there were 445,536 patient-days and 65,871 urinary catheter-days in 65 wards) and 483 NIs (36 bloodstream infections and 447 urinary tract infections). The mean device use rates were 4.6 device-days per 100 patient-days for CVCs (29 wards) and 14.8 device-days per 100 patient-days for urinary catheters (65 wards), respectively. Mean device-associated NI rates were 4.3 infections per 1,000 CVC-days for CVC-associated bloodstream infections and 6.8 infections per 1,000 urinary catheter-days for catheter-associated urinary tract infections. DEVICE-KISS allows non-ICUs to recognize an outlier position with regard to NIs by providing well-founded reference data for non-ICU patients.

Antimicrobial-impregnated catheters for reducing nosocomial catheter-associated blood stream infections in the pediatric intensive care unit

AbstractObjective. Over 250,000 cases of central venous catheter-associated bloodstream infections (CVC-BSI) occur annually in the US leading to increased morbidity, costs, and mortality. While found to decrease the incidence of CVC-BSI in adult patients, no recommendations exist on the use of antimicrobial-impregnated catheters (AIC) in pediatric patients. This study was conducted to assess the effectiveness of AIC in reducing the incidence rates of CVC-BSI in a pediatric intensive care unit (PICU). Design. Retrospective cohort study. Setting. A 16-bed PICU in a tertiary children's hospital. Interventions and measurements. All PICU admissions requiring placement of a central venous catheter (CVC) from January 1999 through June 2003 were assessed for CVC-BSI, 21 months before, and 30 months after, introduction of AICs. Results. Of 5005 admissions during the 51-month study period, 1656 (33%) required CVC placement. Of these, 1441 (87%) admissions were initially assessed. Of these, 612 admissions (3057 CVC ...