Significant reduction of central line-associated bloodstream infection rates in a tertiary neonatal unit

A new perfusion system to reduce the burden of central-venous-line-associated bloodstream infections in neonates

BACKGROUND

Central-venous-line-associated bloodstream infection (CLABSI) is a significant cause of morbidity and mortality in preterm infants. As there is large variation in the reported effect of multi-modal preventive strategies, it could be relevant to propose new additional strategies.

AIM

To assess the impact of a new perfusion system on CLABSI rate.

METHODS

A before-and-after study was performed in infants born at <32 weeks of gestation or with birth weight <1500 g who required a multi-perfusion system connected to a central venous line. In the first 12-month period ('before'), the pre-existing perfusion system (multiple stopcocks) was used. An intervention period then occurred with implementation of a new perfusion closed system, without change in 'bundles' related to various aspects of central line care. During the second 12-month period ('after'), the CLABSI rate was assessed and compared with the pre-intervention period.

FINDINGS

In total, 313 infants were included in this study (before: N=163; after: N=150), and 46% had birth weight <1000 g. The change in perfusion system resulted in a significant decrease in CLABSI rate from 11.3 to 2.2 per 1000 catheter-days (P<0.001). The period was independently associated with an 88% reduction in the risk of CLABSI after implementation of the new perfusion system [odds ratio (OR) 0.12, 95% confidence interval (CI) 0.03-0.39; P<0.001]. The duration of central line use was also associated with CLABSIs (for each additional day: OR 1.05, 95% CI 1.02-1.07; P<0.001).

CONCLUSIONS

Implementation of the new perfusion system was feasible in a large neonatal unit, and reduced the CLABSI rate soon after implementation.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Routine scrubbing reduced central line associated bloodstream infection in NICU

BACKGROUND

The main aim of this study was to estimate the effectiveness of routine scrubbing by change of the incidence of central line-associated bloodstream infections (CLABSI).

METHODS

We surveyed cultures from the NICU environment in December 2017. We found that areas close to infants harbored more bacteria. We implemented routine scrubbing to control sites with the most bacteria starting from January 2018. We retrospectively reviewed and compared the data between the pre (2017) and post (2018) intervention periods.

RESULTS

A total of 916 infants were included; 10 CLABSI episodes were identified, 9 and 1 episodes in the pre- and postintervention periods, respectively. We found that the incidence of CLABSI decreased significantly among all admitted infants (P = .006) and also among very low birth weight infants (P = .085). The number of CLABSI cases per 1,000 central line days decreased from 1.89 in 2017 to 0.23 in 2018 (P = .018). The most common bacterial species found in the cultures established from the NICU environment were identical to the CLABSI-causing coagulase-negative Staphylococcus.

CONCLUSIONS

Routine scrubbing significantly reduced CLABSI in the NICU.

Risk factors for central venous catheter-related bloodstream infection in neonates

We found that low birth weight and type of central venous catheter were associated with catheter-related bloodstream infection in neonates. In the multivariate analysis, only central venous catheter type (dissected veins, tunneled catheters, and short-term nontunneled catheters) remained significantly associated with catheter-related bloodstream infection.

Chlorhexidine Gluconate Utilization for Infection Prevention in the NICU: A Survey of Current Practice

BACKGROUND

Central-line-associated bloodstream infection (CLABSI) contributes to significant morbidity and mortality in the neonatal intensive care unit (NICU). Disinfection of skin is part of bundled cares aimed at prevention of CLABSI. While considered an essential component of insertion and maintenance bundles, the optimal solution to disinfect neonatal skin remains controversial.

PURPOSE

The purpose of this project was to survey neonatal nurse practitioners and nursing leaders across NICUs regarding the current use of chlorhexidine gluconate (CHG) in term and preterm infants.

METHODS

This descriptive study involved the collection of survey data to determine NICU practices related to the use of CHG in their infant population. The sample was composed of nursing directors of NICUs and neonatal nurse practitioners who completed an electronic survey via a provided link.

FINDINGS/RESULTS

Chlorhexidine was reported to be used in 53 (82.81%) of the NICUs and was the primary agent used to prepare the skin for central vascular catheter insertion (53.23%) followed by povidone-iodine (45.16%), and 70% isopropyl alcohol (1.61%). Gestational age or birth weight restrictions for CHG use were reported in 43 (82.69%) NICUs. Trends in the data demonstrated nursing's role in using CHG in the NICU. Adverse events reported from CHG included burns, redness, dermatitis, and other irritations. Concerns included risk of absorption, burns, skin irritation, lack of evidence, and overall safety.

IMPLICATIONS FOR PRACTICE

Systematic monitoring by nurse leaders is needed to identify evidence related to skin disinfection and CHG in neonates. Targeted education for nursing staff related to directed to developmental maturation of the skin, safe use of CHG, review of best evidence, rationale for usage of CHG, and potential iatrogenic effects is recommended.

IMPLICATIONS FOR RESEARCH

Research is needed to evaluate the impact of educational offerings and surveillance for adverse events on CLABSI rates.

Length of stay, cost, and mortality of healthcare-acquired bloodstream infections in children and neonates: A systematic review and meta-analysis

OBJECTIVE

To estimate the attributable mortality, length of stay (LOS), and healthcare cost of pediatric and neonatal healthcare-acquired bloodstream infections (HA-BSIs).

DESIGN

A systematic review and meta-analysis.

METHODS

A systematic search (January 2000-September 2018) was conducted in PubMed, Cochrane, and CINAHL databases. Reference lists of selected articles were screened to identify additional studies. Case-control or cohort studies were eligible for inclusion when full text was available in English and data for at least 1 of the following criteria were provided: attributable or excess LOS, healthcare cost, or mortality rate due to HA-BSI. Study quality was evaluated using the Critical Appraisal Skills Programme Tool (CASP). Study selection and quality assessment were conducted by 2 independent researchers, and a third researcher was consulted to resolve any disagreements. Fixed- or random-effect models, as appropriate, were used to synthesize data. Heterogeneity and publication bias were evaluated.

RESULTS

In total, 21 studies were included in the systematic review and 13 studies were included in the meta-analysis. Attributable mean LOS ranged between 4 and 27.8 days; healthcare cost ranged between $1,642.16 and $160,804 (2019 USD) per patient with HA-BSI; and mortality rate ranged between 1.43% and 24%. The pooled mean attributable hospital LOS was 16.91 days (95% confidence interval [CI], 13.70-20.11) and the pooled attributable mortality rate was 8% (95% CI, 6-9). A meta-analysis was not conducted for cost due to lack of eligible studies.

CONCLUSIONS

Pediatric HA-BSIs have a significant impact on mortality, LOS, and healthcare cost, further highlighting the need for implementation of HA-BSI prevention strategies.

Impact of Continuous Education and Training in Reduction of Central Line-associated Bloodstream Infection in Neurointensive Care Unit

Background

Patients in the neurointensive care unit have high utilization of devices, thereby increased chance of getting device-associated infection (DAI). Central line-associated bloodstream infection (CLABSI) remains one of the most important DAI. Education remains an important part of the hospital infection control and improves the infection-control practices.

Materials and methods

To evaluate the effectiveness of a quality initiative in reducing incidence of CLABSI, a prospective study (January 2017–December 2018) was done estimating CLABSI incidence before and after the intervention. Continuous teaching and training for hand hygiene practice and central-line catheter hub care were used as the tool for this study.

Results

The quality improvement (QI) initiative achieved a 48% reduction in the CLABSI rate from the baseline rate of 8.7 to 4.5 per 1000 catheter days. The overall mortality showed a reduction from 1.5 to 0.05% during the post-intervention period. There was a significant improvement in compliance with the hand hygiene practice and catheter hub care in the post-intervention period.

Discussion and conclusion

This study demonstrates adherence to hand hygiene and catheter hub care with continuous teaching, training, and supervision was highly effective in reducing the CLABSI rate.

Clinical significance

Central line-associated bloodstream infection is one of the most important DAI causing significant morbidity and mortality in critically ill patient. Our findings support that continuous educational intervention of hand hygiene with and training on the catheter hub care are two most important preventive measures in the reduction of CLABSI incidence.

How to cite this article

Mohapatra S, Kapil A, Suri A, Pandia MP, Bhatia R, Borkar S, et al. Impact of Continuous Education and Training in Reduction of Central Line-associated Bloodstream Infection in Neurointensive Care Unit. Indian J Crit Care Med 2020;24(6):414–417.

Attributable length of stay and cost for pediatric and neonatal central line-associated bloodstream infections in Greece

BACKGROUND AND OBJECTIVE

Central line-associated bloodstream infections (CLABSIs) are the most frequent pediatric hospital-acquired infections and are associated with significant morbidity and healthcare costs. The aim of our study was to determine the attributable length of stay (LOS) and cost for CLABSIs in pediatric patients in Greece, for which there is currently a paucity of data.

METHODS

A retrospective matched-cohort study was performed in two tertiary pediatric hospitals. Inpatients with a central line in neonatal and pediatric intensive care units, hematology/oncology units, and a bone marrow transplantation unit between June 2012 and June 2015 were eligible. Patients with confirmed CLABSI were enrolled on the day of the event and were matched (1:1) to patients without CLABSI (non-CLABSIs) by hospital, unit, and LOS prior to study enrollment (188 children enrolled, 94 CLABSIs). The primary outcome measure was the attributable LOS and cost. Baseline demographic and clinical characteristics were recorded. Attributable outcomes were calculated as the differences in estimates of outcomes between CLABSIs and non-CLABSIs, after adjustment for propensity score and potential confounders.

RESULTS

There were no differences between the two groups regarding their baseline characteristics. After adjustment for age, gender, matching characteristics, central line management after study enrollment, and propensity score, the mean LOS and cost were 57.5days and €31,302 in CLABSIs versus 36.6days and €17,788 in non-CLABSIs. Overall, a CLABSI was associated with a mean (95% CI) adjusted attributable LOS and cost of 21days (7.3-34.8) and €13,727 (5,758-21,695), respectively. No significant difference was detected in LOS and cost by hospitalization unit.

CONCLUSIONS

CLABSIs were found to impose a significant economic burden in Greece, a finding that highlights the importance of implementing CLABSI prevention strategies.

Preventive bundles to reduce catheter-associated bloodstream infections in neonatal intensive care

This systematic survey includes a total of 27 studies published between 2002 and 2016 on the benefit of preventive bundles for the prevention of central-line associated bloodstream infections (CLABSI) in neonatal intensive care. These studies are mainly cohort studies or studies analyzing an interrupted time series before and after intervention. The studies showed heterogeneity in terms of endpoint definitions (CLABSI), details of the implemented measures, and evidence of a publication bias favoring the use of of preventive bundles. The cumulative analysis showed a statistically and clinically significant benefit of preventive bundles to avoid CLABSI in neonatal intensive care.

Variation in infection prevention practices for peripherally inserted central venous catheters: A survey of neonatal units in England and Wales

Background

There is uncertainty about the variation in infection prevention practices for central venous catheters (CVC) in neonatal units (NNUs) and how practices relate to national guidance.

Aim

To evaluate evidence supporting infection prevention practices for CVCs recommended in national guidelines and to compare with reported practices for peripherally inserted central catheters (PICC), a type of CVC widely used in NNUs.

Design

We searched national guidelines for neonates and children to identify infection prevention practices for CVCs and conducted an overview of studies to determine the quality of evidence underpinning recommendations. We surveyed 134 NNUs in England and Wales to ascertain reported practice.

Results

We found low quality evidence supporting CVC care bundles and use of 2% alcoholic chlorhexidine to decontaminate catheter ports and skin before insertion. Moderate quality evidence supported recommendations against routinely replacing CVCs and against chlorhexidine-impregnated dressings. 90% (44/49) of NICUs and 40% (34/85) of LNUs responded. 66% (48/73) of NNUs reported using CVC care bundles for insertion; 62% (45/73) used bundles for maintenance. 63% (32/51) of those using bundles reported monitoring adherence. 85% (61/72) of NNUs did not routinely replace PICCs and 89% (63/71) did not use chlorhexidine-impregnated dressings. Antiseptic use varied with alcoholic 2% chlorhexidine used for skin preparation in 33% (23/71) of NNUs and for catheter ports in 52% (37/71).

Conclusions

Lack of consistency across NNUs in antiseptic use and low rates of reported CVC care bundle use may reflect the low quality of evidence of the effectiveness and safety of these interventions in NNUs. Clinical trials are needed to quantify benefits and harms of infection prevention practices in NNUs.

Care bundles to reduce central line-associated bloodstream infections in the neonatal unit: a systematic review and meta-analysis

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are associated with increased mortality, prolonged hospitalisation and increased healthcare costs. Care bundles have reduced CLABSIs in adult intensive care units (ICUs) but replication in paediatric ICUs has had inconsistent outcomes. A systematic review was performed to assess the evidence for the efficacy of care bundles in reducing CLABSIs in the neonatal unit (NNU).

METHODS

MEDLINE, CINAHL and EMBASE were searched from January 2010 up to January 2017. The Cochrane Library, Web of Science, Zetoc and Ethos were searched for additional studies. Randomised controlled trials (RCTs), quasi-experimental and observational studies were eligible. The primary outcome measure was CLABSI rates per 1000 central line, or patient, days. A meta-analysis was performed using random effects modelling.

RESULTS

Twenty-four studies were eligible for inclusion: six were performed in Europe, 12 were in North America, two in Australia and four were in low/middle-income countries. Five were observational studies and 19 were before and after quality improvement studies. No RCTs were found. Meta-analysis revealed a statistically significant reduction in CLABSIs following the introduction of care bundles (rate ratio=0.40 (CI 0.31 to 0.51), p<0.00001), which equates to a 60% reduction in CLABSI rate.

CONCLUSION

There is a substantial body of quasi-experimental evidence to suggest that care bundles may reduce CLABSI rates in the NNU, though it is not clear which bundle elements are effective in specific settings. Future research should focus on determining what processes promote the effective implementation of infection prevention recommendations, and which elements represent essential components of such care bundles.

Establishing nationally representative central line-associated bloodstream infection surveillance data for paediatric patients in Greece

BACKGROUND

Healthcare-associated infections (HCAIs) are associated with increased morbidity and mortality and with excess costs. Central line-associated bloodstream infections (CLABSIs) are the most common HCAIs in neonates and children.

AIM

To establish national benchmark data for rates of CLABSI in neonatal and paediatric intensive care units (NICUs and PICUs) and paediatric oncology units (ONCs).

METHODS

Active surveillance for CLABSI was conducted from June 2016 to February 2017. A collaborative of 14 NICUs, four PICUs, and six ONCs participated in the programme. Surveillance definitions of central line (CL), central line utilization (CLU) ratio, CLABSI event, and CLABSI rate were based on the Centers for Disease Control and Prevention's 2014 National Healthcare Safety Network criteria. Medical records were assessed daily for calculating CL-days, patient-days, and susceptibility of isolated organisms.

FINDINGS

A total of 111 CLABSI episodes were recorded. The overall mean CLABSI rate was 4.41 infections per 1000 CL-days, and the CLU ratio was 0.31. CLABSI rates were 6.02 in NICUs, 6.09 in PICUs, and 2.78 per 1000 CL-days in ONCs. A total of 123 pathogens were isolated. The most common pathogens were Enterobacteriaceae (36%), followed by Gram-positive cocci (29%), non-fermenting Gram-negative bacteria (16%), and fungi (16%). Overall, 37% of Gram-negative pathogens were resistant to third-generation cephalosporins and 37% to carbapenems.

CONCLUSION

Nationally representative CLABSI rates were determined for paediatric patients. These data could be used to benchmark and serve as baseline data for the design and evaluation of infection control and antimicrobial stewardship interventions.

Clinical usefulness of catheter-drawn blood samples and catheter tip cultures for the diagnosis of catheter-related bloodstream infections in neonatology: A systematic review

OBJECTIVES

Neonatal sepsis is the most frequent health care-associated infection in neonatal units. This study aimed to analyze articles on the clinical usefulness of catheter-drawn blood samples and catheter tip cultures for the diagnosis of intravascular catheter-related bloodstream infection (CRBSI) in neonates.

METHODS

A systematic search was performed for studies published from 1987-2017, without language restriction. Observational studies carried out in neonates with CRBSI diagnosed using catheter-drawn blood samples or catheter tip cultures were included.

RESULTS

A total of 412 articles were identified in the databases and 10 articles were included. The 7 studies that evaluated central venous catheter tip cultures and cultures of catheter fragments presented sensitivities ranging from 58.5%-100% and specificities ranging from 60%-95.7%. Three studies that evaluated catheter-drawn blood cultures, paired with peripheral blood cultures, reported sensitivity and specificity of 94% and 71% when evaluated for the differential time to positivity. When quantitative evaluation was performed, the sensitivity and specificity were 80% and 99.4%.

CONCLUSIONS

Most of the studies analyzed cultures from the central venous catheter tip and catheter fragments for the diagnosis of CRBSI in neonatal populations. The results of this review suggest that the analysis of the catheter-drawn blood samples and catheter tip cultures, paired with peripheral blood cultures, are efficient methods for the diagnosis of CRBSI in neonates.

Central and peripheral line-associated bloodstream infections in Australian neonatal and paediatric intensive care units: findings from a comprehensive Victorian surveillance network, 2008-2016

BACKGROUND

Healthcare-associated infections in neonatal and paediatric populations are associated with poorer outcomes and healthcare costs, and surveillance is a necessary component of prevention programmes.

AIM

To evaluate burden of illness, aetiology, and time-trends for central and peripheral line-associated bloodstream infection (CLABSI and PLABSI) in Australian neonatal and paediatric intensive care units (ICUs) between July 1^st, 2008 and December 31^st, 2016.

METHODS

Using National Healthcare Safety Network methods, surveillance in neonatal and paediatric units was performed by hospitals participating in the Victorian Healthcare Associated Infection Surveillance System. Mixed effects Poisson regression was used to model infections over time.

FINDINGS

Overall, 82 paediatric CLABSI events were reported during 37,125 CVC-days (2.21 per 1000 CVC-days), 203 neonatal CLABSI events were reported during 92,169 CVC-days (2.20 per 1000 CVC-days), and 95 neonatal PLABSI events were reported during 142,240 peripheral line-days (0.67 per 1000 peripheral line-days). Over time, a significant decrease in quarterly risk for neonatal CLABSI events was observed (risk ratio (RR): 0.98; 95% confidence interval: 0.97-0.99; P = 0.023) and this reduction was significant for the 751-1000 g birth weight cohort (RR: 0.97; P = 0.015). Most frequently, coagulase-negative Staphylococcus spp. (24.2%) and Staphylococcus aureus (16.1%) were responsible for CLABSI events. A significant reduction in Gram-negative neonatal infections was observed (annual RR: 0.85; P < 0.001).

CONCLUSION

CLABSI rates in neonatal and paediatric ICUs in our region are low, and neonatal infections have significantly diminished over time. Evaluation of infection prevention programmes is required to determine whether specific strategies can be implemented to further reduce infection risk.

Neonatal methicillin-resistant Staphylococcus aureus colonization and infection

INTRODUCTION

Methicillin-resistant Staphylococcus aureus (MRSA) is a common etiological agent of a life-threatening infection in neonatal intensive care units (NICUs). Neonates with very low birth weight and patients with serious diseases are more likely to be exposed to invasive procedures which make them at a high risk of MRSA colonization and infection. Since MRSA colonization is a risk factor for MRSA infection, prevention of MRSA transmission is an important issue in NICUs. NICUs in Japan practice standard contact precautions and active surveillance cultures (ASC) to prevent MRSA transmission. In this report, we analyzed the clinical characteristics of MRSA colonization and infection between January 2010 and December 2015 in our perinatal care center.

METHODS

We conducted retrospective analysis of 1716 neonates hospitalized in our perinatal care center.

RESULTS

120 cases had MRSA colonization (6.99%) and among them 33 neonates were infected. The duration of stay (P≤0.001) and the birth weight (P≤0.001) showed statistically significant differences between MRSA-colonized neonates and non-MRSA-colonized neonates. The number of central venous catheterization showed statistically significant differences (P = 0.001) and the number of digestive system diseases showed marginally significant differences (P = 0.072) between MRSA-colonized non-infected neonates and MRSA-infected neonates.

CONCLUSIONS

As previous reports have shown, we present that the neonates with central venous catheterization were more likely to be infected with MRSA. We also need to pay attention to neonates with digestive system diseases, showing signs of infection, because they may be potentially infected with MRSA.