Central venous catheter-related bacteraemia in critically ill neonates: risk factors and impact of a prevention programme

Adult 'PICC' Device May be Used as a Tunnelled Central Venous Catheter in Children

Purpose

Central venous access in children, in particular small children and infants, is challenging. We have developed a technique employing adult peripherally inserted central venous catheters (PICCs) as tunnelled central venous catheters (TCVCs) in children. The principal advantage of this novel technique is that the removal technique is less complex than that of conventional cuffed TCVCs. The catheter can be removed simply by being pulled out and does not require general anaesthesia. The purpose of this study is to determine the success, safety and utility of this technique and to identify the rate of late complications. We describe the 6-year experience in our unit.

Materials and Methods

Electronic and paper medical records were reviewed for consecutive paediatric patients who had a PICC device inserted as a TCVC over a 6-year period (September 2009 through July 2015). The following data were recorded—patient demographics, setting for PICC as TCVC insertion, use of ultrasound and fluoroscopy, PICC device type, early or late complications and date of and reason for removal.

Results

Twenty-one PICCs were inserted as TCVCs in 19 children, all aged less than 10 years. Mean patient age at the time of placement was 3.7 years. Average patient weight was 15.7 kg. All insertions were successful with no significant immediate complications recorded. The most common indication for insertion in our patient sample was pseudo-obstruction secondary to gastrointestinal dysmotility disorder (24%), with cystic fibrosis infective exacerbation being the second most frequent diagnosis (14%). Suspected catheter-related infection led to early device removal in one case (4.8%). Inadvertent dislodgement occurred in one case (4.8%). Nineteen of the 21 devices (90.4%) lasted for the total intended duration of use.

Conclusion

Using a PICC device as a TCVC in small children appears to be a safe technique, with an acceptable complication profile.

Improving central line maintenance to reduce central line-associated bloodstream infections

OBJECTIVE

A human factors engineering-based intervention aimed at the modification of task behavior to increase adherence to best practices and the reduction of central line-associated bloodstream infections (CLABSI). The hypothesis was tested that a central line maintenance kit would improve adherence and reduce CLABSI compared with a standard, nonkit-based method of performing central line maintenance.

DESIGN

The study design was a 29-month prospective, interventional, nonrandomized, observational, and clinical research study using a pre-post implementation assessment.

SETTING

The study was conducted at a tertiary hospital in the southwestern United States, with participants recruited from a total of 6 patient units (including intensive care units and general wards).

PARTICIPANTS

A total of 95 nurses and 151 patients volunteered to participate in the study.

INTERVENTION

A central line maintenance kit was developed that incorporated human factors engineering design principles. This kit was implemented hospitalwide during the clinical study to assess the intervention's influence on protocol adherence and clinical outcomes compared with a preimplementation control condition (no kit use).

RESULTS

The results of this clinical observations study suggest that a human factors engineering-based kit improved adherence to best practices during central line maintenance. In addition, the number of CLABSIs was significantly reduced during the postimplementation period.

CONCLUSIONS

The application of human factors engineering design principles in the development of medical kits can improve protocol adherence and clinical outcomes.

Prevention of neonatal late-onset sepsis: a randomised controlled trial

BACKGROUND

Late-onset sepsis (LOS), defined as sepsis occurring after 48 h of age causes substantial mortality and morbidity in very low birth weight infants. Risk factors for LOS include immaturity, intravascular catheters, mechanical ventilation, and prolonged parenteral nutrition (PN). Little attention has been paid to studying the effects of PN administration methods. The aim of the study was to compare a bundle of measures for PN line management incorporating a strict aseptic technique with standard line management on LOS in very low birth weight infants.

METHODS

Infants <1500 g birth weight who required PN were randomised to either a bundle of a strict aseptic technique for line management together with single use intravascular catheter for PN or a standard technique. The primary outcome was the incidence of LOS in the first 28 days of life. Secondary outcomes were mortality, neonatal morbidities and developmental outcome at 12 months of age.

RESULTS

There were 126 infants in the aseptic technique group and 123 in the standard technique group. Forty (31.8%) infants in the aseptic technique group and 36 (29.3%) in the standard technique group had an episode of sepsis (p = 0.77). This corresponds to incidences of 15.8 and 14.2 episodes of sepsis per 1000 patient days respectively. Subgroup analyses for infants <1000 g also revealed no difference in the rate of sepsis between the intervention and control groups. (p = 0.43). There were no significant differences in secondary outcomes and development between the groups.

CONCLUSION

A bundle of measures including strict aseptic technique for parenteral nutrition line management did not result in a reduction in LOS when compared to a standard technique. There is no evidence to recommend this as routine practice.

TRIAL REGISTRATION

Interdisciplinary Maternal Perinatal Australasian Collaborative Trials (IMPACT) Network, TRN registration number: PT0363. Date: 06/03/2001; Australian New Zealand Clinical Trials Registry (ANZCTR), TRN registration number: ACTRN12617000455369 . Date: 28/03/2017 (retrospectively registered).

The effect of hospital infection control policy on the prevalence of surgical site infection in a tertiary hospital in South-South Nigeria

BACKGROUND

Surgical site infections (SSIs) are a significant cause of morbidity, emotional stress and financial cost to the affected patients and health care institutions; and infection control policy has been shown to reduce the burden of SSIs in several health care institutions. This study assessed the effects of the implementation of the policy on the prevalence of SSI in the University of Port Harcourt Teaching Hospital, Nigeria.

PATIENTS AND METHODS

A review of the records of all Caesarean sections carried out in the hospital, before and 2 years after the implementation of the infection control policy was conducted. Data collected include the number and characteristics of the patients that had Caesarean section in the hospital during the period and those that developed SSI while on admission.

RESULTS

The proportion of patients with SSI decreased from 13.33% to 10.34%, 2 years after the implementation of the policy (P-value = 0.18). The implementation of the policy did not also result in any statistically significant change in the nature of the wound infection (P-value = 0.230), in the schedule of the operations (P-value = 0.93) and in the other predisposing factors of the infections (P-value = 0.72); except for the significant decrease in the infection rate among the un-booked patients (P-value = 0.032).

CONCLUSION

The implementation of the policy led to a small decrease in SSI, due to the non-implementation of some important aspects of the WHO policy. The introduction of surveillance activities, continuous practice reinforcing communications and environmental sanitation are recommended to further decrease the prevalence of SSI in the hospital.

A Quality Improvement Initiative to Reduce Central Line–Associated Bloodstream Infections in a Neonatal Intensive Care Unit

Objective.

To reduce the rate of late-onset sepsis in a neonatal intensive care unit (NICU) by decreasing the rate of central line–associated bloodstream infection (CLABSI).

Methods.

We conducted a quasi-experimental study of an educational intervention designed to improve the quality of clinical practice in an NICU. Participants included all NICU patients with a central venous catheter (CVC). Data were collected during the period from July 1, 2005, to June 30, 2007, to document existing CLABSI rates and CVC-related practices. A multidisciplinary quality improvement committee was established to review these and published data and to create guidelines for CVC placement and management. Educational efforts were conducted to implement these practices. Postintervention CLABSI rates were collected during the period from January 1, 2008, through March 31, 2009, and compared with preintervention data and with benchmark data from the National Healthcare Safety Network (NHSN).

Results.

The rate of CLABSI in the NICU decreased from 8.40 to 1.28 cases per 1,000 central line–days (adjusted rate ratio, 0.19 [95% confidence interval, 0.08–0.45]). This rate was lower than the NHSN benchmark rate for level III NICUs. The overall rate of late-onset sepsis was reduced from 5.84 to 1.42 cases per 1,000 patient-days (rate difference, −4.42 cases per 1,000 patient-days [95% confidence interval, −5.55 to −3.30 cases per 1,000 patient-days]).

Conclusions.

It is possible to reduce the rate of CLABSI, and therefore the rate of late-onset sepsis, by establishing and adhering to evidence-based guidelines. Sustainability depends on continued data surveillance, knowledge of medical and nursing literature, and timely feedback to the staff. The techniques established are applicable to other populations and areas of inpatient care.

Use of Central Venous Catheter and Peripheral Venous Catheter as Risk Factors for Nosocomial Bloodstream Infection in Very-Low-Birth-Weight Infants

Objective.

To describe the relationship between the use of central and peripheral venous catheters and the risk of nosocomial, primary, laboratory-confirmed bloodstream infection (BSI) for neonates with a birth weight less than 1,500 g (very-low-birth-weight [VLBW] infants).

Methods.

Cox proportional hazard regression analysis with time-dependent variable was used to determine the risk factors for the occurrence of BSI in a cohort of VLBW infants. We analyzed previously collected surveillance data from the German national nosocomial surveillance system for VLBW infants. All VLBW infants in 22 participating neonatal departments who had a complete daily record of patient information were included.

Results.

Of 2,126 VLBW infants, 261 (12.3%) developed a BSI. The incidence density for BSI was 3.3 per 1,000 patient-days. The multivariate analysis identified the following significant independent risk factors for BSI: lower birth weight (hazard ratio [HR], 1.1–2.2), vaginal delivery (HR, 1.5), central venous catheter use (HR, 6.2) or peripheral venous catheter use (HR, 6.0) within 2 days before developing BSI, and the individual departments (HR, 0.0–4.6).

Conclusions.

After adjusting for other risk factors, use of peripheral venous catheter and use of central venous catheter were significantly related to occurrence of BSI in VLBW infants.

Healthcare associated infections (HAI) perspectives

Healthcare associated infections (HAI) are among the major complications of modern medical therapy. The most important HAIs are those related to invasive devices: central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated pneumonia (VAP) as well as surgical site infections (SSI). HAIs are associated with significant mortality, morbidities and increasing healthcare cost. The cited case-fatality rate ranges from 2.3% to 14.4% depending on the type of infection. In this mini-review, we shed light on these aspects as well as drivers to decrease HAIs.

Interventions to improve professional adherence to guidelines for prevention of device-related infections

BACKGROUND

Healthcare-associated infections (HAIs) are a major threat to patient safety, and are associated with mortality rates varying from 5% to 35%. Important risk factors associated with HAIs are the use of invasive medical devices (e.g. central lines, urinary catheters and mechanical ventilators), and poor staff adherence to infection prevention practices during insertion and care for the devices when in place. There are specific risk profiles for each device, but in general, the breakdown of aseptic technique during insertion and care for the device, as well as the duration of device use, are important factors for the development of these serious and costly infections.

OBJECTIVES

To assess the effectiveness of different interventions, alone or in combination, which target healthcare professionals or healthcare organisations to improve professional adherence to infection control guidelines on device-related infection rates and measures of adherence.

SEARCH METHODS

We searched the following electronic databases for primary studies up to June 2012: the Cochrane Effective Paractice and Organisation of Care (EPOC) Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. We searched reference lists and contacted authors of included studies. We also searched the Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) studies and interrupted time series (ITS) studies that complied with the Cochrane EPOC Group methodological criteria, and that evaluated interventions to improve professional adherence to guidelines for the prevention of device-related infections.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias of each included study using the Cochrane EPOC 'Risk of bias' tool. We contacted authors of original papers to obtain missing information.

MAIN RESULTS

We included 13 studies: one cluster randomised controlled trial (CRCT) and 12 ITS studies, involving 40 hospitals, 51 intensive care units (ICUs), 27 wards, and more than 3504 patients and 1406 healthcare professionals. Six of the included studies targeted adherence to guidelines to prevent central line-associated blood stream infections (CLABSIs); another six studies targeted adherence to guidelines to prevent ventilator-associated pneumonia (VAP), and one study focused on interventions to improve urinary catheter practices. We judged all included studies to be at moderate or high risk of bias.The largest median effect on rates of VAP was found at nine months follow-up with a decrease of 7.36 (-10.82 to 3.14) cases per 1000 ventilator days (five studies and 15 sites). The one included cluster randomised controlled trial (CRCT) observed, improved urinary catheter practices five weeks after the intervention (absolute difference 12.2 percentage points), however, the statistical significance of this is unknown given a unit of analysis error. It is worth noting that N = 6 interventions that did result in significantly decreased infection rates involved more than one active intervention, which in some cases, was repeatedly administered over time, and further, that one intervention involving specialised oral care personnel showed the largest step change (-22.9 cases per 1000 ventilator days (standard error (SE) 4.0), and also the largest slope change (-6.45 cases per 1000 ventilator days (SE 1.42, P = 0.002)) among the included studies. We attempted to combine the results for studies targeting the same indwelling medical device (central line catheters or mechanical ventilators) and reporting the same outcomes (CLABSI and VAP rate) in two separate meta-analyses, but due to very high statistical heterogeneity among included studies (I(2) up to 97%), we did not retain these analyses. Six of the included studies reported post-intervention adherence scores ranging from 14% to 98%. The effect on rates of infection were mixed and the effect sizes were small, with the largest median effect for the change in level (interquartile range (IQR)) for the six CLABSI studies being observed at three months follow-up was a decrease of 0.6 (-2.74 to 0.28) cases per 1000 central line days (six studies and 36 sites). This change was not sustained over longer follow-up times.

AUTHORS' CONCLUSIONS

The low to very low quality of the evidence of studies included in this review provides insufficient evidence to determine with certainty which interventions are most effective in changing professional behaviour and in what contexts. However, interventions that may be worth further study are educational interventions involving more than one active element and that are repeatedly administered over time, and interventions employing specialised personnel, who are focused on an aspect of care that is supported by evidence e.g. dentists/dental auxiliaries performing oral care for VAP prevention.

An evidence-based catheter bundle alters central venous catheter strategy in newborn infants

OBJECTIVE

To assess whether introduction of an evidence-based percutaneously inserted central catheter (PICC) care bundle reduced the risk of central line-associated bloodstream infection (CLABSI), thus altering the comparative risk of CLABSI in infants.

STUDY DESIGN

This retrospective cohort study included all infants for whom an umbilical venous catheter (UVC) was placed as part of routine care between Jan 1, 2006, and Dec 31, 2009, a period during which standardized PICC insertion and care bundles were introduced. Duration of UVC use was divided in ≤ 7 days and >7 days.

RESULTS

Infants in the ≤ 7 days UVC group had 1.0 CLABSI/1000 catheter days, and infants in the >7 days UVC group had 4.0 CLABSI/1000 catheter days (P < .001). Controlling for birth weight, gestational age, and antibiotic use, the >7 days UVC group had a greater risk of CLABSI (OR, 5.48) than the ≤ 7 days UVC group. CLABSI rate increased more rapidly in UVC than PICC with increasing duration of catheter rose.

CONCLUSIONS

Replacement of a UVC with a PICC when central venous access is needed after 7 days of age may reduce CLABSI.

Antibiotic susceptibility of coagulase-negative staphylococci isolated from very low birth weight babies: comprehensive comparisons of bacteria at different stages of biofilm formation

Background

Coagulase-negative staphylococci are major causes of bloodstream infections in very low birth weight babies cared for in Neonatal Intensive Care Units. The virulence of these bacteria is mainly due to their ability to form biofilms on indwelling medical devices. Biofilm-related infections often fail to respond to antibiotic chemotherapy guided by conventional antibiotic susceptibility tests.

Methods

Coagulase-negative staphylococcal blood culture isolates were grown in different phases relevant to biofilm formation: planktonic cells at mid-log phase, planktonic cells at stationary phase, adherent monolayers and mature biofilms and their susceptibilities to conventional antibiotics were assessed. The effects of oxacillin, gentamicin, and vancomycin on preformed biofilms, at the highest achievable serum concentrations were examined. Epifluorescence microscopy and confocal laser scanning microscopy in combination with bacterial viability staining and polysaccharide staining were used to confirm the stimulatory effects of antibiotics on biofilms.

Results

Most coagulase-negative staphylococcal clinical isolates were resistant to penicillin G (100%), gentamicin (83.3%) and oxacillin (91.7%) and susceptible to vancomycin (100%), ciprofloxacin (100%), and rifampicin (79.2%). Bacteria grown as adherent monolayers showed similar susceptibilities to their planktonic counterparts at mid-log phase. Isolates in a biofilm growth mode were more resistant to antibiotics than both planktonic cultures at mid-log phase and adherent monolayers; however they were equally resistant or less resistant than planktonic cells at stationary phase. Moreover, for some cell-wall active antibiotics, concentrations higher than conventional MICs were required to prevent the establishment of planktonic cultures from biofilms. Finally, the biofilm-growth of two S. capitis isolates could be enhanced by oxacillin at the highest achievable serum concentration.

Conclusion

We conclude that the resistance of coagulase-negative staphylococci to multiple antibiotics initially remain similar when the bacteria shift from a planktonic growth mode into an early attached mode, then increase significantly as the adherent mode further develops. Furthermore, preformed biofilms of some CoNS are enhanced by oxacillin in a dose-dependent manner.

Is an increased dwell time of a peripherally inserted catheter associated with an increased risk of bloodstream infection in infants?

OBJECTIVE

To estimate the risk of bloodstream infection associated with catheter dwell time in infants.

DESIGN

Retrospective study.

SETTING

Duke University Medical Center neonatal intensive care unit, an academic, level 3 nursery in Durham, North Carolina.

METHODS

A case of catheter-associated bloodstream infection was defined as one that occurred in an infant whose culture-positive blood sample was collected more than 24 hours after catheter insertion or within 72 hours after catheter removal. We used multivariable logistic regression to control for the catheter's position and dwell time as well as the infant's sex, gestational age, age at time of catheter insertion, birth weight, and weight at time of catheter insertion.

RESULTS

We identified 135 cases of catheter-associated bloodstream infection. The mean catheter dwell time was 12.2 days (range, 0-113 days), and the mean time to bloodstream infection was 10.8 days (range, 1-57 days). An increase in catheter dwell time was associated with a lower risk of bloodstream infection (odds ratio, 0.975 [95% confidence interval, 0.954-0.996]; P = .02).

CONCLUSION

No increased risk of catheter-associated bloodstream infection was observed with increased catheter dwell time. This may have been due to the infant's improved nutrition, decreased need for other invasive devices, and maturing skin and immune system as catheter dwell time increased.

A 10-year prospective surveillance of nosocomial infections in neonatal intensive care units

BACKGROUND

We report on nosocomial infections (NIs), causative organisms, and antimicrobial susceptibility patterns in neonates who were admitted to neonatal intensive care units (NICUs), and assess the performance of birth weight (BW) as a variable for risk-stratified NI rate reporting.

METHODS

A prospective, 10-year follow-up, open cohort study that involved six Brazilian NICUs was conducted. The NI incidence rates were calculated using different denominators.

RESULTS

Six thousand two hundred forty-three newborns and 450 NICU-months of data were available for analysis. This included 3603 NIs that occurred in 2286 newborns over 121,008 patient-days. The most frequent NIs were primary bloodstream infection (pBSI; 45.9%), conjunctivitis (12.1%), skin infections (9.6%), and pneumonia (6.8%). Only the pBSI (but not pneumonia or central venous catheter-related pBSI) rate distribution differed significantly with varying BW. Gram-negative rods (mainly Klebsiella sp. and Escherichia coli) were responsible for 51.6% episodes of pBSI. Gram-positive organisms (mainly coagulase-positive staphylococci) accounted for 37.4%. Candida sp. was the fourth isolated organism. A high resistance to third-generation cephalosporins was recorded in K pneumoniae and E coli isolates.

CONCLUSIONS

This report highlights the burden of NI, and identifies the major focus for future NI control and prevention programs. Except for pBSI, BW had a poor performance as a variable for risk-stratified NI rate reporting.

Reducing neonatal nosocomial bloodstream infections through participation in a national surveillance system

A national nosocomial surveillance system for neonatal intensive care patients with a very low birthweight was set up in Germany in 2000 (NEO-KISS). Forty-eight neonatal intensive care units (NICUs) participated in the programme, which focused upon nosocomial bloodstream infections (BSIs) and pneumonia. Only data from NICUs participating for at least three years were included and the years compared. The relative risks and their 95% confidence intervals (CIs) were calculated and a multiple logistic regression analysis performed to identify significant risk factors. Twenty-four units that met the selection criteria accumulated data for 3856 patients and 152 437 patient-days in their first three years of participation. The incidence density of BSIs decreased significantly by 24% from 8.3 BSIs per 1000 patient-days in the first year to 6.4 in the third year. In the multiple logistic regression analysis, BSI in the third year of participation was significantly lower than in the first year of participation (odds ratio=0.73, 95% CI 0.60-0.89). The year of participation was an independent risk factor for BSI but not for pneumonia. Our data suggest that participation in ongoing surveillance of nosocomial infections in NICUs, requiring individual units to feedback data, may lead to a reduction in BSI rates.

Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections

In recent years, several countries have established surveillance systems for nosocomial infections (NIs) on a national basis. Limited information has been published on the effectiveness of these national surveillance systems. The aim of this study was to investigate whether participation in the German national NI surveillance system [Krankenhaus Infektions Surveillance System (KISS)] resulted in reduced rates of NIs. Three major NIs were studied: ventilator-associated pneumonia (VAP) and central-venous-catheter-related primary bloodstream infections (CR-BSIs) in intensive care units (ICUs), and surgical site infections (SSIs) in surgical inpatients. Data were collected from January 1997 until December 2003. Only institutions that had participated in KISS for at least 36 months were considered for analysis. Data from the first 12 months of surveillance were compared with data from the second and third 12-month periods. One hundred and fifty ICUs and 133 surgical departments fulfilled the inclusion criteria. In their first year of participation in KISS, the ICUs had an average VAP rate of 11.2 per 1000 ventilator-days and a CR-BSI rate of 2.1 per 1000 catheter-days. The average SSI rate in the surgical inpatients was 1.6 per 100 operations in their first year of participation. Comparing the infection rates in the third year with the first year, the relative risk (RR) for VAP was 0.71 [95% confidence intervals (CI) 0.66-0.76] and the RR for CR-BSI was 0.80 (95% CI 0.72-0.90). The corresponding RR for SSI was 0.72 [95% CI 0.64-0.80]. Participation in KISS was associated with a significant reduction in these three NIs.

Clonality of clinical methicillin-resistant Staphylococcus epidermidis isolates in a neonatal intensive care unit

OBJECTIVE

Study of the clonality of methicillin-resistant Staphylococcus epidermidis responsible of epidemic infections in a neonatal intensive care unit.

PATIENTS AND METHODS

All S. epidermidis isolates (mecA+) were collected during the epidemic period (December 2003-September 2004) from different pathological products of newborns. Isolates were characterized by genotyping in pulsed-field gel electrophoresis and by electrophoretic profiles obtained by PCR-based analysis of inter-IS256 spacer polymorphisms.

RESULTS

Twenty methicillin-resistant S. epidermidis isolates were collected from newborns during the epidemic period and represented 41.6% of the total isolates of S. epidermidis, which is the first Staphylococcus species isolated from the unit. These isolates were collected from blood cultures (80%), vascular catheters (5%), pus (10%), and intra-tracheal tube (5%). Six genotypic profiles were individualized: type A, type B, type C, type D, type E, and type F, with clear dominance of type A. Five different PCR patterns were found with poor correlation to genotypes defined by PFGE.

CONCLUSION

Neonatal nosocomial outbreak of methicillin-resistant S. epidermidis was caused by multiple clones of this species with predominance of one epidemic and multiresistant clone. This clone may be transmitted between babies and was able to persist in the unit. PCR IS 256 proved to be less discriminative than PFGE for typing MRSE.

A multicenter intervention to prevent catheter-associated bloodstream infections

BACKGROUND

Education-based interventions can reduce the incidence of catheter-associated bloodstream infection. The generalizability of findings from single-center studies is limited.

OBJECTIVE

To assess the effect of a multicenter intervention to prevent catheter-associated bloodstream infections.

DESIGN

An observational study with a planned intervention.

SETTING

Twelve intensive care units and 1 bone marrow transplantation unit at 6 academic medical centers.

PATIENTS

Patients admitted during the study period.

INTERVENTION

Updates of written policies, distribution of a 9-page self-study module with accompanying pretest and posttest, didactic lectures, and incorporation into practice of evidence-based guidelines regarding central venous catheter (CVC) insertion and care.

MEASUREMENTS

Standard data collection tools and definitions were used to measure the process of care (ie, the proportion of nontunneled catheters inserted into the femoral vein and the condition of the CVC insertion site dressing for both tunneled and nontunneled catheters) and the incidence of catheter-associated bloodstream infection.

RESULTS

Between the preintervention period and the postintervention period, the percentage of CVCs inserted into the femoral vein decreased from 12.9% to 9.4% (relative ratio, 0.73; 95% confidence interval [CI], 0.61-0.88); the total proportion of catheter insertion site dressings properly dated increased from 26.6% to 34.4% (relative ratio, 1.29; 95% CI, 1.17-1.42), and the overall rate of catheter-associated bloodstream infections decreased from 11.2 to 8.9 infections per 1,000 catheter-days (relative rate, 0.79; 95% CI, 0.67-0.93). The effect of the intervention varied among individual units.

CONCLUSIONS

An education-based intervention that uses evidence-based practices can be successfully implemented in a diverse group of medical and surgical units and reduce catheter-associated bloodstream infection rates.

The perinatal management of gastroschisis

Gastroschisis is increasing in frequency and is becoming a common condition. It is now invariably detected antenatally and although the long-term outcome in the majority of cases is excellent, the existence of both fetal and postnatal complications has led to variations in practice to try to optimise outcome. This article reviews the evidence for some of these variations where such evidence exists and provides a contemporary view of best practice where it does not.

Bactériémies nosocomiales sur cathéters veineux centraux en néonatologie

OBJECTIVE

The aim of this retrospective study was to identify the risk factors for catheter-associated bloodstream infection (CABSI) in neonates.

METHOD AND RESULTS

Fifteen episodes of CABSI occurred in 108 central catheters over a period of one year (2002). The univariate analysis risk factors were birth weight (1.064 vs 1.413 g; P<0.001), gestation age (28 vs 31 weeks; P<0.001), blood transfusion (8/15 vs 3/34; P<0.01), corticosteroids (7/15 vs 3/34; P<0.01), nasal CPAP duration (13.6 vs 2 days; P<0.01). Nasal CPAP duration was the only risk factor independently associated with CASBI (OR=1.2, 95% confidence interval=1.09-1.5) in the multivariate logistic regression analysis.

CONCLUSIONS

The risk of infection associated with low birth weight is multifactorial suggesting that host-related factors are important. Prevention remains difficult and a policy of strict aseptic catheter care must be promoted.

Is bloodstream infection preventable among premature infants? A tale of two cities

BACKGROUND

Bloodstream infection (BSI) is a significant cause of morbidity and death encountered in the NICU. The rates of BSIs vary significantly in NICUs across the nation. However, no attempt has been made to correlate this variation with specific infection-control practices and policies. We experienced a significant increase in BSIs in the NICU at the George Washington University Hospital and were seeking additional precautionary measures to reduce BSI rates. Our objective was to review policies and practices associated with lower infection rates nationally and to test their reproducibility in our unit.

DESIGN AND METHODS

Data on BSI rates in 16 NICUs were reviewed. The BSI rate at Connecticut Children's Medical Center (CCMC) was the lowest among those reviewed. A team from George Washington University Hospital conducted a site visit to CCMC to examine their practices. Differences in the aseptic precautions used for intravenous line management were noted at CCMC, where a closed medication system is used. This system was applied at George Washington University Hospital starting January 1, 2001. Infection rates among low birth weight infants (<2500 g) at George Washington University Hospital in the period from January 1998 to December 2000 (group 1) were compared with those in the period from January 2001 to December 2003 (group 2). Comparisons between the 2 cohorts were made with Fisher's exact test, the Kruskal-Wallis test, and Student's t test. Multivariate analysis was used to control for differences in birth weight, gestational age, central line days, and ventilator days. Analyses were repeated for the subgroup of very low birth weight infants (<1500 g).

RESULTS

A total of 536 inborn low birth weight infants were included in this retrospective study (group 1, N = 169 infants; group 2, N = 367). The incidence of sepsis decreased significantly from group 1 to group 2 (25.4% and 2.2%, respectively). The reduction of sepsis observed in association with the new practice was statistically significant after controlling for birth weight, central line days, and ventilator days in a multiple regression model (regression coefficient: 0.95 +/- 0.29). The odds ratio of reduction in sepsis after implementation of the new practice was 2.6 (95% confidence interval: 1.5-4.5). The central line-related BSI rate decreased from 15.17 infections per 1000 line days to 2.1 infections per 1000 line days. The study included 233 very low birth weight infants, ie, 90 in group 1 and 143 in group 2. The rate of BSIs decreased significantly from group 1 to group 2 (46.7% and 5.6%, respectively). The decrease in sepsis rate remained significant in a multiple regression model (regression coefficient: 1.42 +/- 0.35). The odds ratio of decreased sepsis in relation to the new policy application among the very low birth weight infants was 4.15 (95% confidence interval: 2.1-8.3).

CONCLUSION

Applying the closed medication system was associated with reduced BSI rates in our unit. This protocol was easily reproducible in our environment and showed immediate results. Serious attempts to share data can potentially optimize outcomes and standardize policies and practices among NICUs.

Short peripheral venous catheters: effect of evidence-based guidelines on insertion, maintenance and outcomes in a university hospital

This study was designed to evaluate the impact of hospital-wide guidelines for short peripheral venous catheters (SPVC) insertion on the frequency of local catheter-related complications. In a 1051-bed Parisian university hospital, two observational, point prevalence surveys were undertaken in 1996 and in 1998, separated by implementation of written guidelines for SPVC insertion. The outcomes of SPVC insertion were defined as the presence or absence of local catheter-related complications (erythema, purulence around the insertion point, tenderness or induration along the cannulated vein). The proportion of polyurethane catheter materials used (56% vs. 81%, P<0.001), correct and sterile fixation (80% vs. 92%, P<0.05), non-movable catheters (92% vs. 98%, P=0.03) and insertion record (58% vs. 76%, P<0.01) increased between 1996 and 1998. The frequency of local catheter-related complications decreased (15% vs. 4%, P<0.01). Age >73 years [odds ratio (OR) 6.0, 95% confidence interval (CI) 1.28-28.05] was positively associated with local catheter-related complications, whereas duration of insertion (until 72 h) (OR 0.29, 95% CI 0.09-0.89) and the implementation of guidelines (OR 0.26, 95% CI 0.09-0.67) were negatively associated with local catheter-related complications. The implementation of guidelines was independently negatively associated with local catheter-related complications (OR 0.31, 95% CI 0.09-0.97). The results suggest that hospital guidelines for SPVC insertion can improve catheter care and significantly reduce local catheter-related complications.

Central venous lines in neonates: a study of 2186 catheters

OBJECTIVE

To describe the use of percutaneously inserted silicone central venous lines (CVLs) in neonates at the Royal Brisbane and Women's Hospital, Australia.

DESIGN

Data for all infants admitted from 1 January 1984 until 31 December 2002 who had a CVL were examined in the neonatal database, completed from paper records and patient charts where necessary. Autopsy reports of all babies who died with a catheter in place were reviewed.

RESULTS

There were 18,761 admissions, 2186 catheters in 1862 babies for a total of 35,159 days (median 14 days, range 1-99 days). The tip was in the right atrium for 1282 (58.6%) of the catheters. A total of 142 babies (7.6%) died with a CVL in place, 89 (4.8%) with the catheter tip in the right atrium. Thirty two of these 89 babies had an autopsy. No autopsies reported tension in the pericardium or milky fluid resembling intralipid. One case (0.05% of catheters) of non-lethal pericardial effusion occurred in a baby whose catheter was inappropriately left coiled in the right atrium. There were no cases of pleural effusion related to CVL use. Most (1523, 69.7%) were removed electively. Septicaemia occurred during the life of 116 catheters (5.3%).

CONCLUSION

This is the largest series of percutaneously inserted silicone central venous catheters reported. It illustrates the safety of these catheters in this context. It highlights the value of keeping prospective records on such catheters. Catheters with their tips in the right atrium and not coiled did not cause pericardial effusion. Strict insertion and management principles for CVLs should be adhered to.

Long-term parenteral nutritional support and intestinal adaptation in children with short bowel syndrome: a 25-year experience

OBJECTIVE

To analyze the outcome of children with short bowel syndrome (SBS) who required long-term parenteral nutrition (PN).

STUDY DESIGN

Retrospective analysis of children (n=78) with SBS who required PN >3 months from 1975 to 2000.

STATISTICS

univariate analysis, Kaplan-Meier method, and Cox proportional regression model were used.

RESULTS

We identified 78 patients. Survival was better with small bowel length (SBL) >38 cm, intact ileocecal valve (ICV), intact colon, takedown surgery after ostomy (all P <.01), and primary anastomosis (P <.001). PN-associated early persistent cholestatic jaundice (P <.001) and SBL of <15 cm (P <.01) were associated with a higher mortality. Intestinal adaptation was less likely if SBL <15 cm (P <.05), ICV was removed, colonic resection was done (both P <.001), >50% of colon was resected (P <.05), and primary anastomosis could not be accomplished (P <.01). Survival was 73% (57), and 77% (44) of survivors had intestinal adaptation.

CONCLUSIONS

SBL, intact ICV, intestinal continuity, and preservation of the colon are important factors for survival and adaptation. Adaptation usually occurred within the first 3 years. Need for long-term PN does not preclude achieving productive adulthood. Patients with ICV even with <15 cm of SBL and patients with SBL >15 cm without ICV have a chance of intestinal adaptation.

Nosocomial bloodstream infections in a neonatal intensive care unit

A study was performed to assess the incidence density of, and to identify the risk factors associated with, nosocomial bloodstream infection (BSI) in a neonatal intensive care unit (NICU) in Athens. Twenty-four of 105 patients developed nosocomial BSI (22.9%). The incidence density of BSI was 10.9 per 1000 patient-days. A multivariate model showed that only two factors were significantly and independently responsible for nosocomial BSI: central venous catheter use and umbilical catheter use. Results showed that the incidence density rate was high and the factors that had most influence on the development of nosocomial BSI were associated with the treatment received by neonates during their stay in the NICU. Therefore, surveillance of nosocomial BSI and strategies such as infection control, nursery design and staffing should be implemented to reduce the incidence of these infections. This effort should be multidisciplinary, involving staff who insert and maintain intravascular catheters, and healthcare managers who allocate resources.

Central venous catheter sepsis in surgical newborns

We examined central venous catheter (CVC) sepsis in newborn surgical patients, as this group appeared to have a higher incidence of this complication. During a 3-year period 79 patients on the surgical service required a tunneled, cuffed, Broviac CVC. Nineteen patients (24% or 9.9 episodes per 1000 catheter days) had proven sepsis and 8 (10% or 1.9/1000 catheter days) had suspected sepsis. An intestinal stoma was definitely related to CVC sepsis ( p<0.001). Other risk factors included lower gestational age, more operations, and younger age at first stoma. Temperature, white blood cell (WBC) count, and platelet count did not correlate with CVC sepsis. We found no better indicator of CVC sepsis than the presentation of an ill child. Certainly temperature, WBC, and platelet count are not reliable indicators. Surgeons have little control over the factors that were found to be related to CVC sepsis. It would appear reasonable from these results to maintain a high index of suspicion in the high-risk groups, to use peripherally inserted central catheters (PIC lines) as the first line of long-term vascular access, and to bring CVCs out of a nonabdominal site, perhaps the scalp, in patients with stomas.

The preventable proportion of nosocomial infections: an overview of published reports

The proportion of nosocomial infections potentially preventable under routine working conditions remains unclear. We performed a systematic review to describe multi-modal intervention studies, as well as studies assessing exogenous cross-infection published during the last decade, in order to give a crude estimate of the proportion of potentially preventable nosocomial infections. The evaluation of 30 reports suggests that great potential exists to decrease nosocomial infection rates, from a minimum reduction effect of 10% to a maximum effect of 70%, depending on the setting, study design, baseline infection rates and type of infection. The most important reduction effect was identified for catheter-related bacteraemia, whereas a smaller, but still substantial potential for prevention seems to exist for other types of infections. Based on these estimates, we consider at least 20% of all nosocomial infections as probably preventable, and hope that this overview will stimulate further research on feasible and cost-effective prevention of nosocomial infections for daily practice.

Implementation of evidence-based potentially better practices to decrease nosocomial infections

OBJECTIVE

Six neonatal intensive care units (NICUs) that are members of the Vermont Oxford National Evidence-Based Quality Improvement Collaborative for Neonatology collaborated to reduce infection rates. There were 7 centers in the original focus group, but 1 center left the collaborative after 1 year. Nosocomial infection is a significant area for improvement in most NICUs.

METHODS

Six NICUs participating in the Vermont Oxford Network made clinical changes to address 3 areas of consensus: handwashing, line management, and accuracy of diagnosis. The summary statements were widely communicated. Review of the literature, internal assessments, and benchmarking visits all contributed to ideas for change.

RESULTS

The principle outcome was the incidence of coagulase-negative staphylococcus bacteremia. There was an observed reduction from 24.6% in 1997 to 16.4% in 2000.

CONCLUSIONS

The collaborative process for clinical quality improvement can result in effective practice changes.

Molecular epidemiology of coagulase-negative staphylococcal bacteraemia in a newborn intensive care unit

We isolated 55 coagulase-negative staphylococci (CoNS) over two separate 12-month periods (26 in 1993 and 29 in 1996) from the blood of neonates in a neonatal intensive case unit (NICU) in Melbourne, Australia and compared them by pulse-field gel electrophoresis profile (PFGE), random amplification of polymorphic DNA (RAPD) and antibiogram. The most common species were Staphylococcus epidermidis, S. haemolyticus and S. warneri. The majority of such isolates were resistant to penicillin and to either or both of methicillin and gentamicin. During 1993, there was an increase in the number of CoNS bloodstream infections compared with previous years. S. epidermidis was the most common isolate, with 88% assessed as clinically relevant. Using the three typing systems, we identified one likely epidemic clone of S. epidermidis, the isolates of which were resistant to penicillin, gentamicin and erythromycin and possessed the mecA gene. There was complete correlation between the detection of mecA and the phenotypic expression of resistance when zone diameters in the disc diffusion assay were interpreted according to the latest NCCLS guidelines (1999). Profiles of the remaining 1993 isolates were generally heterogeneous, suggesting independent acquisition with some evidence of cross-infection. The predominant bloodstream isolates in 1996 were heterogeneous multi-resistant strains of S. epidermidis, S. haemolyticus and S. warneri, about half of which were assessed as clinically relevant. These data support the view that CoNS are significant nosocomial pathogens in NICU and that resistant clones may be transmitted between babies. Molecular epidemiological tools are helpful for understanding transmission patterns and sources of infection, and are useful for measuring outcomes of intervention strategies implemented to reduce nosocomial CoNS sepsis. PFGE was found to be more discriminatory than RAPD, but the latter provides results in a more timely manner.

Catheter manipulations and the risk of catheter-associated bloodstream infection in neonatal intensive care unit patients

A prospective cohort study was performed to evaluate the influence of catheter manipulations on catheter associated bloodstream infection (CABSI) in neonates. Neonates admitted between 1 November 1993 and 31 October 1994 at the neonatal intensive care unit of a university hospital were included in the study. Seventeen episodes of CABSI occurred in 357 central catheters over a period of 3470 catheter-days, with a cumulative incidence of 4.7/100 catheters and an incidence density of 4.9/1000 catheter-days. Patient and catheter-related risk factors independently associated with CABSI were: catheter hub colonization (odds ratio [OR] = 32.6, 95% confidence interval [95% CI] = 4.3-249), extremely low weight (</= 1000 gram) at time of catheter insertion (OR = 9.1, 95% CI = 1.9-42.2). Catheter manipulations independently associated with CABSI were disinfection of the catheter hub (OR = 1.2, 95% CI = 1.1-1.3), blood sampling (OR = 1.4, 95% CI = 1.1-1.8), heparinization (OR = 0.9, 95% CI = 0.8-1.0) and antisepsis of exit site (OR = 0.9, 95% CI = 0.8-1.0). This study indicates that certain manipulations (e.g. blood sampling through the central line) and disconnection of the central venous catheter, which necessitates disinfection of the catheter hub, increase the risk of CABSI, while other procedures (e.g. heparinization and exit site antisepsis), protect against CABSI in neonates.

Risk factors for central vascular catheter-associated bloodstream infections among patients in a neonatal intensive care unit

The aim of this study was to identify risk factors for catheter-associated bloodstream infection (CABSI) in neonates. We undertook a prospective investigation of the potential risk factors for CABSI (patient-related, treatment-related and catheter-related) in a neonatal intensive care unit (NICU) using univariate and multivariate techniques. We also investigated the relationship between catheter hub and catheter exit site colonization with CABSI.Thirty-five episodes of CABSI occurred in 862 central catheters over a period of 8028 catheter-days, with a cumulative incidence of 4.1/100 catheters and an incidence density of 4.4/1000 catheter days. Factors independently associated with CABSI were: catheter hub colonization (odds ratio [OR] = 44.1, 95% confidence interval [CI] = 14.5 to 134.4), exit site colonization (OR = 14.4, CI = 4.8 to 42.6), extremely low weight (< 1000 g) at time of catheter insertion (OR = 5.13, CI = 2.1 to 12.5), duration of parenteral nutrition (OR=1.04, CI=1.0 to 1.08) and catheter insertion after first week of life (OR = 2.7, CI = 1.1 to 6.7). In 15 (43%) out of the 35 CABSI episodes the catheter hub was colonized, in nine (26%) cases the catheter exit site was colonized and in three (9%) cases colonization was found at both sites. This prospective cohort study on CABSI in a NICU identified five risk factors of which two can be used for risk-stratified incidence density description (birthweight and time of catheter insertion). It also emphasized the importance of catheter exit site, hub colonization and exposure to parenteral nutrition in the pathogenesis of CABSI.

Microbiology and risk factors for catheter exit-site and -hub colonization in neonatal intensive care unit patients

OBJECTIVE

To identify risk factors and describe the microbiology of catheter exit-site and hub colonization in neonates.

DESIGN

During a period of 2 years, we prospectively investigated 14 risk factors for catheter exit-site and hub colonization in 862 central venous catheters in a cohort of 441 neonates. Cultures of the catheter exit-site and hub were obtained using semiquantitative techniques at time of catheter removal.

SETTING

A neonatal intensive care unit at a university hospital.

RESULTS

Catheter exit-site colonization was found in 7.2% and hub colonization in 5.3%. Coagulase-negative staphylococci were predominant at both sites. Pathogenic flora were found more frequently at the catheter hub (36% vs 14%; P<.05). Through logistic regression, factors associated with exit-site colonization were identified as umbilical insertion (odds ratio [OR], 8.1; 95% confidence interval [CI95], 2.35-27.6; P<.001), subclavian insertion (OR, 54.6; CI95, 12.2-244, P<.001), and colonization of the catheter hub (OR, 8.9; CI, 3.5-22.8; P<.001). Catheter-hub colonization was associated with total parenteral nutrition ([TPN] OR for each day of TPN, 1.056; CI95, 1.029-1.083; P<.001) and catheter exit-site colonization (OR, 6.11; CI95, 2.603-14.34; P<.001). No association was found between colonization at these sites and duration of catheterization and venue of insertion, physician's experience, postnatal age and patient's weight, ventilation, steroids or antibiotics, and catheter repositioning.

CONCLUSION

These data support that colonization of the catheter exit-site is associated with the site of insertion and colonization of the catheter hub with the use of TPN. There is a very strong association between colonization at both catheter sites.

New technologies to prevent intravascular catheter-related bloodstream infections

Most intravascular catheter-related infections are associated with central venous catheters. Technologic advances shown to reduce the risk for these infections include a catheter hub containing an iodinated alcohol solution, short-term chlorhexidine-silver sulfadiazine- impregnated catheters, minocycline-rifampin-impregnated catheters, and chlorhexidine- impregnated sponge dressings. Nontechnologic strategies for reducing risk include maximal barrier precautions during catheter insertion, specialized nursing teams, continuing quality improvement programs, and tunneling of short-term internal jugular catheters.

Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care

BACKGROUND

Intravascular devices are a leading cause of nosocomial infection. Specific prevention strategies and improved guidelines for the use of intravascular devices can decrease the rate of infection; however, the impact of a combination of these strategies on rates of vascular-access infection in intensive-care units (ICUs) is not known. We implemented a multiple-approach prevention programme to decrease the occurrence of vascular-access infection in an 18-bed medical ICU at a tertiary centre.

METHODS

3154 critically ill patients, admitted between October, 1995, and November, 1997, were included in a cohort study with longitudinal assessment of an overall catheter-care policy targeted at the reduction of vascular-access infections and based on an educational campaign for vascular-access insertion and on device use and care. Incidence of ICU-acquired infections was measured by means of on-site surveillance.

FINDINGS

613 infections occurred in 353 patients (19.4 infections per 100 admissions). The incidence density of exit-site catheter infection was 9.2 episodes per 1000 patient-days before the intervention, and 3.3 episodes per 1000 patient-days afterwards (relative risk 0.36 [95% CI 0.20-0.63]). Corresponding rates for bloodstream infection were 11.3 and 3.8 episodes per 1000 patient-days, respectively (0.33 [0.20-0.56]) due to decreased rates of both microbiologically documented infections and clinical sepsis. Rates of respiratory and urinary-tract infections remained unchanged, whereas those of skin or mucous-membrane infections decreased from 11.4 to 7.0 episodes per 1000 patient-days (0.62 [0.41-0.93]). Overall, the incidence of nosocomial infections decreased from 52.4 to 34.0 episodes per 1000 patient-days (0.65 [0.54-0.78]).

INTERPRETATION

A multiple-approach prevention strategy, targeted at the insertion and maintenance of vascular access, can decrease rates of vascular-access infections and can have a substantial impact on the overall incidence of ICU-acquired infections.