Multinational prospective study of incidence and risk factors for central-line-associated bloodstream infections in 728 intensive care units of 41 Asian, African, Eastern European, Latin American, and Middle Eastern countries over 24 years

Clinical outcomes of peripherally inserted central catheters in patients with gastroenterological diseases: Report of a 9-year experience

BACKGROUND

Peripherally inserted central catheters (PICCs) are safe and useful alternatives to centrally inserted central catheters (CICCs). Several studies have investigated the effectiveness and safety of PICCs; however, few have focused on their use in patients with gastroenterological diseases. In the present study, we evaluated the outcomes of patients with gastroenterological diseases who received PICCs and identified the risk factors associated with central line-associated blood stream infection (CLABSI).

METHODS

We retrospectively examined hospitalized patients at our institution who received PICCs between 2015 and 2023. We evaluated the data on their clinical characteristics, complications, and outcomes. Furthermore, we investigated the risk factors for CLABSIs.

RESULTS

A total of 405 patients were included (262 men and 143 women). The median age was 71 (range, 15-94) years. The vessels were inserted in the basilic, cephalic, and brachial veins in 366 (90%), 22 (6%), and 17 (4%) patients, respectively. The median procedure time was 32 [6-149] min. The median dwell time was 16 [0-188] days. CLABSI, catheter occlusions, phlebitis, and exit-site skin infection occurred in 14 (3.5%; 1.77/1000 catheter days), 6 (1.5%; 0.76/1000 catheter days), 3 (0.7%; 0.38/1000 catheter days), and 1 (0.2%; 0.13/1000 catheter days) patients, respectively. There was no case of deep vein thrombosis or pulmonary thrombosis due to PICC placement. Multivariate analysis performed using a Cox's proportional hazard regression model revealed that patients with gastroenterological malignancies had an independently higher risk for CLABSIs (odds ratio [OR]: 3.25, 95% confidence interval [CI]: 1.05-10.05, p = 0.041) and that older age (⩾70 years) tended to be associated with CLABSIs (OR: 3.61, 95% CI: 0.98-13.32, p = 0.054).

CONCLUSIONS

Gastroenterological malignancies and older age were associated with a higher risk of CLABSIs. Rigorous catheter management is crucial for preventing complications, particularly in vulnerable patient subgroups.

Impact of Central Line-Associated Bloodstream Infections on Mortality and Hospital Stay in Adult Patients at a Tertiary Care Institution in Cali, Colombia, 2015-2018

Background: Central line-associated bloodstream infections (CLABSIs) are a significant healthcare challenge globally, increasing mortality risk and complicating central vascular catheter use. In Colombia, few studies have assessed the impact of CLABSIs on hospital stay and mortality. Objective: To determine the association between CLABSIs and discharge outcomes and hospital stay duration in adult patients at a tertiary care institution in Cali, Colombia, from 1 January 2015 to 31 December 2018. Methods: A nested case-control study was conducted. The odds of mortality associated with CLABSIs were estimated using conditional logistic regression. Non-conditional logistic regression was used to determine the odds of mortality when CLABSIs were caused by resistant microorganisms. Hospital stay duration, catheter duration, and time from catheter insertion to discharge were compared between patients with and without CLABSIs. The most frequent etiological agents were identified. Results: Patients with CLABSIs had 3.89 times the odds of mortality (95% CI [1.33-11.31], p = 0.013) compared to those without CLABSIs. The odds of mortality for patients with resistant microorganism CLABSIs were 4.04 times (95% CI [1.17-13.96], p = 0.027) higher than those with sensitive microorganism CLABSIs. Hospital stay duration (median = 51 days vs. 17 days; p = 0.000), catheter duration (median = 19 days vs. 7 days; p < 0.001), and time from catheter insertion to discharge (median = 40 days vs. 9 days; p < 0.001) were significantly longer in CLABSI patients. Klebsiella pneumoniae was the most isolated pathogen (20.2%), followed by Staphylococcus aureus (14.9%). Implications: CLABSI patients have longer catheter and hospitalization durations and higher mortality risk. Resistant microorganism CLABSIs are associated with elevated mortality risk. Conclusions: This study corroborates the positive relation between CLABSI and the mortality risk, which is influenced by resistant bacteria, though causality is not established. CLABSI is also linked to longer hospital stays, underscoring the need for improving infection control strategies.

Examining the impact of a 9-component bundle and the INICC multidimensional approach on catheter-associated urinary tract infection rates in 32 countries across Asia, Eastern Europe, Latin America, and the Middle East

BACKGROUND

Catheter-Associated Urinary Tract Infections (CAUTIs) frequently occur in the intensive care unit (ICU) and are correlated with a significant burden.

METHODS

We implemented a strategy involving a 9-element bundle, education, surveillance of CAUTI rates and clinical outcomes, monitoring compliance with bundle components, feedback of CAUTI rates and performance feedback. This was executed in 299 ICUs across 32 low- and middle-income countries. The dependent variable was CAUTI per 1,000 UC days, assessed at baseline and throughout the intervention, in the second month, third month, 4 to 15 months, 16 to 27 months, and 28 to 39 months. Comparisons were made using a 2-sample t test, and the exposure-outcome relationship was explored using a generalized linear mixed model with a Poisson distribution.

RESULTS

Over the course of 978,364 patient days, 150,258 patients utilized 652,053 UC-days. The rates of CAUTI per 1,000 UC days were measured. The rates decreased from 14.89 during the baseline period to 5.51 in the second month (risk ratio [RR] = 0.37; 95% confidence interval [CI] = 0.34-0.39; P < .001), 3.79 in the third month (RR = 0.25; 95% CI = 0.23-0.28; P < .001), 2.98 in the 4 to 15 months (RR = 0.21; 95% CI = 0.18-0.22; P < .001), 1.86 in the 16 to 27 months (RR = 0.12; 95% CI = 0.11-0.14; P < .001), and 1.71 in the 28 to 39 months (RR = 0.11; 95% CI = 0.09-0.13; P < .001).

CONCLUSIONS

Our intervention, without substantial costs or additional staffing, achieved an 89% reduction in CAUTI incidence in ICUs across 32 countries, demonstrating feasibility in ICUs of low- and middle-income countries.

Treatment of positive catheter tip culture without bloodstream infections in critically ill patients. A case-cohort study from the OUTCOMEREA network

PURPOSE

This study aimed to evaluate the impact on subsequent infections and mortality of an adequate antimicrobial therapy within 48 h after catheter removal in intensive care unit (ICU) patients with positive catheter tip culture.

METHODS

We performed a retrospective analysis of prospectively collected data from 29 centers of the OUTCOMEREA network. We developed a propensity score (PS) for adequate antimicrobial treatment, based on expert opinion of 45 attending physicians. We conducted a 1:1 case-cohort study matched on the PS score of being adequately treated. A PS-matched subdistribution hazard model was used for detecting subsequent infections and a PS-matched Cox model was used to evaluate the impact of antibiotic therapy on mortality.

RESULTS

We included 427 patients with a catheter tip culture positive with potentially pathogenic microorganisms. We matched 150 patients with an adequate antimicrobial therapy with 150 controls. In the matched population, 30 (10%) subsequent infections were observed and 62 patients died within 30 days. Using subdistribution hazard models, the daily risk to develop subsequent infection up to Day-30 was similar between treated and non-treated groups (subdistribution hazard ratio [sHR] 1.08, 95% confidence interval [CI] 0.62-1.89, p = 0.78). Using Cox proportional hazard models, the 30-day mortality risk was similar between treated and non-treated groups (HR 0.89, 95% CI 0.45-1.74, p = 0.73).

CONCLUSIONS

Antimicrobial therapy was not associated with decreased risk of subsequent infection or death in short-term catheter tip colonization in critically ill patients. Antibiotics may be unnecessary for positive catheter tip cultures.

Challenges and opportunities in neonatal sepsis management: insights from a survey among clinicians in 25 Sub-Saharan African countries

BACKGROUND

Neonatal sepsis (NS) is a global health issue, particularly in Sub-Saharan Africa, where it accounts for a substantial portion of neonatal morbimortality. This multicountry survey aimed to elucidate current practices, challenges and case definitions in managing NS among clinicians in Sub-Saharan Africa.

METHODS

The survey targeted physicians and medical practitioners working in neonatal care who participated in a Self-Administered Web Questionnaire. The main objective was to understand NS and infection case definitions and management from the clinician's point of view and to identify challenges and opportunities in sepsis management. Participants were queried on demographics, definitions and diagnostic criteria, treatment approaches, and infection prevention and control (IPC) measures. A total of 136 participants from 93 healthcare structures responded, providing valuable insights into NS management practices.

RESULTS

From May to July 2022 across 21 Sub-Saharan African countries, 136 neonatal clinicians with an average from 93 structures with on average 10-year experience took the survey. NS ranked highest among prevalent neonatal conditions. Diagnostic case definitions between sepsis and infection were attributed to clinical signs, anamnesis, C reactive protein, white blood cll count and blood cultures with no statistically significant differences. Early-onset sepsis was defined within 72 hours by 48%, while late-onset varied. Antibiotics were likely on admission (86.4%) and during the stay (82.2%). Treatment abandonment was reported unlikely. The preferred antibiotic regimen for early-onset sepsis was intravenous amoxicillin (or ampicillin), gentamycin and cefotaxime. Blood culture availability and IPC protocols were reported as limited, particularly concerning patient environment, pharmacy protocols and clean-dirty circuits.

CONCLUSIONS

This NS survey emphasises clinicians' challenges due to limited access to diagnostic tools and raises concerns about antimicrobial overexposure. IPC also seem limited, according to participants. Addressing these challenges can enhance diagnostic practices, antibiotic stewardship and infection control in the region.

Decreasing central line-associated bloodstream infections rates in intensive care units in 30 low- and middle-income countries: An INICC approach

BACKGROUND

Central line (CL)-associated bloodstream infections (CLABSIs) occurring in the intensive care unit (ICU) are common and associated with a high burden.

METHODS

We implemented a multidimensional approach, incorporating an 11-element bundle, education, surveillance of CLABSI rates and clinical outcomes, monitoring compliance with bundle components, feedback of CLABSI rates and clinical outcomes, and performance feedback in 316 ICUs across 30 low- and middle-income countries. Our dependent variables were CLABSI per 1,000-CL-days and in-ICU all-cause mortality rates. These variables were measured at baseline and during the intervention, specifically during the second month, third month, 4 to 16 months, and 17 to 29 months. Comparisons were conducted using a two-sample t test. To explore the exposure-outcome relationship, we used a generalized linear mixed model with a Poisson distribution to model the number of CLABSIs.

RESULTS

During 1,837,750 patient-days, 283,087 patients, used 1,218,882 CL-days. CLABSI per 1,000 CL-days rates decreased from 15.34 at the baseline period to 7.97 in the 2nd month (relative risk (RR) = 0.52; 95% confidence interval [CI] = 0.48-0.56; P < .001), 5.34 in the 3rd month (RR = 0.35; 95% CI = 0.32-0.38; P < .001), and 2.23 in the 17 to 29 months (RR = 0.15; 95% CI = 0.13-0.17; P < .001). In-ICU all-cause mortality rate decreased from 16.17% at baseline to 13.68% (RR = 0.84; P = .0013) at 17 to 29 months.

CONCLUSIONS

The implemented approach was effective, and a similar intervention could be applied in other ICUs of low- and middle-income countries to reduce CLABSI and in-ICU all-cause mortality rates.

Effect of Infusion Set Replacement Intervals on Central Line-Associated Bloodstream Infection in the Intensive Care Unit: Study Protocol of the INSPIRATION Study

INTRODUCTION

The replacement intervals for infusion sets may differ among healthcare institutions, which may have an impact on the occurrence of central line-associated bloodstream infections (CLABSI). Nevertheless, there exists a limited amount of high-quality evidence available to assist clinicians in determining the most suitable replacement intervals for infusion sets. Therefore, the objective of this trial is to compare the efficacy of 24-h and 96-h replacement intervals for infusion sets on CLABSI among critically ill adults who have central venous access devices.

METHODS

This is a multicenter, parallel-group randomized controlled trial that will investigate the effect of infusion set replacement intervals on CLABSI in adult patients admitted to intensive care units (ICUs). The study will enroll 1240 participants who meet the inclusion criteria, which includes being 18 years or older, expected to stay in the ICU for longer than 96 h, and in need of central venous access. Participants will be randomly assigned to either a control group receiving a 96-h replacement interval or a treatment group receiving a 24-h replacement interval.

PLANNED OUTCOME

The primary outcome of this trial is the rate of CLABSI within 28 days after randomization.

CONCLUSION

This is the first randomized controlled trial to investigate the effects of infusion set replacement at 24-h and 96-h intervals on CLABSI in ICU patients.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT05359601.