Incidence and risk factors for catheter-associated bloodstream infections in neonatal intensive care

Is central line type an independent risk factor of central line-associated bloodstream infection in a neonatal intensive care unit population? Experiences at a pediatric hospital in South Texas

Background

Central line-associated bloodstream infection (CLABSI) causes significant harm in neonatal intensive care unit (NICU) patients. However, data regarding risk factors and prevention strategies for CLABSI in NICU patients is limited.

Objective

To examine risk factors for CLABSI in a NICU population, with particular interest in central line type and site placement.

Design

Retrospective case-control study.

Setting

NICU (Level IV, 67 bed) at a pediatric hospital in South Texas.

Participants

All central line insertions and subsequent CLABSI cases were extracted from the EHR for NICU admissions occurring from January 1, 2018, to November 3, 2022 (N = 1,356), along with potential CLABSI risk factors.

Methods

Central line insertions resulting in CLABSI (N = 35) were compared to instances without CLABSI (N = 1,321) using bivariate and multivariate analysis, with propensity score matching.

Results

Multivariate risk factors include implantable device (odds ratio [OR] = 14.5, P < .001), neck site placement (OR = 7.2, P < .001), and device dwell time (OR = 5.6, P = .001), as well as years 2021 (OR = 5.1, P = .017) and 2022 (OR = 5.9, P = .011). This indicates the odds of contracting CLABSI are 14.5 times higher when an implantable central line is used compared to the reference category (PICC devices). When cases are paired with matched controls, likelihood of CLABSI is 7.1% higher in patients with an implantable device than in similar patients with other central lines (p = 0.034).

Conclusions

Implantable central lines are an independent risk factor for CLABSI in NICU patients at this facility.

Umbilically and Peripherally Inserted Thin Central Venous Catheters Have Similar Risks of Complications in Very Low-Birth-Weight Infants

Catheter complications can be life-threatening in very low-birth-weight (VLBW) infants. We retrospectively evaluated non-elective removals of the first thin (1-2F) umbilical vein catheters (tUVCs (n = 92)) and peripherally inserted central venous catheters (PICCs (n = 103)) among 195 VLBW infants. Catheters were removed non-electively in 78 infants (40%), typically due to suspected infection (n = 42) or catheter dislocation (n = 30). Infants with complications had lower birth weights and gestational ages than others. The frequencies and causes of catheter removal were similar in the tUVC and PICC groups. Thirty-one infants had true catheter infections. The number of infections/1000 catheter days was higher in the tUVC group than in the PICC group. In a multivariable analysis, gestational age was associated with catheter infection, but catheter type was not. The odds of catheter complications decreased with increasing gestational age, but no clear association with thin catheter type was found.

Infectious Risks Related to Umbilical Venous Catheter Dwell Time and Its Replacement in Newborns: A Narrative Review of Current Evidence

The use of umbilical venous catheters (UVCs) has become the standard of care in the neonatal intensive care unit (NICU) to administer fluids, medications and parenteral nutrition. However, it is well known that UVCs can lead to some serious complications, both mechanical and infective, including CLABSI (Central Line-Associated Bloodstream Infections). Most authors recommend removing UVC within a maximum of 14 days from its placement. However, the last Infusion Therapy Standards of Practice (INS) guidelines recommends limiting the UVC dwell time to 7 to 10 days, to reduce risks of infectious and thrombotic complications. These guidelines also suggest as an infection prevention strategy to remove UVC after 4 days, followed by the insertion of a PICC if a central line is still needed. Nevertheless, the maximum UVC dwell time to reduce the risk of CLABSI is still controversial, as well as the time of its replacement with a PICC. In this study we reviewed a total of 177 articles, found by using the PubMed database with the following search strings: "UVC AND neonates", "(neonate* OR newborn*) AND (UVC OR central catheter*) AND (infection*)". We also analyze the INS guidelines to provide the reader an updated overview on this topic. The purpose of this review is to give updated information on CVCs infectious risks by examining the literature in this field. These data could help clinicians in deciding the best time to remove or to replace the UVC with a PICC, to reduce CLABSIs risk. Despite the lack of strong evidence, the risk of CLABSI seems to be minimized when UVC is removed/replaced within 7 days from insertion and this indication is emerging from more recent and larger studies.

A longitudinal analysis of nosocomial bloodstream infections among preterm neonates

Nosocomial bloodstream infections (NBSIs), commonly due to central-line associated bloodstream infections (CLABSI), contribute substantially to neonatal morbidity and mortality. We aimed to identify longitudinal changes in incidence of NBSI, microbiological-spectrum, and antibiotic exposure in a large cohort of preterm neonates admitted to the neonatal intensive care unit. We retrospectively assessed differences in annual rates of NBSI (per 1000 patient-days), CLABSI (per 1000 central-line days), and antibiotic consumption (per 1000 patient-days) among preterm neonates (< 32 weeks’ gestation) hospitalized between January 2012 and December 2020. Multi-state Markov models were created to model states of progression of NBSI and infection risk given a central-line on days 0, 3, 7, and 10 of admission. Of 1547 preterm infants, 292 (19%) neonates acquired 310 NBSI episodes, 99 (32%) of which were attributed to a central-line. Over the years, a significant reduction in central-line use was observed (p < 0.001), although median dwell-time increased (p = 0.002). CLABSI incidence varied from 8.83 to 25.3 per 1000 central-line days, with no significant difference between years (p = 0.27). Coagulase-negative staphylococci accounted for 66% of infections. A significant decrease was found in antibiotic consumption (p < 0.001). Probability of NBSI decreased from 16% on day 3 to 6% on day 10. NBSI remains a common problem in preterm neonates. Overall antibiotic consumption decreased over time despite the absence of a significant reduction in infection rates. Further research aimed at reducing NBSI, in particular CLABSI, is warranted, particularly with regard to limiting central-line dwell-time and fine-tuning insertion and maintenance practices.

Central Subclavian Catheterization in Newborns: Single-Center Experience

Our main aim of this article was to show that central venous catheter (CVC) can be an easy-to-use, less-complicated catheter application such as peripherally inserted central catheter and umbilical catheter placement in the neonatal intensive care unit. We here described our experience with subclavian vein catheterization. Neonates who had venous access through subclavian central catheterization were assessed retrospectively. Data such as gestational age, age at the time of catheter insertion, birth weight, and gender were collected. In addition, problems related to catheterization during hospitalization were documented. This study comprised 40 newborns, 22 male and 18 female, with a mean gestational week of 29.57 ± 3.80 weeks and a mean gestational weight of 2067.50 ± 545.97 g. Due to occlusion, catheters were switched in five cases twice and in three cases once, totaling 53 catheterizations on 40 newborns. None of our patients had pneumothorax or hemothorax. On the postoperative 8th and 21st days, the catheter was withdrawn due to catheter infection in two (5%) patients, and catheter cultures revealed coagulase negative Staphylococcus aureus in both cases. Even in preterm infants, subclavian central venous catheterization is a safe and straightforward technique of gaining venous access in expert hands in the neonatal intensive care unit.

Mindful organizing as a healthcare strategy to decrease catheter-associated infections in neonatal and pediatric intensive care units. A systematic review and grading recommendations (GRADE) system

PURPOSE

To explore the clinical evidence available on mindful organizing (MO) that will improve teamwork for positioning and managing central venous catheters in patients admitted to neonatal intensive care and other pediatric intensive care units to decrease central-line-associated and catheter-related bloodstream infections (CLABSI and CRBSI).

METHODS

We searched several databases (PubMed, Embase, CINAHL, CENTRAL, SCOPUS, and Web of Science) up to June 2018. We included studies investigating the effectiveness of MO teamwork in reducing CLABSI and CRBSI. The systematic review followed the PRISMA guidelines. We used validated appraisal checklists to assess quality.

RESULTS

Seven studies were included: only one was a non-randomized case-controlled trial (CCT). All the others had a pre-post intervention design, one a time-series design and one an interrupted time-series design. The methodological heterogeneity precluded a meta-analysis. Despite the low certainty of evidence with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system, three studies including thousands of participants provided numerical data for calculating risk ratios (RR) and 95% confidence intervals (CI) comparing MO with no intervention for decreasing the CLABSI rate in neonatal and pediatric ICUs. The one CCT disclosed no significant difference in the CLABSI rate decrease between groups (RR = 0.96; 95%CI 0.47-1.97). Nor did the pre- and post-intervention interrupted time-series design disclose a significant decrease (RR = 0.80; 95%CI 0.36 1.77). In the study using a before-after study design, the GRADE system found that the CLABSI rate decrease differed significantly in favor of post-intervention (RR = 0.13; 95%CI 0.03 0.57; p = 0.007).

CONCLUSIONS

Despite the decreased CLABSI rate, the available evidence is low in quality. To reduce the unduly high CLABSI rates in neonatal and pediatric intensive care settings, custom-designed clinical trials should further define the clinical efficacy of MO to include it in care bundles as a new international standard.

Adverse events associated with umbilical catheters: a systematic review and meta-analysis

OBJECTIVE

To determine the incidence of adverse events (AEs) associated with umbilical catheters in the neonatal population.

STUDY DESIGN

Systematic review and meta-analysis of observational studies and randomized controlled trials published between 2010 and 2020.

RESULTS

In total 14,226 umbilical venous catheters (UVCs) and 4228 umbilical arterial catheters (UACs) were included. Overall, 13.4% of UVCs were associated with an AE (95% CI: 10.1-17.0) or 2.4 per 1000 catheter days (95% CI: 1.8-3.0). UACs had an AE rate of 9% (95% CI: 5.9-12.8) or 0.87 per 1000 catheter days (95% CI: 0.4-1.3). UVC malposition was the most common (41.7% [95% CI: 27.6-56.5]). Local injury from UAC taping was the most common AE in one study.

CONCLUSIONS

Umbilical catheters have a high incidence of AEs. Research into accurate methods of tip verification, tip surveillance, and securement is required.

Risk factors for the development of neonatal sepsis in a neonatal intensive care unit of a tertiary care hospital of Nepal

BACKGROUND

Sepsis is an overwhelming and life-threatening response to bacteria in bloodstream and a major cause of neonatal morbidity and mortality. Understanding the etiology and potential risk factors for neonatal sepsis is urgently required, particularly in low-income countries where burden of infection is high and its epidemiology is poorly understood.

METHODS

A prospective observational cohort study was conducted between April 2016 and October 2017 in a level three NICU at a tertiary care hospital in Nepal to determine the bacterial etiology and potential risk factors for neonatal sepsis.

RESULTS

Among 142 NICU admitted neonates, 15% (21/142) and 32% (46/142) developed blood culture-positive and -negative neonatal sepsis respectively. Klebsiella pneumoniae (34%, 15/44) and Enterobacter spp. (25%, 11/44) were the most common isolates. The antimicrobial resistance of isolates to ampicillin (100%, 43/43), cefotaxime (74%, 31/42) and ampicillin-sulbactam (55%, 21/38) were the highest. BlaTEM (53%, 18/34) and blaKPC (46%, 13/28) were the commonest ESBL and carbapenemase genes respectively. In univariate logistic regression, the odds of sepsis increased with each additional day of use of invasive procedures such as mechanical ventilation (OR 1.086, 95% CI 1.008-1.170), umbilical artery catheter (OR 1.375, 95% CI 1.049-1.803), intravenous cannula (OR 1.140, 95% CI 1.062-1.225); blood transfusion events (OR 3.084, 95% CI 1.407-6.760); NICU stay (OR 1.109, 95% CI 1.040-1.182) and failure to breast feed (OR 1.130, 95% CI 1.060-1.205). Sepsis odds also increased with leukopenia (OR 1.790, 95% CI 1.04-3.082), increase in C-reactive protein (OR 1.028, 95% CI 1.016-1.040) and decrease in platelets count (OR 0.992, 95% CI 0.989-0.994). In multivariate analysis, increase in IV cannula insertion days (OR 1.147, 95% CI 1.039-1.267) and CRP level (OR 1.028, 95% CI 1.008-1.049) increased the odds of sepsis.

CONCLUSIONS

Our study indicated various nosocomial risk factors and underscored the need to improve local infection control measures so as to reduce the existing burden of sepsis. We have highlighted certain sepsis associated laboratory parameters along with identification of antimicrobial resistance genes, which can guide for early and better therapeutic management of sepsis. These findings could be extrapolated to other low-income settings within the region.

Association of early skin breaks and neonatal thalamic maturation: A modifiable risk?

OBJECTIVE

To test the hypothesis that a strategy of prolonged arterial line (AL) and central venous line (CVL) use is associated with reduced neonatal invasive procedures and improved growth of the thalamus in extremely preterm neonates (<28 weeks' gestation).

METHODS

Two international cohorts of very preterm neonates (n = 143) with prolonged (≥14 days) or restricted (<14 days) use of AL/CVL were scanned serially with MRI. General linear models were used to determine the association between skin breaks and thalamic volumes, accounting for clinical confounders and site differences. Children were assessed at preschool age on standardized tests of motor and cognitive function. Outcome scores were assessed in relation to neonatal thalamic growth.

RESULTS

Prolonged AL/CVL use in neonates (n = 86) was associated with fewer skin breaks (median 34) during the hospital stay compared to restricted AL/CVL use (n = 57, median 91, 95% confidence interval [CI] 60.35-84.89). Neonates with prolonged AL/CVL use with fewer skin breaks had significantly larger thalamic volumes early in life compared to neonates with restricted line use (B = 121.8, p = 0.001, 95% CI 48.48-195.11). Neonatal thalamic growth predicted preschool-age cognitive (B = 0.001, 95% CI 0.0003-0.001, p = 0.002) and motor scores (B = 0.01, 95% CI 0.001-0.10, p = 0.02). Prolonged AL/CVL use was not associated with greater incidence of sepsis or multiple infections.

CONCLUSIONS

Prolonged AL/CVL use in preterm neonates may provide an unprecedented opportunity to reduce invasive procedures in preterm neonates. Pain reduction in very preterm neonates is associated with optimal thalamic growth and neurodevelopment.

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.

Hyperosmotic Infusion and Oxidized Surfaces Are Essential for Biofilm Formation of Staphylococcus capitis From the Neonatal Intensive Care Unit

Staphylococcus capitis is an opportunistic pathogen often implicated in bloodstream infections in the neonatal intensive care unit (NICU). This is assisted by its ability to form biofilms on indwelling central venous catheters (CVC), which are highly resistant to antibiotics and the immune system. We sought to understand the fundamentals of biofilm formation by S. capitis in the NICU, using seventeen clinical isolates including the endemic NRCS-A clone and assessing nine commercial and two modified polystyrene surfaces. S. capitis clinical isolates from the NICU initiated biofilm formation only in response to hyperosmotic conditions, followed by a developmental progression driven by icaADBC expression to establish mature biofilms, with polysaccharide being their major extracellular polymer substance (EPS) matrix component. Physicochemical features of the biomaterial surface, and in particular the level of the element oxygen present on the surface, significantly influenced biofilm development of S. capitis. A lack of highly oxidized carbon species on the surface prevented the immobilization of S. capitis EPS and the formation of mature biofilms. This information provides guidance in regard to the preparation of hyperosmolar total parenteral nutrition and the engineering of CVC surfaces that can minimize the risk of catheter-related bloodstream infections caused by S. capitis in the NICU.

Enhanced infection control interventions reduced catheter-related bloodstream infections in the neonatal department of Hung Vuong Hospital, Vietnam, 2011-2012: a pre- and post-intervention study

Background

Catheter-related bloodstream infections (CR-BSI) cause high neonatal mortality and are related to inadequate aseptic technique during the care and maintenance of a catheter. The incidence of CR-BSI among neonates in Hung Vuong Hospital was higher than that of other neonatal care centres in Vietnam.

Methods

An 18-month pre- and post-intervention study was conducted over three 6-month periods to evaluate the effectiveness of the intervention for CR-BSI and to identify risk factors associated with CR-BSI. During the intervention period, we trained all nurses in the Department of Neonatology on BSI preventive practices, provided auditing and feedback about aseptic technique during catheter care and maintenance, and reorganised preparation of total parenteral nutrition. All neonates with intravenous catheter insertion ≥48 h in the pre- and post-intervention period were enrolled. A standardised questionnaire was used to collect data. Blood samples were collected for cultures. We used Poisson regression to calculate rate ratio (RR) and 95% confidence interval (CI) for CR-BSI incidence rates and logistic regression to identify risk factors associated with CR-BSI.

Results

Of 2225 neonates enrolled, 1027 were enrolled in the pre-intervention period, of which 53 CR-BSI cases occurred in 8399 catheter-days, and 1198 were enrolled in the post-intervention period, of which 32 CR-BSI cases occurred in 8324 catheter-days. Incidence rates of CR-BSI significantly decreased after the intervention (RR = 0.61, 95% CI 0.39-0.94). Days of hospitalisation, episodes of non-catheter-related hospital-acquired infections, and the proportion of deaths significantly decreased after the intervention (p < 0.01). The CR-BSI was associated with days of intravenous catheter (odds ratio [OR] = 1.05, 95% CI 1.03-1.08), use of endotracheal intubation (OR = 2.27, 95% CI 1.27-4.06), and intravenous injection (OR = 8.50, 95% CI 1.14-63.4).

Conclusions

The interventions significantly decreased the incidence rate of CR-BSI. Regular refresher training and auditing and feedback about aseptic technique during care and maintenance of catheters are critical to reducing CR-BSI.

Neonate Bloodstream Infections in Organization for Economic Cooperation and Development Countries: An Update on Epidemiology and Prevention

The term neonatal sepsis is used to describe a generalized bloodstream infection of bacterial, viral, or fungal origin which is associated with hemodynamic changes and other clinical symptoms and signs, however, there is no unified definition. There are no basic criteria regarding differentiation of early-onset sepsis (EOS) versus late-onset sepsis (LOS). Stratification used in studies on neonatal sepsis also rarely includes the general condition of the newborn according to unambiguous assessment at birth, which hampers the establishment of a clear, uniform epidemiological description of neonatal sepsis. We aim to review the published data about the epidemiology and microbiology of sepsis in Organization for Economic Cooperation and Development (OECD) countries. Data was also collected on sepsis prevention programs that can be implemented in neonatal units. The outcomes of interest were incidence or incidence density of EOS and LOS, microbiology of EOS and LOS, and data on the methodology of the research, in particular the criteria for inclusion and exclusion of newborns from the study. Pubmed, EMBASE, LILACS Embase, Scopus, and Google Scholar were used. For the preselection step, inclusion criteria included: "bloodstream infection" or "neonatal sepsis" (MesH), "very low birth weight", and "country" full-text studies, human, and English language. Exclusion criteria included: studies published in languages other than English and studies available only as an abstracts. For proper selection, inclusion criteria included: information about epidemiology or microbiology bloodstream infection (BSI), study population and case definitions, exclusion criteria, narrative reviews, commentaries, case studies, pilot studies, study protocols, pediatric studies, and only clinical data (without microbiology or epidemiology) or studies with only one etiological factor analysis. The data review indicated the lack of an unequivocal, unified definition and no unambiguous basic criteria with regard to differentiation of EOS versus LOS. Among infants <1500 g, studies reported an EOS rate from 7% to 2%. For studies using other definitions (mostly all inborn babies), the rate of EOS ranged from 1% to 3%. The LOS incidences were much more varied among countries; the highest rates were in the multicenter studies focused on very low birth weight (VLBW) infants. The main pathogens in EOS are GBS and Gram-negative bacteria in LOS. Our review data shows that LOS microbiology is very diverse and that Gram-positive cocci, especially staphylococci, predominate versus Gram-negative rods. Unfortunately, the lack of uniform, international prevention programs results in high newborn morbidity and insufficient postnatal prevention of late-onset infections.

Reduction of hospital-acquired infections in the neonatal intensive care unit: A long-term commitment

We instituted quality improvement program. We compare the infection rate before (2011-2012) and after (2013-2015). Central line associated blood stream infection episodes decreased from 15.2 to 2.29 episodes per 1000 catheter days (P = .004). We found two major changes, 1. Hand hygiene increased mainly "before aseptic task", from 69.9% to 89.9% and 2. A significant decrease in the length of the catheter use from 5.4 ± 4.5 before to 4.4 ± 2.5 days after the intervention (P = .001).

Impact of central line bundle for prevention of umbilical catheter-related bloodstream infections in a neonatal intensive care unit: A pre-post intervention study

BACKGROUND

Central line-associated bloodstream infection is the most common infection associated with healthcare in preterm infants. The purpose of this 18-month cross-sectional study was to evaluate the effectiveness of bundle applications in the prevention of umbilical venous catheter (UVC)-associated bloodstream infections.

METHODS

This study included patients in whom UVCs were inserted and who were diagnosed with central line-associated bloodstream infection between July 1, 2016, and December 31, 2017, according to the Centers for Disease Control and Prevention criteria. During the second 9-month period of the study (April 1, 2017, to December 31, 2017), bundles were implemented.

RESULTS

In the prebundle period, 589 patients were admitted to the neonatal intensive care unit, and 6,769 hospitalization days and 485 UVC days were recorded. Similarly, during the bundle period, 508 patients were admitted to the neonatal intensive care unit, and 7,789 hospitalization days and 508 UVC days were recorded. The UVC-associated bloodstream infection rate was 12.4 per 1,000 catheter days in the prebundle period and decreased to 3.9 per 1,000 catheter days in the bundle period. Thus, after introducing bundle applications, the rate of infection decreased by 68% (P < .01).

CONCLUSIONS

This study showed that bundle application effectively reduced UVC-associated bloodstream infection.

The idle central venous catheter in the NICU: When should it be removed?

PURPOSE

There is debate regarding the optimal timing of central line removal in the neonatal intensive care unit (NICU). The purpose was to evaluate outcomes of idle peripherally inserted central catheters (PICCs) and tunneled central venous catheters (TCVCs) and determine the incidence of line-related infections and replacements.

METHODS

Patients in the NICU with T-CVCs placed between 11/2008 and 8/2015 (n=134) or PICCs placed between 7/2013 and 10/2015 (n=467) were included. Demographics and outcomes were compared.

RESULTS

The most common indications for line placement were parenteral nutrition for PICCs (74%) and lack of access for T-CVCs (53%). T-CVCs had a greater proportion of idle days (T-CVC- 25.2% vs PICC- 5.1%, p<0.001) and removal within 24h of discharge (T-CVC-53% vs PICC-5.8%, p<0.001). Conversely, 81% of PICCs were removed within 24h of nonuse. Line replacement after removal for nonuse was required in 6% of PICCs and zero T-CVCs. In both groups, the central line-associated bloodstream infection (CLABSI) rate was lower in idle lines compared to ones in use.

CONCLUSION

Patients treated with PICCs and T-CVCs are different populations and should have different guidelines for removal. In neonates with difficult access, the low risk of CLABSIs in idle surgically placed catheters may justify maintaining access until discharge.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

2% chlorhexidine-70% isopropyl alcohol versus 10% povidone-iodine for insertion site cleaning before central line insertion in preterm infants: a randomised trial

OBJECTIVE

To determine whether 2% chlorhexidine gluconate-70% isopropyl alcohol (CHX-IA) is superior to 10% aqueous povidone-iodine (PI) in preventing catheter-related blood stream infection (CR-BSI) when used to clean insertion sites before placing central venous catheters (CVCs) in preterm infants.

DESIGN

Randomised controlled trial.

SETTING

Two neonatal intensive care units (NICUs).

PATIENTS

Infants <31 weeks' gestation who had a CVC inserted.

INTERVENTIONS

Insertion site was cleaned with CHX-IA or PI. Caregivers were not masked to group assignment.

MAIN OUTCOME MEASURES

Primary outcome was CR-BSI determined by one microbiologist who was masked to group assignment. Secondary outcomes included skin reactions to study solution and thyroid dysfunction.

RESULTS

We enrolled 304 infants (CHX-IA 148 vs PI 156) in whom 815 CVCs (CHX-IA 384 vs PI 431) were inserted and remained in situ for 3078 (CHX-IA 1465 vs PI 1613) days. We found no differences between the groups in the proportion of infants with CR-BSI (CHX-IA 7% vs PI 5%, p=0.631), the proportion of CVCs complicated by CR-BSI or the rate of CR-BSI per 1000 catheter days. Skin reaction rates were low (<1% CVC insertion episodes) and not different between the groups. More infants in the PI group had raised thyroid-stimulating hormone levels and were treated with thyroxine (CHX-IA 0% vs PI 5%, p=0.003).

CONCLUSIONS

We did not find a difference in the rate of CR-BSI between preterm infants treated with CHX-IA and PI, and more infants treated with PI had thyroid dysfunction. However, our study was not adequately powered to detect a difference in our primary outcome and a larger trial is required to confirm our findings.

TRIAL REGISTRATION

This study was registered with the EU clinical trials register before the first patient was enrolled (Eudract 2011-002962-19). (https://www.clinicaltrialsregister.eu).

Risk factors for central venous catheter-related infections in a neonatal population - systematic review

OBJECTIVE

This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population.

DATA SOURCE

The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified.

DATA SYNTHESIS

A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs.

CONCLUSION

Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

Dwell time and risk of central-line-associated bloodstream infection in neonates

BACKGROUND

Umbilical venous catheters (UVCs) or peripherally inserted central catheters (PICCs), widely used in high-risk neonates, may have a threshold dwell time for subsequent increased risk of central-line-associated bloodstream infection (CLABSI).

AIM

To evaluate the CLABSI risks in neonates having either UVC, PICC, or those having both sequentially.

METHODS

The study included 3985 infants who had UVC or PICC inserted between 2007 and 2009 cared for in 10 regional neonatal intensive care units: 1392 having UVC only (group 1), 1317 PICC only (group 2), and 1276 both UVC and PICC (group 3).

FINDINGS

There were 403 CLABSIs among 6000 venous catheters inserted, totalling 43,302 catheter-days. CLABSI rates were higher in group 3 infants who were of lowest gestation (16.9 per 1000 UVC-days and 12.5 per 1000 PICC-days; median: 28 weeks) when compared with group 1 (3.3 per 1000 UVC-days; 37 weeks) and group 2 (4.8 per 1000 PICC-days; 30 weeks). Life table and Kaplan-Meier hazard analysis showed that UVC CLABSI rate increased stepwise to 42 per 1000 UVC-days by day 10, with the highest rate in group 3 (85 per 1000 UVC-days). PICC CLABSI rates remained relatively stable at 12-20 per 1000 PICC-days. Compared to PICC, UVC had a higher adjusted CLABSI risk controlled for dwell time. Among group 3, replacing UVC electively before day 4 may have a trend of lower CLABSI risk than late replacement.

CONCLUSION

There was no cut-off duration beyond which PICC should be removed electively. Early UVC removal and replacement by PICC before day 4 might be considered.

Bloodstream Infection Incidence of Different Central Venous Catheters in Neonates: A Descriptive Cohort Study

Central venous catheters (CVCs) in neonates are associated with a risk of central line-associated bloodstream infections (CLABSI). Most reports on the incidence of CLABSI in neonates focus on umbilical venous catheters (UVCs) and peripherally inserted central catheters (PICCs). We evaluated the incidence and risk factors for CLABSI in a cohort of neonates with femoral venous catheters (FVCs), UVCs, and PICCs, with a gestational age ≥34 weeks born between January 1, 2006 and June 30, 2013. We included 2,986 neonates with a total of 656 catheters. The CLABSI incidence rate varied from 12.3 per 1,000 catheter-days in FVCs to 10.6 per 1,000 catheter-days in UVCs and 5.3 per 1,000 catheter-days in PICCs. In a Kaplan-Meier survival analysis, we did not find a difference in CLABSI risk between the catheter types (p = 0.29). The following factors were independently associated with an increased risk of CLABSI: parenteral nutrition [hazard ratio (HR) 2.60, 95% confidence interval (CI) 1.25-5.41], male gender (HR 2.63, 95% CI 1.17-5.90), and higher birth weight (HR 1.04, 95% CI 1.002-1.09), whereas antibiotic treatment at birth (HR 0.25, 95% CI 0.12-0.52) was associated with a decreased risk.

CONCLUSION

In our cohort, we did not find a difference between the CLABSI incidence in FVCs, PICCs, and UVCs. Occurrence of CLABSI is associated with parenteral nutrition, male gender, and higher birth weight. Antibiotic treatment at birth was associated with a decreased risk of CLABSI.

Very low birthweight infants face an increased risk of bloodstream infections following the removal of umbilical catheters

AIM

This study examined whether there was a temporal association between removing umbilical catheters and bloodstream infections (BSI) in a neonatal intensive care unit, as this is an area of research that has not received sufficient attention.

METHODS

We carried out a retrospective study of all neonates receiving umbilical catheters during 2011 and 2012 in the neonatal intensive care unit at Sahlgrenska University Hospital, Gothenburg, Sweden. The time from umbilical catheter removals to the first subsequent BSI was recorded.

RESULTS

A total of 372 infants had umbilical catheters inserted and 146 of these had a birthweight of <1500 g. Antibiotics were discontinued when umbilical catheters were removed in 67 of these low birthweight infants and 20 of them needed to be retreated for BSI within 72 hours. We found that very low birthweight infants had a significantly increased risk of developing BSI if antibiotics were discontinued at the same time as umbilical catheters were removed, rather than being continued after removal (p < 0.001).

CONCLUSION

This NICU study demonstrated a temporal association between removing umbilical catheters and BSI in very low birthweight infants weighting <1500 g.

Skin-to-skin contact with an umbilical venous catheter: prospective evaluation in a level 3 unit

The aim was to assess the incidence of complications related to skin-to-skin contact (SSC) in newborns with an umbilical venous catheter (UVC). We carried out a prospective follow-up study of all UVCs in a level 3 unit where SSC is systematic. A total of 333 babies were included (mean gestational age of 31.3 weeks (24-41), mean birth weight of 1618 g (454-4900). Two hundred sixty-three babies (78.9 %) had SSC, at a mean postnatal age of 24 h (3-144 h). Two babies presented with a significant umbilical bleeding, all in the first 3 h, before SSC. In 17 cases of UVC leaking, this necessitated an unwanted withdrawal of the UVC; of these, 14 UVCs (82 %) were in sub-hepatic position. In five cases of UVC displacement, babies had no SSC. The overall incidence (3 % [95 % CI = 1.4-5.4]) and incidence density (6.2/1000 UVC-day [95 % CI = 3-11.4]) of catheter-associated infections are similar to those identified by the French multicenter network NEOCAT in 2012 (5 % [95 % CI = 4.1-5.9] and 11.3/1000 UVC-day [95 % CI = 9.3-13.2]).

CONCLUSION

In this prospective, non-randomized study in a level unit, routine practice of SSC with a UVC does not seem to influence the incidence of mechanical and infectious complications. What is known? • SSC is beneficial for pretem infants. • Fear of mechanical problems and/or infections with a UVC is an obstacle to early use of SSC. What is New: • In this study, SSC for preterm infants with a UVC is associated with low risks of mechanical complications, and does not seem to be associated with any higher risk of catheter-related infections.

Risk of Infection Using Peripherally Inserted Central and Umbilical Catheters in Preterm Neonates

OBJECTIVE

To compare the rates of catheter-associated bloodstream infection (CABSI) in preterm infants born at <30 weeks' gestation who received a peripherally inserted central catheter (PICC) versus an umbilical venous catheter (UVC) immediately after birth as their primary venous access.

METHODS

This retrospective matched cohort study examined data from infants born at <30 weeks' gestation and admitted between January 2010 and December 2013 to neonatal units in the Canadian Neonatal Network. Eligible infants who received a PICC on the first day after birth (day 1) were matched with 2 additional groups of infants, those who received a UVC on day 1 and those who received a UVC on day 1 that was then changed for a PICC after 4 days or more. The primary outcome was number of infants with CABSI per 1000 catheter days, which was compared between the 3 groups using multivariable analyses.

RESULTS

Data from 540 eligible infants were reviewed (180 per group). There was no significant difference in infants with CABSI/1000 catheter days between the 3 groups (9.3 vs 7.8 vs 8.2/1000 catheter days, respectively; P > .05) despite lower rates of late onset sepsis in the group of infants who received only a UVC.

CONCLUSIONS

There was no significant difference in the incidence of CABSI between very preterm neonates who received a PICC, UVC, or UVC followed by PICC as the primary mode of venous access after birth. A prospective randomized controlled trial is justified to further guide practice regarding primary venous access and reduction of infection.

Complications of Central Venous Access Devices: A Systematic Review

CONTEXT

The failure and complications of central venous access devices (CVADs) result in interrupted medical treatment, morbidity, and mortality for the patient. The resulting insertion of a new CVAD further contributes to risk and consumes extra resources.

OBJECTIVE

To systematically review existing evidence of the incidence of CVAD failure and complications across CVAD types within pediatrics.

DATA SOURCES

Central Register of Controlled Trials, PubMed, and Cumulative Index to Nursing and Allied Health databases were systematically searched up to January 2015.

STUDY SELECTION

Included studies were of cohort design and examined the incidence of CVAD failure and complications across CVAD type in pediatrics within the last 10 years. CVAD failure was defined as CVAD loss of function before the completion of necessary treatment, and complications were defined as CVAD-associated bloodstream infection, CVAD local infection, dislodgement, occlusion, thrombosis, and breakage.

DATA EXTRACTION

Data were independently extracted and critiqued for quality by 2 authors.

RESULTS

Seventy-four cohort studies met the inclusion criteria, with mixed quality of reporting and methods. Overall, 25% of CVADs failed before completion of therapy (95% confidence interval [CI] 20.9%-29.2%) at a rate of 1.97 per 1000 catheter days (95% CI 1.71-2.23). The failure per CVAD device was highest proportionally in hemodialysis catheters (46.4% [95% CI 29.6%-63.6%]) and per 1000 catheter days in umbilical catheters (28.6 per 1000 catheter days [95% CI 17.4-39.8]). Totally implanted devices had the lowest rate of failure per 1000 catheter days (0.15 [95% CI 0.09-0.20]).

LIMITATIONS

The inclusion of nonrandomized and noncomparator studies may have affected the robustness of the research.

CONCLUSIONS

CVAD failure and complications in pediatrics are a significant burden on the health care system internationally.

Improving central line infection rates in the neonatal intensive care unit: Effect of hospital location, site of insertion, and implementation of catheter-associated bloodstream infection protocols

INTRODUCTION

Catheter associated blood stream infections (CABSIs) are morbid and expensive for all ages, including neonates. Thus far, the impact of CABSI prevention protocols, such as insertion and maintenance bundles, in the neonatal intensive care unit (NICU) is largely unknown. We hypothesized that lines placed in the operating room (OR) would have a lower infection rate due to established insertion protocols and a more sterile environment.

METHODS

A retrospective chart review of NICU patients who received a percutaneous or tunneled central venous catheter between 2005 and 2012 was performed. ECMO cannulas, PICC and umbilical catheters were excluded. Variables of interest included demographics, anatomical site, hospital location, line days, and line infection. Line infection was defined as a positive blood culture drawn through the catheter.

RESULTS

A total of 368 catheters were placed in 285 NICU patients. Majority of catheters (65.5%) were placed in OR. Saphenous and femoral veins were most common anatomical sites (50.8%). Twenty-eight catheters were infected (7.6%). After adjusting for preoperative antibiotics, anatomical site, and SNAPPE-II scores, lines placed in OR were three times less likely to become infected (Odds Ratio=0.32, p=0.038). Although implementation of CABSI prevention protocols resulted in statistically significant reductions in infection (Odds Ratio=0.4, p=0.043), lines placed in the OR remained less likely to become infected.

CONCLUSIONS

NICU line infection rates decreased with implementation of CABSI prevention protocols. Despite this implementation, catheters placed in the NICU continued to have higher infection rates. As a result, when patient status allows it, we recommend that central lines in newborns be placed in the operating room.

Central line bloodstream infections can be reduced in newborn infants using the modified Seldinger technique and care bundles of preventative measures

AIM

There has been no evidence to show whether care bundles of preventive measures reduce central line-associated bloodstream infection (CLABSI) in peripherally inserted central catheters using the modified Seldinger technique, which requires more specific skills than the traditional technique. The aim of this study was to address that gap in our knowledge and to determine whether other variables influenced the outcome.

METHODS

This prospective observational study was conducted on a neonatal intensive care unit. We observed the incidence of CLABSI in 45 newborn infants with peripheral catheters before the introduction of bundles of preventative measures and 88 infants after the introduction.

RESULTS

Laboratory-confirmed CLABSI decreased after the introduction of the bundles, from 12.9 per 1000 days to 4.7/1000 days (p = 0.09). When we combined the rates for laboratory-confirmed CLABSI and clinical CLABSI in a survival analysis, the incidence reduced significantly after introduction of the bundles (p = 0.02). There were no other variables that affected the outcome.

CONCLUSION

Cost-effective care bundles reduced CLABSI in peripherally inserted central catheters using the modified Seldinger technique, despite the specific insertion skills that were required. The bundles of preventative measures may increase healthcare professionals' awareness of the need to care for central catheters and reduce CLABSI infections.

Staphylococcal infections in infants: updates and current challenges

Staphylococci are common pathogens in the neonatal period. Increased survival of premature infants leads to prolonged hospital stay with associated risk factors for developing invasive staphylococcal disease. Challenges of diagnosing coagulase-negative staphylococcal infections result in conflicting definitions and inconsistent clinical practice. Resistance to methicillin influences the choice of empirical therapy.

Scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec reduced neonatal sepsis

AIM

The aim of this study was to investigate whether scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec could reduce the incidence of neonatal sepsis in a level-three neonatal intensive care unit.

METHODS

We studied the incidence of neonatal sepsis caused by coagulase-negative staphylococci (CoNS) for 16.5 months before the initiative was launched on May 15, 2012 and then for a further 8.5 months after it was introduced. The hub routine was applied to all intravenous catheters.

RESULTS

During the control period before the initiative was launched, there were nine cases of CoNS sepsis compared with no cases after it was introduced, resulting in a decrease in sepsis incidence from 1.5% to 0% with a risk reduction of 1.5% (0.53-2.58%) (p = 0.06). In the preterm infant population, the incidence of sepsis decreased from 3.6% to 0% (1.1-6.0%) (p = 0.11).

CONCLUSION

Scrubbing the hub of intravenous catheters with an alcohol wipe for 15 sec seemed to be an efficient way of preventing sepsis caused by CoNS in newborn infants. However, the evidence for the benefits will remain weak until a large randomised trial has been completed.

Bloodstream infections: epidemiology and resistance

Bloodstream infections in the neonatal intensive care unit (NICU) are associated with many adverse outcomes in infants, including increased length of stay and cost, poor neurodevelopmental outcomes, and death. Attention to the insertion and maintenance of central lines, along with careful review of when the catheters can be safely discontinued, can minimize central-line-associated bloodstream infections rates. Good antibiotic stewardship can further decrease the incidence of bloodstream infections, minimize the emergence of drug-resistant organisms or Candida as pathogens in the NICU, and safeguard the use of currently available antibiotics for future infants.