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research paper

Indian Pediatr 2016;53:790-792

Risk Factors for Central line – associated Bloodstream Infections

 

Shilpa Tomar, *Rakesh Lodha, Bimal Das, Seema Sood and Arti Kapil

From the Department of Microbiology and *Pediatric Intensive Care Unit, AIIMS, New Delhi, India.

Correspondence to: Dr Tugba Koca, Department of Pediatrics, Suleyman Demirel University School of Medicine, Cunur, Isparta, Turkey.
Email: [email protected]

Correspondence to:  Dr Arti Kapil, Professor,  Department of Microbiology, All India Institute of Medical Sciences,
New Delhi 110 029, India.
Email: [email protected]

Received: May 22, 2015;
Initial review: October 28, 2015;
Accepted: June 04, 2016.

Published online: July 01, 2016. PII:S097475591600013



Objective:
To carry out surveillance of central line – associated bloodstream infections in a Pediatric intensive care unit (PICU) and determine associated risk factors.

Methods: This prospective study was conducted over 1.5 years in the PICU. CDC definitions for these infections were followed and associated risk factors were identified.

Results: Of 265 enrolled children with central line, 13 developed blood stream infections (incidence density 5.03/1000 central-line days). Significant risk factors included changing the central-line, especially triple lumen, and frequently accessing the central-line.

Conclusion: Central-line associated bloodstream infections are preventable primary bacteremias and intervention strategies for prevention should be based on evidence generated to devise future protocols.

Keywords: Bacteremia, Central venous catheterization, ICU, Nosocomial infections


Healthcare-associated bloodstream infections (BSI) are associated with high mortality and morbidity, and increase duration of hospitalization of patients substantially [1]. Vascular access, especially central lines, is responsible for almost 60% of these infections, [2]. Clear definitions for central line-associated bloodstream infections (CLABSI) and their surveillance using standard protocols is necessary, as correct diagnosis can avoid indiscriminate removal of central line if the sepsis is not related to central line. In developing countries, situation of CLABSI has not been systematically analyzed [3]. In a previous study done in our Pediatric intensive care unit (PICU), the incidence density of catheter-related blood stream infection was 8.3/1000 patient days [4]. In developed countries, zero CLABSI rates are considered as the standard of healthcare, and are an important parameter for accreditation process of a healthcare facility.

We carried out the surveillance of CLABSI in our PICU [5], and aimed to determine the risk factors and bacterial profile of CLABSI.

Methods

This prospective cohort study was conducted in PICU of All India Institute of Medical Sciences, New Delhi, for a period of 1.5 years (August 2011 to January 2013). Ethical clearance was obtained from Institutional Ethics Committee.

Children, who stayed in PICU for more than 48 hours and had no infection incubating at the time of admission, were included in the study. The definition of CLABSI, their incidence density and antimicrobial profile has been published elsewhere [5]. The definition for CLABSI was based on CDC criteria [6], and incidence density was calculated as episodes of CLABSI per 1000 central line days.Central-line days were calculated by daily count of enrolled patients on central line, admitted in PICU.

All children on central line were monitored. Type of central line inserted, frequency of access/day [for drugs, total parenteral nutrition(TPN), gastric acid blockers, blood products] was noted.

Statistical analysis: Multiple parameters to determine risk factors associated with CLABSI were analyzed, which included the type of central line inserted, frequency of access/day and the affect of receiving various infusates through the central line.Data were managed on MS Excel and analyzed using Stata software, version 7.0 (Stata Corp., College Station, TX). Statistical significance between morbidity and mortality parameters was assessed by Two-sample Wilcoxon rank sum (Mann-Whitney) test and by Pearson chi-square test.

Results

During the study, 349 patients were enrolled. Nineteen developed BSI, of which 13 (68.4%) had CLABSI and 6 (31.6%) secondary BSI. Central line was placed in 265 (75.9%) patients (172 males) in PICU. Of these, 129 (48.7%) had triple lumen, 117 (44.1%) single lumen, 15 (5.7%) PICC line and 4 (1.5%) had umbilical catheters. Type of central line inserted was not related to development of CLABSI (P= 0.533).

Majority (55.8%) of the patients were <2 years of age, 31.6% were in the age group of 5-15 years and 12.6% were 2-5 years. Most common presentation/systems involved in patients who were put on central line were respiratory (28.7%), CNS (15%), cardiopulmonary (11.3%), sepsis/shock (10.2%), renal (8.3%), metabolic disorders(6.8%). Less commonly, gastrointestinal tract involvement (5.7%), blood disorders (3.0%), autoimmune diseases (2.3%) were noted.

Central-lines were changed in 66 (24.9%) patients. Changing central line was associated with higher incidence of CLABSI (P=0.024), especially with triple lumen CL change (P= 0.017) (Table I).

TABLE I Relationship Between Central Line-associated Bloodstream Infections and Change of Central Line 
Central line
Total
Blood stream
infections, No. (%)
Unchanged 199 6 (3.0%)
  Triple lumen 105 3 (2.9%)
  Single lumen 77 3 (3.9%)
  Others 17 0
Changed* 66 7
  Triple lumen 24 5 (20.8%)
  Single lumen 40 1 (2.5%)
  Others 2 1
Number of times changed*  
  Once 40 5 (12.5%)
  Twice 23 2 (8.7%)
  Thrice 2 0
  Six times 1 0
*P<0.05.

Majority (89.8%, n=238) of central lines were inserted in femoral vein; others in subclavian, brachial and umbilical vein. Site of central line insertion and development of CLABSI showed no relation (P =0.761). Also, no higher risk of CLABSI incidence was found in patients who received total parenteral nutrition (166 vs 99) or gastric acid blockers (167 vs 98).

Mean number of times CL was accessed/day in patients who developed CLABSI was much higher (18.46 vs. 11.70; P<0.001). Mean length of stay of patients with CLABSI was longer (27.30 vs. 8.76 d ) (P<0.001). Also, CLABSI was associated with higher mortality of 38.5% (5/13) compared to 13.7% (46/336) in patients without CLABSI.

In six patients with secondary BSI, lower respiratory tract was primary site of infection for four episodes of BSI (2 Acinetobacter spp., 1 Pseudomonas spp. and 1 Klebsiella spp.), and urinary tract for two (Candida spp.). Broncho-alveolar lavage (BAL) and urine sample were taken for culture, respectively and same isolates were later cultured from blood samples.

Predominance of gram negative pathogens was found in our study. Klebsiella spp. caused 5 , Pseudomonas spp. 3 (23.1%), S.epidermidis 2, and Acinetobacter spp., Proteus spp. and Enterococcus faecium each caused one episode of CLABSI. The antimicrobial susceptibility showed a high percentage of multidrug resistant bacteria with gram negative bacteria showing susceptibility to carbapenems and beta lactamase inhibitor combi-nations,while gram positive being susceptible to vancomycin and linezolid [5].

Discussion

In this study, we found that triple lumen central line was the most common type of line used and femoral vein was the most common site of central line insertion. We did not find any relationship between these variables and CLABSI. Also, patients receiving TPN or gastric acid blockers did not show higher risk of developing CLABSI. Important risk factors associated with CLABSI were frequency of central line access/day and changing triple lumen central line once or more.

Limitations of our study include a small study population and short duration of the study. Catheter manipulation is a known risk factor in development of catheter-related sepsis [7,8], as chances of introducing patient’s own skin flora or transferring an epidemic strain via hands of healthcare workers increases.

CDC recommends that central line should not be removed on basis of fever alone and clinical judgment be applied [9]. Central line was unchanged in six CLABSI patients and managed using systemic antimicrobial therapy. Of 66 patients, in whom central line was changed (catheter blockage, local site infection or suspicion of a BSI), 7 consequently developed CLABSI (central line in place for >2 calendar days).

Femoral vein is avoided in adults for central line placements because of higher colonization rates and risk of deep-vein thrombosis. But for pediatric population, CDC states "no recommendation can be made for a preferred site of central line insertion" [9].

Most common causative pathogens for CLABSI in the US are coagulase-negative staphylococci [10], S. aureus, enterococci, and Candida spp. Gram negative bacilli account for 19% of CLABSIs [11]. We found a predominance of gram-negative bacilli, similar to a study done on nosocomial BSI in Chandigarh, India [12]. A previous study done in our PICU also found 96.5% of bacterial isolates causing healthcare-associated infections to be gram-negative bacteria [4]. Thus, gram-negative bacill continue to dominate in developing countries where infection control practices are suboptimal. Moreover, approximately 31% of our isolates were nil-fermenters, which are now on the rise in healthcare settings. Emerging multi-drug resistant gram-negative bacteria are a major challenge in treatment of these infections, as also seen in our study.

Although, our hospital does not have a written antibiotic optimization policy, each department has antibiotic guidance protocols based on the local data of culture positive cases. The department of microbiology shares this data with the departments/units, which is updated regularly based on the spectrum of infections and antibiotic resistance pattern of organisms. Infection control nurse takes regular rounds and conducts surveillance of healthcare associated infections in various wards and ICU’s of the hospital.

CLABSI are preventable primary bacteremias. Based on the present data, we suggest that the number of times the central line is accessed should be minimized and that too under strict aseptic precautions. Unnecessary change of line must be avoided and ongoing surveillance and evidence based studies should support such decisions. Healthcare workers should be educated about importance of hand hygiene and full barrier precautions [13].

Acknowledgments: We thank the Pediatric ICU of All India Institute of Medical Sciences, New Delhi, India.

Contributors: ST: concept and design, planning and execution of study in the PICU, draft revision and final approval; RL, BD and SS: concept and design, guidance, planning of study, pediatric knowledge, draft revision and final approval; AK: concept and design, planning of study, draft revision and final approval.

Funding: None; Competing interests: None stated.


What This Study Adds?

• Unnecessary change of central line and its frequent access predispose to central line-associated bloodstream infections.

References

1. Barnett A, Page K, Campbell M, Martin E, Rashleigh-Rolls R, Halton K, et al. The increased risks of death and extra lengths of hospital and ICU stay from hospital-acquired bloodstream infections: A case-control study. BMJ Open. 2013;3:e003587.

2. Crnich C, Maki D. The role of intravascular devices in sepsis. Curr Infect Dis Rep. 2001;3:496-506.

3. Rosenthal V. Central line-associated bloodstream infections in limited-resource countries: A review of the literature. Clin Infect Dis. 2009;49:1899-907.

4. Gupta A, Kapil A, Lodha R, Kabra SK, Sood S, Dhawan B, et al. Burden of healthcare-associated infections in a paediatric intensive care unit of a developing country: A single centre experience using active surveillance. J Hosp Infect. 2011;78:323-6.

5. Tomar S, Lodha R, Das B, Sood S, Kapil A. Central line-associated bloodstream infections (CLABSI): Micro-biology and antimicrobial resistance pattern of isolates from the Pediatric ICU of a tertiary care Indian hospital. Clin Epidemiol Glob Health. 2015;3:S16-9.

6. Centers for Disease Control and Prevention. Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and Non-central line-associated Bloodstream Infection). January 2015. Available from: http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABS current.pdf. Accessed February 26, 2015

7. Hampton A, Sherertz R. Vascular-access infections in hospitalized patients. Surg Clin North Am. 1988;68: 57-71.

8. Murphy L, Lipman T. Central venous catheter care in parenteral nutrition: a review. J Parenter Enteral Nutr. 1987;11:190-201.

9. CDC. Guidelines for the Prevention of Intravascular Catheter-Related Infections. 2011. Available from: http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. Accessed November 8, 2015

10. Newman C . Catheter-related bloodstream infections in the pediatric intensive care unit. Semin Pediatr Infect Dis. 2006;17:20-4.

11. Wisplinghoff H, Bischoff T, Tallent S, Seifert H, Wenzel R, Edmond M. Nosocomial bloodstream infections in US hospitals: Analysis of 24,179 cases from a prospective nationwide surveillance study. Clin Infect Dis. 2004;39: 309-17.

12. Lakshmi KS, Jayashree M, Singhi S, Ray P. Study of nosocomial primary bloodstream infections in a pediatric intensive care unit. J Trop Pediatr. 2006;53:87-92.

13. Tomar S, Lodha R, Das B, Kapil A. Hand hygiene compliance of healthcare workers in a pediatric intensive care unit. Indian Pediatr. 2015;52:620-1.


 

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