A Prospective Study of Epidemiology of Central Line Associated Bloodstream Infections at a Tertiary Hospital Makkah Saudi Arabia

Received: 25-Nov-2020 Accepted Date: Dec 21, 2020 ; Published: 28-Dec-2020

Introduction

Central Line Related Blood Stream Infections (CLABSI), defined as the presence of bacteremia originating from an intravenous catheter, accounts for 11% of all healthcare-associated infections [1]. According to the Centre for Disease and Drug Control (CDC), CLABSI is one of the leading causes of death and disability among patients with end-stage renal failure [2]. Studies have further confirmed that a single episode of CLABSI can independently increase hospital stay from 7 to 21 days and healthcare-related cost from $4,000 to $56,000, putting a substantial economic burden on the healthcare resources of a country [3,4]. CLABSI rate in a hospital is therefore an important quality indicator to assess its healthcare standards [5]. These bloodstream infections among hemodialysis patients are potentially preventable and their prevalence in a healthcare setting can be significantly reduced through evidence-based infection prevention and control measures such as practicing hand hygiene, adherence to aseptic techniques, use of PPE, and chlorhexidine dressings; collectively referred to as “CVC Care Bundle”. Nevertheless, there exist individual risk factors that can independently increase the rate of CLABSI among hemodialysis patients even in the face of best infection control strategies. These risk factors include the type of central venous catheter, operator’s experience, presence of neutropenia, duration of catheterization, and lengthy hospitalization before insertion of catheter [6,7]. This study assesses the rates of CLABSI among patients admitted in Al-Noor Specialist Hospital, determines the incidence of central line-related bloodstream infections among patients, identifies the commonest organisms responsible for CLABSI among patients, and documents the predisposing factors among patients leading to an increase in the risk of acquiring CLABSI. Knowledge gained through this study will allow the Infection Prevention and Control Department to implement evidence-based practices in the Hospital regarding the care of patients with a central line to ensure better and improved outcomes.

Materials and Methods

This is a prospective observational study conducted between January 2016 to December 2018. In total, 120 patients admitted to a Tertiary Hospital in various departments who had double lumen catheters inserted mainly for hemodialysis (and few patients who had plasmapheresis through it) and with CLABSIs were included. Patients were then followed up and observed for signs of infection including fever, redness, or any pus discharge from the catheter site, rising white-blood-counts, and culture positive. Other causes of infection were excluded. Data were collected using a standard form to gather the information that included patient characteristics, potential underlining factors predisposing patients to CLABSI, CVC access site, and type, and microorganisms isolated through blood cultures. Central line-associated bloodstream infections were defined according to the CDC as the presence of clinical signs of infection, for example, culture growth of the same bacteria from blood extracted from peripheral vein, catheter tip, or blood from catheter of any patient with no other source of infection apart from the catheter [8]. The study included all patients aged 18 years and older admitted to this Tertiary Hospital that requires central line insertion. Those that got transferred to the hospital but had their catheter inserted outside were excluded.

Statistical Analysis:

Statistical analyses were performed with SPSS 20.0 for Windows software (SPSS Inc., Chicago, IL, USA). Data are presented as mean ± SD, median (range), and frequency in percentage (%). Frequencies were compared using the chi-square test. A p-value of <0.05 was considered significant. The CLABSI rate is calculated per 1,000 catheter days. Ethics approval: This study was first approved by the Institutional Review Board of Al-Noor Specialist Hospital, Ministry of Health. Written consent was obtained from the patient to participate in the study.

Discussion

Central Line-Associated Bloodstream Infection Rates

Our study results showed that the CLABI rate overall between 2016 and 2018 was 16.39 per 1000 catheter days. The rates were 30.67, 23.06, and 16.39 in 2016, 2017, and 2018 respectively per 1000 catheter days. These rates though higher than those obtained in countries such as US rate variation like these findings were reported in the WHO South- East Asia Region. For example, such as found in a study carried out by Singh et al., in India, a rate of 0.48 CLABSIs per 1000 CL days who found [9]. Similarly, other studies in the Region such as Chopdekar et al., found CLABSI rates of 27.065, and Singh et al., also found 16.0,66 CLABSIs per 1000 CL days [10,11]. A recent systematic literature review and meta-analysis carried out by Ling et al., also in the South-East Asia Region showed the pooled incidence density of CLABSI to be 4.7 per 1000 catheter-days (95% CI, 2.9-6.5) [12]. Correspondingly, the results in the Eastern Mediterranean WHO Region were similar or higher than obtained in our study. In Iran, the study by Johnson et al., showed 29.3 CLABSIs per 1000 CL days and that of Askarian et al., was 147.3 CLABSIs per 1000 patient-days [13,14]. Findings in the previous study in Saudi Arabia by Balkhy et al., was 8.2 CLABSI rate per 1000 CL days which is similar to the 10.0 rate found by AlTawfiq et al., also in Saudi Arabia [15,16]. The rates in our present study were similar to two studies from Tunisia conducted by Ben Jaballah et al., who found the CLABSI rates per 1000 CL days to be 15.3 and 14 respectively [17,18]. However, in the European WHO Region, the CLABSI rates were lower. For example, in Turkey rates varied ranging from 2.8 CLABSIs per 1000 CL found Tutuncu et al., and 3.8 found by Yalaz et al., days [19,20]. Other studies in the Region such as that of Huang et al., and Dogru et al., reported 7.69 and 11.8 respectively [21,22].

CLABSI Causative microorganism

In our study, we found a common statistically significant (p=0.000) causative organism to be Klebsiella pneumoniae (35%) of all isolated microorganisms. Others are the E.coli, MRSA, Staphylococcus, and Stenotrophomonas. Other studies found coagulase-negative Staphylococci, Staphylococcus aureus, enterococci, and Candida spp. to be the most frequently reported causative pathogens [23]. In CLABSIs reported to CDC by Gaynes R, Edwards, Gram-negative bacilli accounted for 19% while it accounted for 21% Surveillance and Control of Pathogens of Epidemiological Importance (SCOPE) database, respectively [24,25]. Methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella pneumoniae, and E. coli isolated are very important due to their antimicrobial resistivity [24].

Intrinsic Risk Factors (non-modifiable characteristics of patients)

These factors include the patient’s age, underlying diseases or conditions, and patient’s gender. In our study, no statistically significant difference was found in any of these factors except those who had a previous history of CLABSI (p=0.003). Other studies also found no significant relationship between CLABSI and age, sex, or APACHE II scores of the patients [11]. However, we found most patients who had the catheter to be patients on hemodialysis. Among these patients, infection is the most common cause of morbidity, and the second most common cause of death [1]. These infections are numerous and costly as found by a study in 2008 estimated 37,000 BSIs among hemodialysis patients with central lines [2]. Another study a long time ago estimated the cost to treat 1 Bloodstream Infection (BSI) as a result of Staphylococcus aureus to be $24,034 [3]. The implication of this can be understood better when one considered another estimated incidence of sepsis in end-stage renal disease patients found to be up to 100 times higher than in the general population [4]. These risks are prone to increase considering the suggested estimate that the number of patients with end-stage renal disease may increase to 150% by 2020 [1]. Centres for Disease Control and Prevention (CDC) has therefore labeled the challenge as a national priority5 and leading authorities in the field to conclude and the body suggested a more proactive prevention procedure to be part of all routine patient care [6].

Extrinsic Risk Factors (potentially modifiable factors associated with CVC insertion or maintenance) These factors include the prolonged hospitalization before CVC insertion, Multiple CVCs, Parenteral nutrition, Femoral or internal jugular access site, Heavy microbial colonization at the insertion site, Multilumen CVCs, Lack of maximal sterile barriers for CVC insertion, CVC insertion in an ICU or emergency department. In our study, the site commonly used for CVC insertion was femoral. The recent evidence-based prevention of CLABSI advice emphasizes avoiding femoral veins among others known as prevention bundles [8-10]. Previous studies by Lorente et al., and Frasca et al., reported increased infection and complications when the insertion site was either femoral or internal jugular [8,9]. A more recent study also found more frequent infection rate increased when the catheter was inserted through a femoral route (p =0.015) [9].

Recommendation and Conclusion

This study concludes that strict infection control practices with an emphasis on optimum hand hygiene, use of CLABSI prevention bundles, and avoiding femoral CVC insertion site will drastically reduce the incidence of CLABSI.

Declerations

Significance Statement

The occurrence of bacteremia intravenous catheters is a serious healthcare issue. Our study found the history of CLABSI to cause reoccurrence while the most causal organism is Klebsiella pneumoniae. It is suggested that the catheter be promptly removed after use

Acknowledgments

The authors wish to thank colleagues from the Department of Infection Prevention and Control Programme, and the sta of the Medical and Hemodialysis Units, Al Noor Specialist Hospital Makkah, Kingdom of Saudi Arabia for their support during the conduction of this study.

Authors’ contributions

MMA designed the study and interpreted the results. AHA (corresponding author) designed the study tools, performed the preliminary statistical analysis, interpreted the results, prepared the manuscript for publication, and submitted the final manuscript. HK performed final statistical analysis. ZH drafted the study protocol and collected data and critically revised the methodology. DA coordinated data collection and performed data entry. SA drafted the initial study design and reviewed the initial results. NAM participated in data collection. All authors read and approved the final manuscript.

References

1. Maki, Dennis G., Daniel M. Kluger, and Christopher J. Crnich. "The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies." Mayo Clinic Proceedings, Vol. 81, No. 9, 2006, pp. 1159-71.
2. Gahlot, Rupam, et al. "Catheter-related bloodstream infections." International Journal of Critical Illness and Injury Science, Vol. 4, No. 2, 2014, pp. 162-7.
3. Wilcox, Tracie A. "Catheter-related bloodstream infections." Seminars in Interventional Radiology, Vol. 26, No. 2, 2009, pp. 139-43.
4. Chopra, Vineet, et al. "Prevention of central line-associated bloodstream infections: brief update review." Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Rockville (MD): Agency for Healthcare Research and Quality (US), 2013.
5. Zimlichman, Eyal, et al. "Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system." JAMA Internal Medicine, Vol. 173, No. 22, 2013, pp. 2039-46.
6. Bong, Jin J., et al. "The use of a rapid in situ test in the detection of central venous catheter-related bloodstream infection: a prospective study." Journal of Parenteral and Enteral Nutrition, Vol. 27, No. 2, 2003, pp. 146-50.
7. Dobbins, Brian M., Mark H. Wilcox, and Mlchael J. McMahon. "Rapid diagnosis of central-venous-catheter-related bloodstream infection without catheter removal." The Lancet, Vol. 354, No. 9189, 1999, pp. 1504-7.
8. Horan, Teresa C., Mary Andrus, and Margaret A. Dudeck. "CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting." American Journal of Infection Control, Vol. 36, No. 5, 2008, pp. 309-32.
9. Singh, S., et al. "Surveillance of device-associated infections at a teaching hospital in rural Gujarat-India." Indian Journal of Medical Microbiology, Vol. 28, No. 4, 2010, pp. 342.
10. Chopdekar, K., et al. "Central venous catheter-related blood stream infection rate in critical care units in a tertiary care, teaching hospital in Mumbai." Indian Journal of Medical Microbiology, Vol. 29, No. 2, 2011, pp. 169.
11. Singh, Shivinder, et al. "Incidence of healthcare associated infection in the surgical ICU of a tertiary care hospital." Medical Journal Armed Forces India, Vol. 69, No. 2, 2013, pp. 124-9.
12. Ling, Moi Lin, Anucha Apisarnthanarak, and Gilbert Madriaga. "The burden of healthcare-associated infections in Southeast Asia: a systematic literature review and meta-analysis." Clinical Infectious Diseases, Vol. 60, No. 11, 2015, pp. 1690-9.
13. Johnson, Erica N., Vincent C. Marconi, and Clinton K. Murray. "Hospital-acquired device-associated infections at a deployed military hospital in Iraq." Journal of Trauma and Acute Care Surgery, Vol. 66, No. 4, 2009, pp. S157-63.
14. Askarian, Mehrdad, et al. "Incidence and outcome of nosocomial infections in female burn patients in Shiraz, Iran." American Journal of Infection Control, Vol. 32, No. 1, 2004, pp. 23-6.
15. Balkhy, Hanan H., et al. "Neonatal rates and risk factors of device-associated bloodstream infection in a tertiary care center in Saudi Arabia." American Journal of Infection Control, Vol. 38, No. 2, 2010, pp. 159-61.
16. Al-Tawfiq, Jaffar A., Antony Amalraj, and Ziad A. Memish. "Reduction and surveillance of device-associated infections in adult intensive care units at a Saudi Arabian hospital, 2004–2011." International Journal of Infectious Diseases, Vol. 17, No. 12, 2013, pp. e1207-11.
17. Ben, N. Jaballah, et al. "Epidemiology of nosocomial bacterial infections in a neonatal and pediatric Tunisian intensive care unit." Medicine and Infectious Diseases, Vol. 36, No. 7, 2006, pp. 379-85.
18. Jaballah, Nejla Ben, et al. "Epidemiology of hospital-acquired bloodstream infections in a Tunisian pediatric intensive care unit: a 2-year prospective study." American Journal of Infection Control, Vol. 35, No. 9, 2007, pp. 613-8.
19. Tutuncu, Emin E., et al. "Device-associated infection rates and bacterial resistance in the intensive care units of a Turkish referral hospital." Saudi Medical Journal, Vol. 32, No. 5, 2011, pp. 489-94.
20. Yalaz, Mehmet, et al. "Evaluation of device-associated infections in a neonatal intensive care unit." The Turkish Journal of Pediatrics, Vol. 54, No. 2, 2012, pp. 128.
21. Huang, Yhu-Chering. "Device-associated healthcare-associated infections in the neonatal intensive care unit." Pediatrics and Neonatology, Vol. 54, No. 5, 2013, pp. 293-4.
22. Dogru, Arzu, et al. "The rate of device-associated nosocomial infections in a medical surgical intensive care unit of a training and research hospital in Turkey: one-year outcomes." Japanese Journal of Infectious Diseases, Vol. 63, No. 2, 2010, pp. 95-8.
23. Wisplinghoff, Hilmar, et al. "Nosocomial bloodstream infections in US hospitals: analysis of 24,179 cases from a prospective nationwide surveillance study." Clinical Infectious Diseases, Vol. 39, No. 3, 2004, pp. 309-17.
24. Weinstein, Robert A., et al. "Overview of nosocomial infections caused by gram-negative bacilli." Clinical Infectious Diseases, Vol. 41, No. 6, 2005, pp. 848-54.
25. Atilla, Aynur, et al. "Central line-associated bloodstream infections in the intensive care unit: importance of the care bundle." Korean Journal of Anesthesiology, Vol. 69, No. 6, 2016, pp. 599-603.