CLABSI Prevention in the Post-COVID-19 Era

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CVADs: Essential Vascular Access Devices

Central Venous Access Devices (CVADs)—typically long catheters with tips terminating in larger veins near the heart—are commonly used for stable, long-term vascular access. They serve various purposes, including infusion therapy and administering nutrition and medications in outpatient and acute care settings.¹ There are 4 main CVAD classes: tunneled central venous catheter (CVC), non-tunneled CVC, peripherally inserted central catheter (PICC), and totally implantable venous access port (TIVAP).² For many patients, CVADs are lifelines.

Understanding CLABSIs: Risks and Impact

Central line-associated bloodstream infections (CLABSIs) are publicly reported healthcare-associated infections in acute care, tied to hospital reimbursement by the Centers for Medicare and Medicaid Services (CMS).³ The $2 billion spent each year to treat CLABSIs in the US has caught the attention of policymakers, as the infections are regarded as largely preventable.⁴

CLABSIs remain a concern, regardless of whether one uses the National Health Safety Network’s (NHSN’s) surveillance-based definition (focusing on CVAD duration and lab confirmation) or the Infectious Disease Society of America’s (IDSA’s) clinical criteria (emphasizing clinical signs and specific blood culture results).⁵ Pediatric-specific risk factors include prematurity, parenteral and lipid infusions for neonates, and genetic syndromes.⁶ Moreover, parenteral nutrition, multilumen devices, chemotherapy treatment, immune system compromise and the duration of catheterization place all patients at risk for CLABSIs.⁷ In neonatal intensive care unit (NICU) patients, CLABSIs also impact neurodevelopmental outcomes, adjusted hospital costs, and lengths of stay.^8-10

Overall, CLABSIs increase morbidity, prolong hospital stays, and raise mortality rates by 12-25%.⁵

Optimizing CLABSI Prevention Strategies Through Stratification

The NHSN employs a standardized infection ratio (SIR) to monitor and improve prevention efforts. This ratio compares the actual number of CLABSIs reported by hospitals to the expected number based on central line days and hospital characteristics.¹¹ However, NHSN estimates of preventable CLABSIs may be overly broad, as they do not differentiate patients with unpreventable etiologies for bacteremia, such as advanced obstructive biliary malignancies.

Thus, experts have argued that further stratifying the surveillance-based CLABSI definition to account for end-of-life CLABSI or factors unrelated to a patient’s central line would acknowledge bloodstream infections (BSIs) nearly unpreventable due to underlying comorbidities. This distinction could aid clinical reflection on which patients would benefit from early goals of care discussions instead of practicing reflexive medicine.¹²

Progress and Challenges: CLABSI Reduction in the US

The US witnessed substantial progress in reducing CLABSIs from 2015 to 2019, achieving a 31% decline in the national SIR.¹¹ CLABSI bundle elements such as insertion with sterile barriers, hand washing, use of disinfectant, and careful selection of insertion sites contributed to this success. Other important approaches included maintenance protocols, timely CVAD removal, and technological innovations, such as antimicrobial catheters and port protectors.¹³

Unfortunately, the COVID-19 pandemic disrupted this progress. Notably, during the latter part of 2020, CLABSI rates surged by 46% to 47% compared to the previous year. Even in 2021, CLABSI rates remained persistently elevated, hitting their highest point between July and September.¹¹ A retrospective analysis of 78 US hospitals over 12 months before and 6 months during the pandemic revealed Coagulase-negative Staphylococcus CLABSIs increased by 130% (from 0.07 to 0.17 events per 1,000 line days) and Candida spp by 56.9% (from 0.14 to 0.21 per 1,000 line days).³

Figure 1: Examples of CLABSI Prevention Strategies^15,18

(Credit: Author)

CLABSI rates have also fluctuated across healthcare settings, particularly affecting critically ill children in low-income neighborhoods.¹⁴ Therefore, further efforts are needed, as addressing preventable CLABSI cases (65% to 70%) could improve patient safety and result in cost savings.¹³

Journey to Fewer CLABSIs

Evidence-Based Recommendations

Based on the 2022 Executive Summary from SHEA/IDSA/APIC, health care professionals should prioritize using ultrasound guidance when inserting a catheter, ideally at a subclavian location, and daily chlorhexidine gluconate (CHG) bathing for ICU patients aged older than 2 months.¹⁵

However, continuous use of CHG may have limitations, such as adverse events or, in the case of nursing home residents, rendering the antiseptic ineffective by developing more multidrug-resistant organisms in these vulnerable individuals.¹⁶ Fortunately, results from the PROTECT trial showed a promising additive effect of nasal iodophor on CHG bathing as a strategy for reducing infection-related transfers of nursing home residents to hospitals.^16,17

Other evidence-based recommendations include maintaining an appropriate nurse-to-patient ratio, reducing float nurses in the ICU, using chlorhexidine-containing dressings for CVADs, and monitoring for CLABSI both inside and outside of ICU settings (Figure 1).^15,18 Additionally, vascular access line guards serve a dual purpose: maintaining tubing visibility and protecting patients and staff during intravenous drug delivery, eg, chemotherapy.¹⁹ The Association for Vascular Access has also provided a guide for patients and families to prevent infection (Figure 2).²⁰

Recent Trends and Successes

Figure 2: I Save that Line: Patient and Caregiver Poster (with copyright permission from the American Association of Vascular Access)²⁰

Collectively, care bundles including common elements such as hand hygiene, maximal sterile barrier precautions, and effective skin antisepsis have been shown to effectively reduce CLABSI—up to 60% in select NICUs and 66% across 103 ICUs in 67 hospitals with more than 375,000 catheter-days of observation.^21,22

Between 2021 and 2022, the NHSN also reported a 9% national reduction in CLABSI cases, with the most significant decline observed in the ICU (21%). Moreover, Bohan and colleagues analyzed a CLABSI increase during COVID-19 at their institution. They identified opportunities for improvement, including novel insertion and maintenance elements of prevention bundles. By addressing dressing disruptions and implementing secure texting for timely central line removal, among other factors, their interprofessional team reduced CLABSI by over 40% from 2021 (1.6 per 1,000 line days) to the fourth quarter of 2022 (0.91), maintaining a rate below or around the national average (0.86) for the last 3-quarters of 2022.¹³

An interprofessional approach, which also integrated nurses' learning needs, resulted in a significant decrease in CLABSI rates. Specifically, Baldassare and colleagues reported a 75% reduction in CLABSI rates from 2012 to 2013, with the monthly rate dropping from 2.92 infections to 0.74 during that period.

After December 2013, the rate remained at zero for 7 consecutive months.²³ Weekly rounding of an interprofessional team to focus efforts on identifying and addressing real-time concerns regarding central lines also led to short-term CLABSI reductions in one pediatric cardiac ICU.²⁴ These studies highlight the importance of interprofessional teams consistently implementing prevention bundles and patient involvement in reducing CLABSI rates.

Quo Vadis, CLABSIs?

The decline in CLABSI incidence, driven by technology and redoubled infection prevention efforts, warrants both optimism and vigilance. The current CLABSI prevention system remains fragile, particularly during crises like the pandemic. O’Grady has proposed a streamlined CLABSI rate definition, covering all hospital-acquired bacteremia cases as captured by technology. Additionally, simultaneously implementing multiple evidence-based prevention strategies, even if seemingly redundant, could enhance reliability in a system that lacks real-time adaptability to evolving situations.²⁵

References

1. Alexander M, Corrigan A, Gorski L, et al. Infusion nursing: An evidence-based approach. Elsevier Health Sciences; 2009.

2. Fu M, Yuan Q, Yang Q, et al. Risk factors and incidence of central venous access device-related thrombosis in hospitalized children: a systematic review and meta-analysis. Pediatric Research. 2024.

3. Fakih MG, Bufalino A, Sturm L, et al. Coronavirus disease 2019 (COVID-19) pandemic, central-line-associated bloodstream infection (CLABSI), and catheter-associated urinary tract infection (CAUTI): The urgent need to refocus on hardwiring prevention efforts. Infect Control Hosp Epidemiol. 2022;43(1):26-31.

4. Theodoro D, Olsen MA, Warren DK, et al. Emergency Department Central Line-associated Bloodstream Infections (CLABSI) Incidence in the Era of Prevention Practices. Acad Emerg Med. 2015;22(9):1048-55.

5. Chopra V. Central Line-Associated Bloodstream Infection (CLABSI): An Introduction. Centers for Disease Control and Prevention (CDC). Updated 2024. Accessed June 27, 2024. https://www.cdc.gov/infection-control/media/pdfs/Strive-CLABSI101-508.pdf

6. Prestel C, Fike L, Patel P, et al. A Review of Pediatric Central Line-Associated Bloodstream Infections Reported to the National Healthcare Safety Network: United States, 2016–2022. Journal of the Pediatric Infectious Diseases Society. 2023;12(9):519-521.

7. Lafuente Cabrero E, Terradas Robledo R, Civit Cuñado A, et al. Risk factors of catheter-associated bloodstream infection: Systematic review and meta-analysis. PLoS One. 2023;18(3):e0282290.

8. Mahieu LM, De Dooy JJ, Lenaerts AE, et al. Catheter manipulations and the risk of catheter-associated bloodstream infection in neonatal intensive care unit patients. J Hosp Infect. 2001;48(1):20-6.

9. Payne NR, Barry J, Berg W, et al. Sustained reduction in neonatal nosocomial infections through quality improvement efforts. Pediatrics. 2012;129(1):e165-73.

10. Stoll BJ, Hansen NI, Adams-Chapman I, et al. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. Jama. 2004;292(19):2357-65.

11. Harrington EM, Trautman K, Davis MB, et al. Descriptive epidemiology of central line-associated bloodstream infections at an academic medical center in Iowa, 2019-2022. Am J Infect Control. 2024;52(4):436-442.

12. Hsueh L, de St Maurice A, Uslan DZ. Utilizing new subdefinitions to improve the identification of preventable central-line-associated bloodstream infections (CLABSIs). Infect Control Hosp Epidemiol. 2023;44(3):523-524.

13. Bohan CO, Mlinarich J, Hahn D, et al. The CLABSI Playbook: Design and Implementation of a Multipronged Approach to Decrease CLABSIs. J Healthc Qual. 2024;46(3):131-136.

14. Gutierrez SA, Chiou SH, Raghu V, et al. Associations between hospital-level socioeconomic patient mix and rates of central line-associated bloodstream infections in short bowel syndrome: A retrospective cohort study. JPEN J Parenter Enteral Nutr. 2024;

15. Yokoe DS, Advani SD, Anderson DJ, et al. Executive Summary: A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute-Care Hospitals: 2022 Updates. Infect Control Hosp Epidemiol. 2023;44(10):1540-1554.

16. Katz MJ, Cosgrove SE. Universal Decolonization in Nursing Homes - Apparent Benefits but Feasible? N Engl J Med. 2023;389(19):1815-1816.

17. Miller LG, McKinnell JA, Singh RD, et al. Decolonization in Nursing Homes to Prevent Infection and Hospitalization. N Engl J Med. 2023;389(19):1766-1777.

18. Yokoe DS, Advani SD, Anderson DJ, et al. Introduction to A Compendium of Strategies to Prevent Healthcare-Associated Infections In Acute-Care Hospitals: 2022 Updates. Infect Control Hosp Epidemiol. 2023;44(10):1533-1539.

19. Doellman D. Guarding the central venous access device: a new solution for an old problem. Br J Nurs. 2023;32(19):S20-s25.

20. I Save That Line: A Guide for Patients and Families. Association for Vascular Access. Updated 2024. Accessed 5 July, 2024. https://cdn.ymaws.com/www.avainfo.org/resource/resmgr/files/i_stl_patient_guide_final.ol.pdf

21. Muller M, Bryant KA, Espinosa C, et al. SHEA Neonatal Intensive Care Unit (NICU) White Paper Series: Practical approaches for the prevention of central-line-associated bloodstream infections. Infect Control Hosp Epidemiol. 2023;44(4):550-564.

22. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-32.

23. Baldassarre D, Finkelston G, Decker M, et al. Fighting CLABSI: An Interdisciplinary Approach for Best Practice Outcomes. Journal of Health Science. 2014;2:453-457.

24. Welter A, Villanueva J. CLABSI reduction strategy: utilizing weekly rounds with an interdisciplinary team. Pediatric Quality & Safety. 2022;7:e611.

25. O'Grady NP. Prevention of Central Line-Associated Bloodstream Infections. N Engl J Med. 2023;389(12):1121-1131.