|Year : 2021 | Volume
| Issue : 1 | Page : 28-32
Incidence, risk factors, and microbiology of central venous catheterization-associated bloodstream infections at a surgical tertiary intensive care unit
Abhishek Shrivastava1, Shalendra Singh1, Priya Taank2, Kaminder Bir Kaur1, KC Pradip1, Vikas Marwah3, Munish Sood4
1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, India
2 Department of Ophthalmology, Command Hospital (SC), Pune, Maharashtra, India
3 Department of Pulmonology and Critical Care, Military Hospital CTC, Pune, Maharashtra, India
4 Department of Orthopaedics, INHS, Mumbai, Maharashtra, India
|Date of Submission||18-Jul-2020|
|Date of Acceptance||22-Nov-2020|
|Date of Web Publication||5-May-2021|
Dr. Shalendra Singh
Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune - 410 040, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Central venous catheters (CVCs) can act as a portal for bloodstream infections, which increases the morbidity and mortality in intensive care units (ICUs). Objective: The primary aim of this study was to find out the incidence, to ascertain risk factors of bloodstream infections related to CVC, and to know the microbiological profile of organisms causing catheter-related bloodstream infection (CRBSI) in an ICU of a tertiary level hospital. Methodology: All patients who had CVC insertion in the operation theater before the procedure and were later transferred to ICU, and those patients who were directly admitted to the ICU and had CVC inserted were included in the study. On suspicion of an insertion-site infection, site swabs were sent for microbiological analysis. If catheter tip colonization/infection or CRBSI was suspected, the CVC was removed, and the tip of the catheter along with two sets of blood (peripheral and central) was sent for culture analysis. A semi-quantitative culture analysis was done to confirm CRBSI. Results: On review of data, 150 patients with cumulative 1056 catheter surveillance days revealed an incidence of 24.66% for CVC-related infections, which included exit site infections (5.33%), catheter tip infections (13.33%), and CRBSI (6%). The rate of CRBSI associated with CVCs placed in the surgical ICU was 35.3 per 1000 catheter surveillance days. Staphylococcus aureus was the most common organism causing CRBSI and CONS (coagulase-negative staphylococcus) was the most common organism causing catheter tip and exit site infections.
Keywords: Catheter, catheter-related bloodstream infection, central venous catheterization, infection, Staphylococcus aureus, the intensive care unit
|How to cite this article:|
Shrivastava A, Singh S, Taank P, Kaur KB, Pradip K C, Marwah V, Sood M. Incidence, risk factors, and microbiology of central venous catheterization-associated bloodstream infections at a surgical tertiary intensive care unit. J Sci Soc 2021;48:28-32
|How to cite this URL:|
Shrivastava A, Singh S, Taank P, Kaur KB, Pradip K C, Marwah V, Sood M. Incidence, risk factors, and microbiology of central venous catheterization-associated bloodstream infections at a surgical tertiary intensive care unit. J Sci Soc [serial online] 2021 [cited 2021 Jun 17];48:28-32. Available from: https://www.jscisociety.com/text.asp?2021/48/1/28/315454
| Introduction|| |
Central venous catheters (CVCs) are an integral part of patient care in the intensive care unit (ICU). CVCs are often used as a portal for the delivery of medications, parenteral nutrition, and collection of blood samples and monitoring of hemodynamic variables in critically ill patients. However, complications associated with CVCs occur in 15% of patients, which include mainly infectious complications (5%–26%), mechanical complications (5%–19%), and thrombotic complications (2%–26%). These complications result in increased morbidity and mortality causing prolongation of ICU and hospital stay.
In the ICU setting, the incidence of infection is often higher than in perioperative/ambulatory care setting as CVCs might be needed for extended periods associated with colonization with hospital-acquired organisms, frequent handling of CVC line for drugs, and infusions. Moreover, some catheters will be inserted in urgent situations, during which optimal attention to aseptic technique might not be feasible, and this unintentional breach of sterility adds to the risk.
Due to the paucity of data on CVCs-associated infection from our region of the country, we planned to conduct this study in the surgical ICU of a tertiary care government hospital. The primary aim of this study was to find out the incidence and risk factors of bloodstream infections related to CVCs in the surgical ICU of a tertiary level hospital. The secondary aim was to determine the distribution of organisms involved in the causation of catheter-related bloodstream infection (CRBSI) as secondary outcomes.
| Methodology|| |
This was a prospective observational study carried out in a surgical ICU of a tertiary level hospital for a period of 13 months between May 2017 to June 2018. Institutional ethics committee approval and written informed consent were taken. 150 patients, between 14 and 86 years, received CVC in the jugular, subclavian, or femoral vein either as a part of anesthetic care in the operation theater or in the ICU, were enrolled for this study. Patients with the presence of any significant uncorrected coagulopathy or platelet count <50,000/cumm were excluded from the study. All the cannulations were performed either by an ICU consultant or by a 2nd or 3rd-year resident (with a minimum prior experience of at least 20 CVC insertions under the supervision of a consultant). The choice of the CVC insertion site (either internal jugular vein [IJV]/subclavian vein/femoral) was left to the discretion of the performing doctor. All lines were placed percutaneously using the seldinger technique. Aseptic precautions in the form of the use of a cap, mask, sterile gloves, full-sleeved sterile gown, and large sterile drapes and skin preparation with 2% chlorhexidine with 70% alcohol were followed for all CVC insertions. After CVC insertion, the inserted site was covered by a dry sterile gauze occlusive transplant dressing for 24 h and then changed to a sterile, transparent, semipermeable dressing. No topical antibiotic ointment was used on insertion sites. Local signs of infection such as purulence, erythema, and induration were checked regularly by palpation daily during dressing change. On suspicion of an insertion-site infection, site swabs were sent for microbiological analysis. If catheter tip colonization/infection or CRBSI was suspected, the CVC was removed, and the tip of the catheter along with two sets of blood (peripheral and central) was sent for culture analysis. A negative semi-quantitative culture (SQC) result was defined as an SQC yielding <15 colony-forming units (CFUs) in the absence of positive blood culture. Catheter-associated infections were defined as follows:
- Exit site infection erythema, tenderness, induration, or purulence within 2 cm of skin at the insertion site of the catheter along with microbiological growth on the culture of the purulent exudates
- Catheter tip colonization growth of more than 15 CFUs on the culture of the distal segment of the CVC with clinical signs of infection
- CRBSI isolation of the same organism from the catheter tip culture and at least one of the two blood cultures, along with signs and symptoms of infection.
Thus, patients with clinical signs of infection and in whom the CVC tip yielded a positive growth (but without associated bacteremia) were considered as having catheter tip infections, while patients with clinical evidence of infection along with positive growth of the same organism on blood culture as well as CVC tip were diagnosed to have CRBSI. Besides the data related to CVCs, the outcomes of all patients at the end of ICU stay, i.e., died or discharged, were also recorded.
SPSS (Statistical Package for Social Sciences) Software Version 20.0 was used for statistical analysis. Results were expressed as the means, standard deviations (SD), numbers, and percentages (%). The measure of the strength of the association between the two variables was done using the P values obtained through the Chi-square test. P < 0.05 was considered to be significant.
| Results|| |
One hundred and fifty patients with CVCs placed in the surgical ICU were enrolled in the study, making 1056 catheter surveillance days. Univariate analysis comparing the demographic profile revealed 63% males and 37% females with an overall mean age of 53.82 ± 16.4 years [Table 1]. Insertion site variable analysis showed that internal jugular is the most preferred site in 86.6% of patients [Table 1]. It revealed an incidence of 24.66% for CVC-related infections, which included exit site infections (5.33%), catheter tip infections (13.33%), and CRBSI (6%). The rate of CRBSI associated with CVCs placed in the surgical ICU was 35.3 per 1000 catheter surveillance days. Staphylococcus aureus was the most common organism causing CRBSI, and CONS was the most common organism causing catheter tip and exit site infections. Out of all the multiple times CVCs placed, 92% were elective and 8% were placed as an emergency procedure, with 87 (58%) catheters being placed in the first attempt, 53 (35.3%) in two attempts and 10 (6.7%) in three or more attempts. The mean duration of catheterization was 7.04 ± 2.2 days. A total of 9 (6%) catheters were in situ for <3 days and 141 (94%) catheters were in for more than 3 days [Table 2]. The increased duration of the catheter in situ in the patient has a significant increase in the incidence of infection. Exit site infection was present in 8 (5.33%) patients.
|Table 1: Univariate analysis comparing the demographic profile and insertion characteristics among different cannulation site|
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|Table 2: The frequency distribution of variables related to catheter-associated infections|
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Twenty-nine catheters were positive on SQC, of which 20 (13.33%) had Catheter tip colonization and 9 (7.41%) had CRBSI. The rate of infections associated with CVCs placed in the surgical ICU was 35.03 per 1000 catheter days. Five organisms were found responsible for CRBSI in blood culture with S. aureus being the dominant isolate.[Table 2]. Exit site infections causing organisms were coagulase-negative staphylococci (CONS) (3/8, i.e., 37.50%), S. aureus (2/8 i.e., 25%), Escherichia coli (1/8 i.e., 12.50%), Pseudomonas (1/8 i.e., 12.50%), and Acinetobacter (1/8 i.e., 12.50%).
The clinically significant factors that directly correlated with the risk of CRBSI were found to be site (subclavian vs. femoral vs. IJV), procedure (elective vs. emergency), the number of punctures (one vs. two vs. three), duration (<3 days vs. >3 days), side of insertion (Rt vs. Lt), technique (ultrasonography vs. landmark), and the number of lumens [Table 3]. The growth pattern in culture taken from exit site exudates was no growth in 60% of cases, CONS (15%), S. aureus (10%), and 5% each of Pseudomonas, Acinetobacter, and E. coli. 5% of patients died who had exit site exudate culture positive. In CRBSI, four patients out of 23 were known cases of hypertension (HTN) and diabetes mellitus; however, in exit site infection, 2 patients out of 23 are known cases of HTN and diabetes mellitus. Patient-related factors included age, comorbidities such as HTN, diabetes mellitus, and immunosuppression showed relevance in causing CRBSI. In catheter tip infection, two patients out of 23 were known cases of HTN and diabetic mellitus. A total of 8 (5%) patients whom CVC inserted died over a study period.
|Table 3: The frequency distribution of patients for different sites of central venous cannulation according to Catheter tip culture, blood culture, exit site exudate culture|
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| Discussion|| |
Our study revealed a total of 24.6% of CVC-related infections, which included exit site infections (5.33%), catheter tip infections (13.33%), and CRBSI (6%). The rate of CRBSI associated with CVCs placed in the surgical ICU was 35.3 per 1000 catheter line days which is above 90th percentile of Brazilian ICUs (11.8 CVC-BSIs per 1000 CVC-days) and higher than National Healthcare Safety Network (NHSN 2013 estimated incidence of 1.2 BSIs/1000 CVC-days in medical ICUs in the USA). This incidence was 30 times higher than in the USA, which might be due to heterogeneous groups of population with multiple comorbidities during the time of admission itself, catheter-related factors which were quite significant in our study, and the user-related factors. The statistically significant risk factors in our study are concomitant with APIC guidelines for the prevention of CRBSI.
Our study revealed similar results as were shown by a study conducted by Parameswaran et al. in 2001, which had Staphylococcus aureus as the most common organism causing CRBSI and CONS was the most common organism causing catheter tip and exit site infections. Incidence of CRBSI might have been higher in our studies than the general trend in epidemiology as a recent review by Maki et al. of over 200 published reports found incidence and estimate of density to vary between 0.1% and 22.5% and between 0.1 and 2.7/1000 catheter line days. In a study by Atilla et al., the catheterization duration was significantly longer in patients with a CLABSI (P ≤ 0.01), and the frequency was higher with the femoral access than in other routes, which corroborated with our results. Our study points attention to underlying medical conditions as an important risk factor for developing CRBSI. The presence of HTN and diabetes was significantly associated with CRBSI incidence. In a study by Callister et al., prolonged catheter days were significantly related to increased chances of infection, both CRBSI and exit site infection. Our study supported these results.
Various bundles are in place to reduce the incidence of CRBSI (APIC guidelines); however, even with the application of the bundle and strictly following the guidelines, CRBSI, if occurs, forms a great threat to patient safety, leading to increased morbidity, mortality, and economic burden.,,
The limitations of our study include a single-centered study, lack of checklist for the pre-placement, and daily handling of a CVC (following of bundles) and also the short duration of the study. Another limitation of our study is the insufficient study subjects making it difficult to draw a definitive conclusion on the incidence of CVC-related bloodstream infections in the region.
| Conclusion|| |
This study revealed the incidence of catheter-related infection in patients of an ICU and discloses risk factors for catheter-related infection, factors related to patients' conditions, but also to medical personnel practice that needs to be improved. It gave us an idea about the epidemiology of infection in our country. The incidence of 24.66% for CVC-related infections revealed in our study. The rate of CRBSI associated with CVCs placed in the surgical ICU was 35.3 per 1000 catheter surveillance days. The predominant microorganism isolated was S. aureus. The intermittent close observation of the epidemiology of organisms is important in taking preventable measures for the prevention of infection, and its control measures such as hand hygiene, better nurse–patient ratio, and total asepsis during the procedure is important.
We are indebted to the doctors, residents, and nurses of the ICU who provided care for the patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaur R, Mathai AS, Abraham J. Mechanical and infectious complications of central venous catheterizations in a tertiary-level intensive care unit in northern India. Indian J Anaesth 2012;56:376-81.
] [Full text]
Ramritu P, Halton K, Cook D, Whitby M, Graves N. Catheter-related bloodstream infections in intensive care units: A systematic review with meta-analysis. J Adv Nurs 2008;62:3-21.
Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: A meta-analysis of the literature. Crit Care Med 1996;24:2053-8.
Ministry of Health. National Health Surveillance Agency (ANVISA) Newsletter: Patient Safety and Quality in Health Services no11, Year VI. Evaluation of national indicators of care-related infection in 2014 and progress report. 2015;37.
Dudeck M. A, Edwards J. R, Allen-Bridson K, et al
. National healthcare safety network report, data summary for 2013, device-associated module. American Journal of Infection Control. 2015;43:1–19.
Parameswaran R, Sherchan JB, Varma D M, Mukhopadhyay C, Vidyasagar S. Intravascular catheter-related infections in an Indian tertiary care hospital. J Infect Dev Ctries 2011;5:452-8.
Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: A systematic review of 200 published prospective studies. Mayo Clin Proc 2006;81:1159-71.
Atilla A, Doğanay Z, Çelik HK, Tomak L, Günal Ö, Kılıç SS. Central line-associated bloodstream infections in the intensive care unit: Importance of the care bundle. Korean J Anesthesiol 2016;69:599-603.
Callister D, Limchaiyawat P, Eells SJ, Miller LG. Risk factors for central line-associated bloodstream infections in the era of prevention bundles. Infect Control Hosp Epidemiol 2015;36:214-6.
Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee Society for Healthcare Epidemiology of America Association for Professionals in Infection Control Infectious Diseases Society of America Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23:S3-40.
Padilla Fortunatti CF. Impact of two bundles on central catheter-related bloodstream infection in critically ill patients. Rev Lat Am Enfermagem 2017;25:e2951.
Lin WP, Chang YC, Wu UI, Hung MC, Chuang PY, Wang JT, et al
. Multimodal interventions for bundle implementation to decrease central line-associated bloodstream infections in adult intensive care units in a teaching hospital in Taiwan, 2009-2013. J Microbiol Immunol Infect 2018;51:644-51.
[Table 1], [Table 2], [Table 3]