Reviewed by: Dr. Michael Payne, MD; London Health Sciences Centre
Central line-associated bloodstream infections (CLABSI) are associated with both increased patient morbidity and health care system costs. The foundation of CLABSI prevention is a bundle of interventions directed at decreasing the risk of infection by improving practices before, during and after line insertion. SHEA/IDSA/APIC have provided an evidence based 2022 update to their previous 2014 guidelines, outlining practices to prevent CLABSI. CLABSI bundle interventions were recently evaluated in a large cluster randomized REDUCCTION trial which failed to show benefit of a bundle intervention approach to prevent CLABSI infections in a hemodialysis population. However, some components of the study interventions were present at baseline for study sites, as well the baseline infection rate for this study population were low, which may limit the power of this study to detect an effect and may not reflect bundle effectiveness in other acute/critical care settings.
The updated SHEA/IDSA/APIC practice recommendations separate interventions into those which are essential practices that should be adopted by all acute-care hospitals or those which are additional approaches that can be considered for use when CLABSIs are not controlled after implementation of essential practices. Key updates include: preference for the subclavian vein for placement, recommended use of chlorhexidine-containing dressings and the routine replacement of administration sets (for non-blood or lipid products) to occur up to 7 days.
The REDUCCTION study evaluated if multifaceted interventions (care bundles) reduce catheter related bloodstream infections (CRBSIs) from central venous catheters used for hemodialysis. Using a stepped wedge, cluster randomized design set in 37 renal services across Australia, it included all adult patients who required insertion of a new hemodialysis catheter. A baseline observational period occurred for all study sites, followed by a service-wide multifaceted intervention care bundle that included elements of catheter care (insertion, maintenance, and removal). Care bundles were implemented at one of three randomly assigned time points between December 2016 and March 2020. The primary endpoint was the rate of CRBSI in the baseline phase compared with intervention phase at the renal service level using the intention-to-treat principle. A total of 1.14 million hemodialysis catheter days were included for 6364 patients. A total of 315 CRBSIs occurred (158 in the baseline phase and 157 in the intervention phase) with a rate of 0.21 per 1000 days of catheter use in the baseline phase and 0.29 per 1000 days in the intervention phase, giving an incidence rate ratio of 1.37 (95% confidence interval 0.85 to 2.21; P=0.20). The rates in both the baseline and intervention phases are lower than the calculated expected rate for this study of 2.5 per 1000 days of catheter use (based on pilot data and published literature). However, even with the lower rates found in this study, this still translates to one in 10 patients who undergo dialysis for a year with a catheter experiencing an episode of CRBSI. Therefore, in this study the implementation of a multifaceted intervention did not reduce the rate of CRBSI among hemodialysis patients. However, many centers in this study already had implemented components of the intervention bundle previous to study and the rate of CRBSI was low at baseline which would decrease the power of study to detect an effect of the intervention. This study may suggest that centers that have implemented standard of care practices, as recommended by guidelines, may not see further reductions in nosocomial infections with structured care bundle interventions, particularly for lower risk populations with central lines.
References:
Sradha Kotwal, et al. Multifaceted intervention to reduce haemodialysis catheter related bloodstream infections: REDUCCTION stepped wedge, cluster randomised trial. BMJ 2022;377:e069634. DOI: https://doi.org/10.1136/bmj-2021-069634. Niccolò Buetti, et al. Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infection Control & Hospital Epidemiology (2022), 1–17. DOI: https://doi.org/10.1017/ice.2022.87.