Reviewed by Valeria Fabre, MD, Johns Hopkins University School of Medicine
Central-line–associated bloodstream infections (CLABSIs) are preventable healthcare-associated infections with high morbidity, mortality, and hospital readmissions. Reducing blood culture contamination, optimizing central line care and correct identification of CLABSIs are important strategies for CLABSI prevention. These strategies are discussed in the following 3 articles.
Recognizing that 60% of CLABSIs are non-insertion related (maintenance), Gohil and colleagues sought to assess whether directed attention to line insertion sites using a standardized nursing-physician score could improve central-line (CL) care. Patients with temporary, non-tunneled, non-dialysis CLs were included. A Central-Line Insertion Site Assessment (CLISA) score was developed that quantifies erythema in relation to the standardized width of a central venous catheter (3 mm) and provides a practice recommendation. Any purulence yields the maximum score of 3. A score of 2 or 3 prompts discussion of line removal. The tool was integrated into the EHR where nurses documented a CLISA score on every shift and the score was subsequently reported in the EHR to the physician for documentation of central line (CL) indication. The intervention led to a reduction of lines with a CLISA score 2-3 by almost 80% (22%to ~5%), and faster removal of CLs in patients with a CLISA score 2 or 3 (from 6 days to 3 days). The authors also observed an increase in documentation of CL insertion site exam for both physicians and nurses. Even though there was a non-statistically significant decrease in CLABSI rates, there was a significant decrease in device days. Nurses reported the tool was easy to adopt and facilitated standardized communication with prescribers regarding CL management. This study highlights the benefit of improved communication between nurses and prescribers and standardization of CL assessment and management. In this single center study with low CLABSI rates, erythema assessment through the CLISA tool was a metric-friendly approach that reduced CL utilization and improved CL care.
Current NHSN site-specific definitions have some limitations with respect to clinical criteria and gut translocation in neonates that may lead to potential misclassification and inaccurate reporting. Advani and colleagues evaluated the epidemiology of healthcare-associated bloodstream infections (HABSIs) and identified opportunities for NHSN-site specific definitions for more accurate reporting in this patient population. The authors conducted a retrospective single center-study in a 54-bed neonatal intensive care unit (NICU) at a university hospital over 6 years. HABSI cases were reviewed and with source attributed by reviewers. There were 86 HABSIs during the study period for a rate of 0.8 HABSIs per 1,000 patient days. Most of these infections were non-central venous catheter (CVC) related. Both CLABSIs and non-CVC BSIs occurred primarily in preterm, low-birth-weight neonates and were associated with a long duration of hospitalization and high sepsis-related mortality (P > .05). Most HABSIs were caused by Gram-positive bacteria, namely Staphylococcus aureus (n = 29, 33.7%). A large proportion of HABSIs (60.5%) were caused by a mucosal barrier injury (MBI) organism. Based on NHSN definitions almost 30% of cases had an unidentified source. NHSN definitions were significantly less likely than clinical definitions to identify a skin soft-tissue infection (2 vs 8 infections; P = .04). In 50% of neonates who did not have a source of infection identified by NHSN definitions, BSIs occurred secondary to an MBI organism, likely from gut translocation. The authors provide thoughtful modifications to current definitions to better suit the neonate population.
In another study, Sanders et al. evaluated the impact of three interventions on blood culture contamination rates: (1) re-education of staff/departments with highest rates of blood culture contamination, (2) mandate for phlebotomists to wear surgical face masks, hair nets (and to have the patient do this too, when possible), and (3) replacement of RNs with phlebotomists for blood culture collection in high-volume departments. The study was conducted at a 325-bed size hospital in the Midwest. Of the interventions, only use of surgical masks along with hair net was associated with a statistically and clinically significant effect on blood culture contamination (mean reduction from 2.8% to 1.1 % (P<0.0001)), a change that was sustained over several years.