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| ORIGINAL ARTICLE |
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| Ahead of print publication |
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Incidence of central line-associated bloodstream infection in the intensive care unit: A prospective observational study
Shailendra Singh1, Punit Yadav1, Akhil Goel2, Nitin Ahuja3
1 O/o DGMS (Air), Air HQ, New Delhi, India
2 Department of Anaesthesia and Critical Care, Command Hospital, SC, Pune, Maharashtra, India
3 AMC Centre and College, Lucknow, Uttar Pradesh, India
| Date of Submission | 09-May-2022 |
| Date of Decision | 29-Jun-2022 |
| Date of Acceptance | 10-Aug-2022 |
| Date of Web Publication | 30-Dec-2022 |
Correspondence Address:
Nitin Ahuja,
AMC Centre and College, Lucknow - 226 002, Uttar Pradesh
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmms.jmms_73_22
Aims: The aim of this study was to determine the incidence of central line-associated bloodstream infections (CLABSIs) in the medical and surgical intensive care units (ICUs) of a tertiary care hospital. Materials and Methods: One hundred and twenty patients admitted to medical and surgical ICU with an indwelling, nontunneled central venous catheter (CVC) inserted at admission in the department of emergency medicine or at medical and surgical ICU for more than 48 h were monitored. The patients were followed up daily for the development of new-onset sepsis after 48 h of insertion of CVC, by analyzing the culture of two sets of blood samples, over a span of 24 h. The data were evaluated statistically using Microsoft Excel version 11 and SPSS version 17 (IBM, USA). Results: Among 120 patients hospitalized for an aggregate of 972 days, 7 patients had acquired CLABSI with an incidence rate of 7.2/1000 central line days. The organisms isolated were Staphylococcus aureus, Acinetobacter spp., Pseudomonas aeruginosa, and Klebsiella pneumoniae. Conclusion: The incidence rate of CLABSI in this study was in line with other studies on the CLABSI rate in India. The study found a significant association of CLABSI with duration of CVC catheterization, underlying comorbid conditions and diseases of patients, and indication of CVC insertion. However, there was no significant association of CLABSI with age of patients, their gender, and site of insertion.
Keywords: Central line-associated bloodstream infection, intensive care unit, incidence rate
| Introduction | |  |
Health-care-associated infection (HCAI) is perhaps the most important factor that adversely affects the performance and image of a hospital. Besides increasing morbidity and mortality, it prolongs the hospital stay of patients, increases bed occupancy, and puts undue pressure on the already strained resources of the hospital, patients, and community.[1]
One of the most common HCAIs is central line-associated bloodstream infection (CLABSI). CLABSIs are also responsible for increased health-care costs, as reported in studies from high-income countries; however, no data on costs of CLABSIs are available from India.[2]
CLABSI has been estimated to increase the duration of hospitalization by 7–21 days. The incidence rate of CLABSI has been reported from 1.6 to 44.6 cases/1000 central line days in adult and pediatric intensive care units (ICUs) and from 2.6 to 60.0 cases/1000 central line days in neonatal ICUs.[3] In comparison to developed nations, the baseline rate of CLABSI is found to be around eight-fold higher in India.[4] In a study by Chirag et al., a CLABSI rate of 7.9% was detected in medical, surgical, and neurosurgical ICUs in India.[4] Similarly, in neonatal ICU, it was observed that 30% of bloodstream infections were CLABSIs with an incidence rate of 57.14/1000 central line days.[5] The most common organisms associated with CLABSI have been Klebsiella spp., Acinetobacter spp., Candida spp., Staphylococcus aureus, Enterococcus spp., and coagulase-negative staphylococci as per reports.[6],[7],[9]
Considering the grave nature of the condition, the present study was carried out to calculate the incidence of CLABSI, identify the organisms causing it, and determine the occurrence of infection from the various sites.
| Materials and Methods | | |
Setting and study design
This study was conducted in the medical and surgical ICU of a tertiary care hospital of a metropolitan city after obtaining approval from the institutional ethics committee. The study was designed as a single worker prospective observational study. The study is being reported as per the STROBE guidelines.[6]
Selection criteria
Inclusion criteria
- Age >18 years
- Insertion of first central venous catheter (CVC) during the medical and surgical ICU stay or in the department of emergency medicine of our hospital
- ICU stay with an indwelling CVC for more than 48 h.
Sample size calculation
A total of 120 patients were included in the study, as per the sample size calculation using 95% confidence interval with allowable error of tolerance of 0.05.
Patients follow-up
The patients were followed up for more than 48 h, until the removal of the catheter or discharge or death, whichever was earlier.
Work-up of patients and microbiological study
All patients enrolled in the study were followed daily for the development of new-onset sepsis 48 h after the insertion of the CVC by recording temperature, pulse rate, blood pressure, and respiratory rate twice daily. Total and differential leukocyte counts were also obtained every alternate day or earlier if sepsis was suspected. New-onset sepsis was suspected when two or more of the following conditions were present along with suspicion of the infection: fever (temperature >38°C) or hypothermia (<36°C), tachycardia (>90 beats/min), tachypnea (>24 breaths/min), and leukocytosis (>12,000/cumm) or leukopenia (<4000/cumm).
In a case of new-onset sepsis, two sets of blood samples were drawn, one from CVC and one from peripheral vein by skin puncture over the span of 24 h. An attempt to exclude other sources of infection was made by focused physical examination and relevant investigations including urine cultures, sputum cultures, tracheal aspirates, and imaging studies depending on the clinical profile of the patient. If no other apparent source of infection was found, then a BSI was suspected and the CVC was removed using a sterile technique. The distal 10-cm segment of the catheter was cut with a sterile blade into two equal pieces; one piece was placed in a sterile transport tube and cultured using the semiquantitative method and the other piece was cultured for fungal isolates. Simultaneously, a peripheral blood sample was sent for culture from the same patient [Figure 1].
Data collection
For each patient, the following data were recorded at inclusion: age, gender, duration of catheterization, comorbidities, indication of catheterization, site of catheterization, findings on thorough general examination and systemic examination, chest radiograph at the time of admission, complete blood counts, liver function tests and renal function tests at admission, and presence or absence of antimicrobial therapy at the time of inclusion.
Statistical analysis
The data were evaluated statistically using Microsoft Excel version 11 and SPSS version 17 (IBM, Armonk, New York, USA). The descriptive statistics were assessed based on frequency distribution for univariate analysis. Fisher's exact and Chi-square tests were carried out for multivariate analysis. P < 0.05 was considered statistically significant.
| Results | | |
The present study evaluated the incidence of CLABSI among 120 patients. The descriptive statistics of the baseline clinical characteristics of the enrolled patients are mentioned in [Table 1]. The mean age of the study population was 53.12 years, whereas the median was 58 years with a standard deviation of 16.313 years. The minimum age of the population was 19 years and maximum was 86 years, with majority (74.16%) being above 40 years of age with a male predominance (59.16%). The total number of central line days was 972 over the period of the study duration. Out of 120 patients, 7 patients developed CLABSI. The incidence rate per 1000 catheter days was 7.2. The organisms isolated were S. aureus, Acinetobacter, Pseudomonas aeruginosa, and Klebsiella pneumonia.
Out of 120 patients, 71 patients were male and 49 were female, 5 (7%) catheterized male patients developed CLABSI of total 71 catheterized male patients, and 2 (4.1%) catheterized female patients developed CLABSI out of 41 catheterized female patients. There was no significant association found between CLABSI and gender of CLABSI patients (Fisher's exact two-tailed, P = 0.699) [Figure 2]. Eighty-three patients (69.16%) patients had CVC for more or equal to 7 days and 37 patients (30.84%) had CVC for <7 days. One patient had developed CLABSI out of 83 patients in whom the catheter was kept for <7 days and 6 patients out of the remaining 37 patients in whom the catheter was kept for more than 7 days. | Figure 2: Distribution of CLABSI patient as per gender of CLABSI patient, CLABSI: Central line-associated bloodstream infection
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A significant association was found between CLABSI and duration of catheterization (Fisher's exact, P = 0.003) [Figure 3]. Twenty-nine patients were catheterized with CVC for parenteral nutrition admission and the rest 91 patients for CVP monitoring. Out of 29 patients, 5 (17.2%) patients and, out of 91 patients, 2 (2.2%) patients were diagnosed as CLABSI positive. There was a significant association between CLABSI and indication of catheterization (central line inserted for parenteral nutrition) (Chi-square test, P < 0.05) [Figure 4]. | Figure 3: Distribution of CLABSI patient as per duration of catheterization, CLABSI: Central line-associated bloodstream infection
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 | Figure 4: Distribution of CLABSI patient as per indication of catheterization, CLABSI: Central line-associated bloodstream infection
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In 85 patients, the CVC was inserted in right internal jugular vein (IJV), and in the rest of 35 cases, femoral vein and right subclavian vein were used. Five cases out of 85 cases were CLABSI positive, in which right IJV was used, and two cases were positive, in which other veins (femoral and subclavian) were used. There was no significant association between CLABSI and site of catheterization (Fisher's exact two, P = 1) [Figure 5]. Out of 120 patients included in the study, a total of 31 patients are of <40 years and 89 patients are of more than 40 years of age. There was no significant association between CLABSI and age of patients for CLABSI (Chi-square test applied, P = 0.78) [Table 2]. Twenty-three patients out of Four patients out of 23 patients with comorbidity were diagnosed with CLABSI. There was a significant association between CLABSI and comorbid conditions of patients (Chi-square test applied, P = 0.03) [Table 3]. | Figure 5: Distribution of CLABSI Patient as per site of catheterization, CLABSI: Central line-associated bloodstream infection
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 | Table 2: Distribution of central line-associated bloodstream infection patient as per age of central line-associated bloodstream infection patient
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 | Table 3: Distribution of central line-associated bloodstream infection patient according to comorbid conditions
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| Discussion | | |
The present study assessed the incidence rate of CLABSI in tertiary care hospital setting prospectively.
Vascular catheters are commonly used in both inpatient and outpatient settings. Nearly 300 million catheters are used in the United States each year, with nearly 3 million of those being CVCs, also known as central lines. Every year, approximately 250,000 CVCs are used in the United Kingdom.[10] CVCs play an important role in modern health care, enabling for the infusion of intravenous fluids, medications, parenteral nutrition, and blood products. It is also vital in providing hemodialysis access and in hemodynamic monitoring, but their use is associated with risk of bloodstream infection (CLABSI). CLABSI is caused by microorganisms colonizing the device's external surface or the fluid pathway when it is inserted or used.[11] CVCs are the most common cause of health-care-associated bloodstream infections.[12] CLABSI remains a serious and the most common cause of HAIs worldwide. CLABSIs are estimated to occur in 80,000 ICUs in the United States each year. In the overall setting, the estimate rises to 250,000 cases of CLABSI each year.[13] Mehta et al.[14] reported a CLABSI rate of 7.92/1000 catheter days. Sinha et al.[15] reported the incidence of 6.7%. Similarly, Kaur et al.[16] also reported an incidence rate of 7.67/1000 central line days for CLABSI. The present study also corroborates the finding of the previous studies with an incidence rate of 7.2/1000 catheter days. The organisms isolated included extended-spectrum beta-lactamase +ve Klebsiella pneumoniae, HLAR + Enterococcus faecium, S. aureus, and ß-lactamase + Acinetobacter spp. Although no case of laboratory-confirmed CLABSI could be demonstrated, the CLABSI rate according to the surveillance definition was 1.3% or 1.03/1000 CVC days. The incidence of clinical sepsis was 27.6% or 8.2/1000 CVC days.
The present study did not find any significant association between CLABSI and age of patients for CLABSI contrary to Zingg et al. who reported higher CLABSI rates among children than adults, particularly in neonates [Table 2].[17] The present study found no difference between gender in contray to Kritchevsky et al, who reported male gender in occurance of CLABSI as risk factor.[18]
The present study finding corroborates with Advani et al.[19] and Wylie et al.[20] which has shown that the chances of CLABSI increase with the duration of CVC dwell time as well as a significant association between CLABSI and duration of catheterization.
The present study also supports the findings reported by Advani et al.[19] in relation to CLABSI and morbid conditions and found a significant association between CLABSI and comorbid conditions of patients.
The present study found a significant association between CLABSI and indication of catheterization (central line inserted for parenteral nutrition). Similar findings have also been reported by Advani et al.,[19] Wylie et al.,[20] and Almuneef et al.[21] However, the present study did not find any significant association between CLABSI and site of catheterization in contrast to studies by Almuneef et al. that BSI occurred more often in catheters inserted in the femoral site compared with jugular or subclavian sites.[21]
| Conclusion | | |
The incidence rate of CLABSI in the present study was in accordance with the average CLABSI rate detected in other studies in India. The study also showed that there was a significant association of CLABSI with duration of CVC catheterization, underlying comorbid conditions and diseases of patients, and indication of CVC insertion. However, the present study did not find any significant association of CLABSI with age and gender of patients and site of CVC insertion.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]
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