Between 2-10% of All Babies Central Line Infection
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Central-line associated bloodstream infections in a tertiary care children'south University hospital: a prospective study
BMC Infectious Diseases volume 16, Article number:725 (2016) Cite this article
Abstract
Groundwork
The central-line associated bloodstream infections (CLABSI) are the almost common healthcare-associated infections in babyhood. Despite the international information bachelor on healthcare-associated infections in selected groups of patients, in that location is a lack of large and expert quality studies. The present survey is the beginning prospective report monitoring for 6 months the occurrence of key-line associated bloodstream infections in all departments of an Italian tertiary intendance children's university hospital.
Methods
The study involved all children aged less than xviii years admitted to Meyer Children's University Infirmary, Florence, Italy who had a central line admission between the October 15th, 2014 and the April 14th, 2015. CLABSI were defined according to the Center for Illness Command and Prevention criteria. CLABSI incidence rates with 95% confidence limits were calculated and stratified for the study variables. For each factor the relative risk and 95% conviction intervals were evaluated. Statistical analysis was performed using the statistical software SPSS for Windows, version 22.0 (SPSS Inc., Chicago, IL), p < 0.05 was considered statistically significant.
Results
CLABSI rate was 3.73/1000 (95% CI: 2.54–5.28) central line-days. A college CLABSI incidence was seen with female gender (p = 0.045) and underlying medical atmospheric condition (excepting prematurity, surgical diseases and malignancy) (p = 0.06). In our study five infections, were caused by extended-spectrum β-lactamase producing organisms and in one case by carbapenem-resistant Klebsiella pneumoniae.
Conclusions
Our written report confirms the spreading of multi-resistant pathogens every bit causes of healthcare associated infections in children. An increased incidence rate of CLABSI in our study was related to underlying medical conditions. Pediatric studies focusing on healthcare infections in this type of patients should be done in guild to deepen our agreement on associated risk factors and possible intervention areas.
Peer Review reports
Background
The central line associated bloodstream infections (CLABSI) are the most common healthcare-associated infections (HAIs) in childhood. The results of the International Nosocomial Infection Control Consortium surveillance study from Jan 2007 to Dec 2012 in pediatric intensive care units (PICU) in Latin America, Asia, Africa and Europe, showed CLABSI rate of 6.1/one thousand (95% CI: v.7–6.v) central line-days [1]. The 2014 report of the European Middle for Disease Prevention and Control (ECDC) estimated a hateful device-adapted rate in patients staying in an ICU for more than than two days was 3.0 CLABSI episodes per 1000 central line-days (IQR: 0.v–four.i) [2]. A cohort written report performed from 2007 to 2012 in 173 neonatal intensive care unit (NICU) and 64 PICU reporting information to the Centers for Disease Control and Prevention's National Healthcare Safety Network in United States, showed a reduction of CLABSI rates from 4.ix to ane.5/chiliad central line-days in NICU and from four.7 to i.0/1000 key line-days in PICU in 5 years time [three]. A trend of infection rate reduction was seen likewise in a prospective 2-yr quality improvement British project conducted in 21 PICU with overall 34,635 key line-days analyzed [iv].
Despite the international data available on HAIs in selected groups of patients, at that place is a lack of large and good quality studies. The best methodology to obtain reliable data would be a continuous prospective study. However, this blazon of study would require dedicated staff and enormous financial resources. Short prospective study or Point-prevalence survey are possible strategies. In the first example, data are collected about a sure catamenia of fourth dimension, giving a good estimate of the global burden and existence price-saving. The point-prevalence survey gives a punctiform picture (usually a day), allows collecting information in an piece of cake and depression-cost way merely it is less accurate than the previous method. A Canadian betoken-prevalence survey was washed on about 1353 pediatric patients with central-line access or with assisted-ventilation. Information were nerveless for 24 h in thirty hospitals. One hundred-eighteen patients (8.7%) had a HAI, of those 38 events (30.vii%) were CLABSI [v]. A prospective study performed in 29 NICU in U.s. between October 2006 and December 2007 constitute that the take a chance of CLABSI is very low during the outset week of catheterization and especially with lines inserted in the jugular vein, whereas it is increased in oncological and gastrointestinal patients and in instance of prolonged catheterization [half-dozen]. Further recent studies estimated that CLABSI results in additional hospital costs on a per-instance basis of 45,000 dollars [7–ix]. The available studies are usually limited to selected groups of patients as oncological children or patients admitted to PICU. There are few prospective studies performed in a whole hospital in order to investigate the global incidence of HAIs. A Swiss written report performed in a single establishment between April 2008 and March 2009 on 152 patients showed an overall CLABSI incidence of 0.95/1000 central line-days. In this study, CLABSI incidence varied past blazon of catheter and by patient's age, with the highest take a chance in neonates with Silastic® percutaneous cardinal line [10].
Available data regarding children'due south HAIs in Italy are limited to selected grouping of patients. A study washed in Naples on 120 oncologic children found a positivity of blood cultures from fundamental line in about one third (28.3%; 128/425 samples) of cases clinically suspected for infection [xi]. At that place are two prospective studies performed in Turin: the first included 748 oncologic or immunologic patients within 7 years, registering 174 episodes of CLABSI [12], whereas the second enrolled 153 children with previous cardio-surgery, founding a CLABSI incidence of xi.vii/1000 primal line-days [13]. The only signal-prevalence survey available in the Italian pediatric population was set in a large third intendance children's hospital in Rome between 2007 and 2010. A two-weeks flow monitoring was performed each year of the study, with 1506 patients included. Overall, 102 (half-dozen.8%) HAIs were identified, one third of which were CLABSI [14].
The nowadays study is the kickoff prospective study monitoring for 6 months the occurrence of CLABSI in all departments of a tertiary intendance children's University infirmary.
Methods
Study setting
The Meyer Children's University Hospital is a 198-bed 3rd care university infirmary in Florence, Italy. It is the Tuscany Region Pediatric Hospital, merely one fourth of children come from other Italian Regions or from abroad. The hospital is structured for intensity of care, with two intensive care units (NICU and PICU), and Departments of oncology, surgery, neuroscience unit (including also neurosurgery patients) and a os marrow transplant unit. Moreover, in that location are two medical wards for 14 pediatric medicine sub-specialties, and an unit of measurement for elective specialty admissions. The annual hospital inpatient admissions were 8898 in 2014, for overall 53,988 admission-days.
Study population
The written report involved prospectively children aged less than eighteen years admitted to Meyer Children's University Hospital who had a central line admission inserted betwixt the October 15th 2014 and Apr 14th 2015.
Data drove
During the study period the global number of children admitted to the hospital was monitored daily and the patients meeting the inclusion criteria were enrolled in the report. The data were collected daily by the trained healthcare staff involved in infirmary infection control. Ethical approving was not required because the survey was carried out for surveillance purposes according to the criteria of hospital skillful clinical practice. The surveillance of CLABSI was performed in all the intensive intendance, medical, surgical and neonatal wards. The data were nerveless using a standardized format. The data were collected anonymously and entered in the written report database, following the international guidelines for information protection.
For each child the post-obit data were entered into the study database: demographic information, reason for admission, underlying illness, type of device, antibiotic treatment. Reasons to stop the follow-up were: hospital discharge, device removal or infection event related to the device. Clinical, hematological and microbiological criteria for diagnosis were recorded in instance of infection. The pathogen identified was also documented.
Example definitions
CLABSI were divers co-ordinate to the Center for Disease, Control and Prevention (CDC) criteria [xv]. CLABSI are defined as laboratory-confirmed bloodstream infection where fundamental line or umbilical catheter was in identify for >two agenda days on the engagement of event and the line was in place on the date of effect or the twenty-four hour period before [15]. In order to capture data only about infections acquired during the hospitalization, the definition of CLABSI was considered valid but if the positive claret culture and clinical signs/symptoms of infection occurred later at least 48 h from admission.
Statistical analysis
Median and interquartile range (IQR) was calculated for continuous measurement in the study groups (i.e., age). Categorical information were compared using the Chi-squared test (or Fisher's exact exam, when expected cell sizes were smaller than 5). CLABSI incidence rates with 95% conviction limits were calculated and stratified for the study variables. Specifically, the variables included in the assay were: historic period, gender, underlying illness, type of device, handling. For each factor the relative risk (RR) and 95% confidence intervals (95% CI) were evaluated. Statistical assay was performed using the statistical software SPSS for Windows, version 22.0 (SPSS Inc., Chicago, IL), p < 0.05 was considered statistically significant.
Results
Overall, 388 children with fundamental line access were enrolled during their hospital stay, resulting in 7783 catheter observation-days. The median age was 21 months (IQR: three–105.5). The underlying conditions of the children enrolled in the study were: medical (n = 135, 34.viii%), oncological (n = 118, 30.4%), surgical (n = 116, 29.9%) and prematurity (due north = 19, four.9%). Median catheter dwell time during hospital admission was 4 days (IQR: 2–9).
During the report period there were 29 episodes of CLABSI in 26 patients. In particular, 2 children had respectively 2 and 3 infections during the observation catamenia. The characteristics of the children with CLABSI are reported in Table one.
The global incidence of CLABSI was iii.73/1000 (95% CI: 2.54–five.28) primal line-days.
The risk of infection in our study population was significantly correlated to female gender (RR = 2.17, 95% CI: i.02–4.86, p = 0.045). Considering the catheter type, the incidence of CLABSI appeared higher for Broviac and short-term catheters, resulting nigh double than Port-a-Cath and peripherally inserted central catheters (PICC). This deviation could be explained because in our setting PICC are used mostly for antibiotic treatment compared to Broviac catheters which are mainly used for parenteral nutrition and in oncology patients.
The highest rate of CLABSI resulted in children with an underlying medical condition (i.due east., respiratory, renal or cardiac diseases, neurological or metabolic atmospheric condition). In this group of patients, the number of infections were xvi for 2951 key line-days, with an incidence rate of 5.42/1000 catheter-days (IQR 3.10–8.80) and a RR of two.01 (95% CI: 0.96–4.28), p = 0.06. The risk of CLABSI was significantly college in patients within the respiratory sub-group compared to all the other conditions (RR = four.38, 95% CI: 1.30–11.74, p = 0.021). Patients admitted to intensive care unit and to medical wards had a higher rate of infection (respectively 5.42 and five.69/1000 catheter-days) compared with the other units; withal, this result was not statistically pregnant. The incidence of CLABSI by population characteristics is reported in Table 2.
In more than half of the patients the pathogens identified were Enterobacteriaceae and Candida spp. The consummate list of the microorganisms found is displayed in Fig. one.
Microorganisms identified in children with CLABSI. The complete list of the microorganisms plant is displayed in the figure. The pathogens isolated in patients with CLABSI are mainly Enterobacteriaceae and Candida spp. 5 infections, out of the 9 cases caused by Enterobactriaceae identified are due to extended-spectrum β-lactamase producing organisms (three Escherichia coli, 2 Klebsiella pneumoniae) and in 1 case by carbapenem-resistant Klebsiella pneumoniae. Specifically, Candida albicans has been identified in 5 (71.4%) patients and Candida parapsilosis in other 2 (28.six%) children
Give-and-take
The present study is designed to assess the incidence rate of CLABSI in a whole pediatric children 3rd care hospital in a half-dozen-months prospective surveillance. In our study CLABSI charge per unit is 3.73/1000 (95% CI: ii.54–5.28) primal line-days. Comparing studies on CLABSI is challenging due to unlike written report population and methodology used. Only another prospective written report, conducted in a whole pediatric infirmary, is available in literature [x]. This study included 152 patients for overall 14,752 catheter observation days, with a CLABSI rate of 0.95/grand central line-days [10]. This lower CLABSI rate should be interpreted considering that, differently from our survey, Wagner and colleagues enrolled mainly neonatal, hematological/oncological and surgical patients. If we consider simply these types of patients in our study, the CLABSI rate decreases to 2.69/1000 catheters-days (95% CI: i.43–4.60). Moreover, the authors concluded that the heterogeneous instance mix of the patients enrolled, including also out-patients settings, accounts for the low CLABSI rate establish [x]. On the contrary, our study is conducted on inpatients only; therefore, the case mix index of our study population could be estimated on the footing of the average diagnosis-related grouping (DRG) weight, which was i.48 in 2014.
Moreover, the present study can exist compared with ii previous 1-month prospective surveys carried out in 2012 and in 2013 in our tertiary-intendance children's academy hospital [sixteen]. The data collected were respectively on 97 children with CLABSI (935 fundamental line-days) in 2012 and on 122 children (1123 central line-days) in 2013. CLABSI incidence rate constitute in the two reports was respectively three.21/1000 catheter days (95% CI: i.03–9.95) in 2012 and ane.78 (95% CI: 0.45–7.12) in 2013 [16]. CLABSI incidence rate notice in the present study almost overlaps with the ane found in 2012 survey, but it results higher than the 2013 ones. This fact is probably due to the increasing instance mix of our hospital, objectively documented by hospital DRG, as explained in a higher place. However, an of import limitation of the previous surveys performed in our hospital was the curt length of the study, which explains the wide confidence intervals obtained and may justified this difference.
In 2012, our hospital participated to the point prevalence survey coordinated past the ECDC, resulting to take a prevalence of HAIs of 8% (LC 95% 3.9–14.1), nine.1% of those were CLABSI (prevalence 1.8%, 95% CI −0,7–4.2%) [17]. On the other paw, the rate of HAIs in our hospital in 2014 was retrospectively estimated on the footing of laboratory-derived microbiological isolates, resulting 5.half dozen/1000 infirmary stay-days (300 infections during 53,988 days of hospitalization, 95% CI 4.nine–half-dozen.2). Specifically, the analysis of microbiological information showed 39 positive blood cultures in children with central line access, with a CLABSI incidence of 0.51/1.000 central line-days (7605 central line- twenty-four hour period, estimated past the prospective study), lower than the incidence of iii.4/1.000 fundamental line-days in 2013. All the same, the retrospective methodology might underestimate the incidence of CLABSI.
Interestingly, our study points the attention on underlying medical conditions equally an important risk factor for developing CLABSI. In the bachelor literature this type of patients was poorly studied, as the attention focused mainly on intensive care and oncological patients [1, three, 4, half dozen, 11, 12]. Still, in this wide group are included children with loftier hazard of developing catheter related infections for different reasons. For example, in gastroenterological disorders (i.e., brusque bowel syndrome or inflammatory bowel disease), the parenteral diet was seen to be an adjunctive risk for infections [ten, 18]. Unfortunately, this data has not been nerveless in our study. Moreover, in chronic disorders as renal diseases (chronic renal failure, dialysis patients), chronic respiratory conditions (bronchodysplasia, congenital tracheobronchial anomalies) and metabolic diseases the infection adventure might be increased past possible immunosuppressive mechanisms in these chronic diseases. Moreover, patients with polymalformative syndromes might require multiple devices for enteral feeding and respiratory support. These conditions could increment the risk of bacteremia and catheter colonization. The run a risk of infection seems to be particularly higher in the sub-grouping of respiratory patients. This might be related to the complexity of these patients, who might require a superior intensity of care [nineteen–21].
The gamble of developing CLABSI in our study population is almost double in patient with Broviac and curt term catheters compared to Port-a-Cath and PICC. Despite few pediatric studies available on CLABSI incidence in patients with PICC [19, 21], studies directly comparing differences by catheter type are limited [ten, 22]. Moreover, comparison of unrelated studies is hard because of heterogeneity in report populations and study methods [23]. Large pediatric prospective studies focuses on identifying the device with lower infections rate are needed.
The pathogens isolated in patients with CLABSI are mainly Enterobacteriaceae and Candida spp. Enterobacteriaceae spread is an emergent crusade of severe infections. These pathogens are of increasing concern due to the rise of carbapenem resistance, which has created a generation of organism resistant to multiple antibiotic classes [24]. In Italia, gram negative resistance rate to 3rd generation cephalosporins is between xxx and 56% [25], whereas the rate of carbapenem resistant Klebsiella is around 34% in invasive infections [26]. At that place is a lack of prevalence data in pediatric patients.
In our study 5 infections, out of the 9 cases identified are caused past extended-spectrum β-lactamase producing organisms (3 Escherichia coli, 2 Klebsiella pneumoniaeast) and one time by carbapenem-resistant Klebsiella pneumoniae. In our surveillance no methicillin resistant Staphylococcus aureus nor vancomycin resistant Enterococcus infections were detected. The CLABSI caused by Candida spp. are beyond the neonatal period thanks to the spreading employ of fluconazole prophylaxis. Specifically, Candida albicans has been identified in five (71.four%) patients and Candida parapsilosis in other 2 (28.6%) children.
Regarding CLABSI rate, our study is designed to assess the incidence rate during patients' hospital admission. Therefore, our results could not exist extrapolated as an overall CLABSI incidence for each central line implanted, every bit this rate might differ if the follow-up was extended to the outpatient clinics and to the home-care. Moreover, our results might not necessarily reflect the HAIs incidence of other Italian hospitals because of different settings and example complexity. Monitoring HAIs is the best way to assess the risk factors for infection globally and specifically for each institution. Moreover, it helps in planning preventive interventions to reduce patient's morbidity and mortality, to save costs and to command resistant-microorganisms spread. Point prevalence surveys are cheaper and easier to conduct than long prospective studies, just might underestimate the existent risk. Toll-effectiveness balance should exist done to choose the best monitoring strategy for each setting.
Conclusions
Our written report confirms the spreading of multi-resistant pathogens equally causes of healthcare associated infections in children. An increased incidence rate of CLABSI in our study was related to underlying medical weather. Pediatric studies focusing on healthcare infections in this blazon of patients should be done in order to deepen our understanding on associated take chances factors and possible intervention areas.
Abbreviations
- CDC:
-
Center for affliction, command and prevention
- CI:
-
Confidence interval
- CLABSI:
-
Central-line associated bloodstream infections
- DRG:
-
Diagnosis-related group
- ECDC:
-
European centre for disease prevention and control
- HAIs:
-
Healthcare-associated infections
- IQR:
-
Interquartile range
- NICU:
-
Neonatal intensive care unit
- PICC:
-
Peripherally inserted central catheters
- PICU:
-
Paediatric intensive care unit
- RR:
-
Relative risk
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Acknowledgments
CLABSI study group. Alterini M1, Anziati Mxi, Baccini Cii, Bardelli Tthree, Baroni Thousand4, Catarzi Ffive, Ciriello Eone, Cozza S5, Diani Ghalf-dozen, Ficozzi Ltwo, Francini South7, Gervaso Pxi, Guidozzi 50v, Ingargiola Aeight, Lega 50eight, Lenzi L3, Lodi A9, Loru S1, Morganti Mvi, Morrione T8, Neri Cvii, Paoli F1, Pierucci E6, Prato Thousandxi, Putrino R10, Sollai S11, Tintori V1, Tondo A1, Trefoloni D3
i Oncology Section, Meyer Children's University Infirmary, Florence, Italy
2 Healthcare associated infections control committee, Meyer Children's University Hospital, Florence, Italy
3 Pediatric Medicine Department, Meyer Children's University Hospital, Florence, Italy
4 Accreditation and quality assurance, Meyer Children'southward University Hospital, Florence, Italian republic
five Outpatients Department, Meyer Children'south Academy Infirmary, Florence, Italia
six Pediatric Intensive Care Unit of measurement, Meyer Children's University Hospital, Florence, Italy
seven Neurology and Neurosurgery ward, Meyer Children's Academy Hospital, Florence, Italy
8 Neonatal Intensive Care Unit of measurement, Meyer Children's University Hospital, Florence, Italy
9 Surgery ward, Meyer Children's University Hospital, Florence, Italy
10 Week Infirmary, Meyer Children's University Hospital, Florence, Italy
xi Infectious diseases Sectionalisation, Pediatric Medicine Department, Meyer Children'south University Infirmary, Florence, Italy
Funding
Not applicative.
Availability of data and materials
Raw information are recorded inside the study database which is part of the infection control database of our hospital. The datasets analysed during the current study is available from the corresponding author on reasonable request.
Authors' contributions
EV drafted the manuscript. SB and AB contributed in the acquisition of data, or assay and estimation of data. CM, EC, KPB and SDM participated in the pattern of the written report and performed the statistical analysis. LG and MdM conceived of the written report, and participated in its design and coordination and helped to draft the manuscript. All authors read and canonical the final manuscript.
Competing interests
The authors declare that they have no competing interests.
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Not applicative.
Ethics approving and consent to participate
In our study the ethical committee approval was not required because this written report was conducted for surveillance purposes following infirmary infection control advices.
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Venturini, East., Montagnani, C., Benni, A. et al. Central-line associated bloodstream infections in a 3rd care children'south University hospital: a prospective study. BMC Infect Dis 16, 725 (2016). https://doi.org/10.1186/s12879-016-2061-6
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DOI : https://doi.org/x.1186/s12879-016-2061-6
Keywords
- CLABSI
- Children
- Central-line
- Infection
Source: https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-016-2061-6
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