The Natural History of Central Line Infections in a Hospital Which Uses Best Practice Line Insertion and Line Maintenance Bundles

Abstract

Purpose: Central line associated bloodstream infections (CLABSI) are a major problem in critical care. They are associated in the literature with duration of catheter dwell time and their occurrence rates have improved with the use of insertion and site care bundles, all of which have been instituted and carefully followed in our institution. We sought to determine if such adherence to the bundles would modify not only the occurrence rate but also the natural history of such infections. Methods: Study design: 100% review of all central line associated infections identified by this hospital's central line infection surveillance program. Data on clinical status, length of stay, duration of catheter dwell time, demographics, antibiotic use, outcome, type of catheter placed, location of patients in the hospital and the nature of the flora cultured from the blood of the patients were collected and correlated. Results: 29 distinct bloodstream infections in 22 patients were identified during 15 months. The catheters were 13 PICC lines, six CVP lines and 10 dialysis catheters. The PICC lines had an average dwell time of 27 days, the CVP lines 10 days and the dialysis catheters 33 days. The mean length of stay in hospital for the patients was 40 days. 11 patients survived and 11 died. Two thirds of the Infections occurred in patients who were in the intensive care and step down units. The infections were caused by multidrug drug-resistant microorganisms in 16 of 22 patients and by multiply sensitive organisms in the other 6. There was no relationship between incidence rate and either the cultured flora or the number of antibiotics received by the patients. There was no relationship found between catheter dwell time or length of stay and the rate of infection occurrence. No patient showed any sign of inflammation or infection at the site of catheter insertion. Conclusions: In patients in whom careful attention is paid to all of the elements of evidence-based central line insertion and insertion site maintenance guidelines there is no significant relationship between catheter dwell time, skin infection, antibiotic use or type of catheter used. Interruption of the tubing system integrity during changes of fluid bags, catheter capping and blood drawing seems the most likely cause of these infections. Clinical Implications: Care in the use of aseptic technique and frequency of reservoir change, piggyback addition, catheter capping and blood drawing from central catheters is necessary to further reduce the incidence of CLABSI.