Central line + positive blood culture = CLABSI (not!)

There's a thoughtful commentary in a recent issue of Clinical Infectious Diseases by Tom Fraser and Steve Gordon at Cleveland Clinic on problems related to CDC's central line associated bloodstream infection (CLABSI) case definition. We've blogged about this before. The definition is old and was designed to maximize sensitivity long before anyone thought about public reporting. But the issues of poor specificity of this definition are haunting many of us, particularly those who work at hospitals with cancer centers. Unfortunately, neutropenic cancer patients not uncommonly have translocation of enteric flora across their intestinal mucosa and the resulting bloodstream infection in the presence of a central line forces us to label these as CLABSIs, even though these infections are not at all related to the central line. Ten years ago no one cared about this surveillance technicality. Now, in the era of public reporting this is a big problem. In fact, nearly every "CLABSI" in the medical ICU of my hospital falls into this category. Fraser and Gordon show us how this is handled at their hospital with a modification to the CDC definition that is used for internal purposes. Hopefully relief is on the way. CDC is very interested in this issue and has assembled a committee that is actively evaluating the issue.

From those who brought you “getting to zero”

Here’s a comment that has received an unusually robust response on the Emerging Infections Network:

My hospital system plans to do blood cultures on all patients who are admitted with a central line in place (decision not yet final, but momentum is great). Such cultures would prevent mis-labeling of community-acquired infections as hospital-acquired, if infection actually happened to be present on admission and was not clinically suspected. This would allow upgrade of DRGs, to increase reimbursement, and would prevent a CLABSI from being labeled wrongly as hospital acquired. Our state has mandatory reporting and comparison of CLABSI for all hospitals and there is great pressure to reduce rates. I have great reservations about this practice, having seen this done before when blood contaminants stalled the entire purpose of the admission, adding to antibiotic use and length of stay. Does anyone else have opinions or experience with this practice?

So just to be clear: as a result of pressure to get their publicly reported rates of CLABSI to zero (and to maximize reimbursement), this hospital plans to obtain admission blood cultures on every patient with a central venous catheter. Not only will these non-indicated cultures drive up healthcare costs, they will result in untold days of unnecessary antibiotic use (for the blood culture contaminants that will greatly outnumber true pathogens), increase pressure for antimicrobial resistance, prolong hospital stays, and could result in potentially lethal adverse effects (drug reactions, C. difficile, etc.).

Happy Monday!

Bundle the baby

There's a new paper in Pediatrics that evaluates implementation of central line insertion and maintenance bundles across all referral NICUs (n=18) in New York state. Surveillance for infections followed NHSN methodology and evaluated a 12-month period prior to implementation of the bundles to a 10-month period after the bundles were implemented. Overall, there was a 40% reduction in CLABSI. Higher volume NICUs demonstrated lower infection rates and less variation in performance. For each standard deviation increase in maintenance checklist usage, there was a 16.5% decrease in CLABSI rate. However, the authors point out that "in light of some agencies’ considering CLABSIs to be “never events,” it is important to note that no NICU achieved an overall CLABSI rate of 0."

Pathogen-specific preventability?

As Mike pointed out yesterday, one of the interesting findings in the CDC CLABSI report is the difference in percent reduction by pathogen. The most dramatic reduction (73%) was found among Staphylococcus aureus, with more modest reductions among gram negative bacilli (37%), Enterococcus spp. (55%), and Candida (46%).

These findings, discussed in some detail in the MMWR report itself, are consistent with a point I made in a prior post on the preventability of CLABSIs. The CLABSI prevention bundle elements prevent infections due to organisms that gain access to the bloodstream from the catheter-skin interface. No amount of skin preparation, site care, sterile barriers and hand hygiene can prevent organisms from translocating across the gut wall of a seriously ill patient—and so far, no one has developed catheter material that can completely prevent such organisms from adhering once they do gain access to the bloodstream. Furthermore, many of the organisms that arise from gut or other peripheral sites will be misclassified as CLABSIs even if they never adhere to the catheter.

We should expect that interventions which focus on reducing bacterial burden at the catheter insertion site will have their greatest impact on skin bugs, and their least impact on common gut flora. As for getting to zero, it won’t happen until we have ways of addressing infection sources other than the catheter insertion site (and by “addressing”, I mean both improved prevention approaches and improved definitions).

Some good news for a change

Yesterday, CDC released a report on central line associated bloodstream infections (CLABSI), which showed that these infections decreased in US ICUs from 3.64 to 1.65 infections/1,000 catheter days from 2001 to 2009. This represents a 58% reduction. Of note, CLABSIs due to Staph. aureus decreased by 73%, while those due to gram-negative organisms fell by 37%. CDC estimates that up to 27,000 lives were saved due to the infections averted.

Finally we have some higher quality data that shows that HAIs in the US are indeed being reduced. This is consistent with what each of us are seeing at our own hospitals. Importantly, this did not happen spontaneously. The reduction seen is due to countless hours of hard work by hospital epidemiologists, infection preventionists, and frontline providers. So we should all take a minute or two to savor this milestone. Obviously there is still more to do, but progress is being made.

Targeting zero credibility?

I have written before about the unintended adverse consequences of an inability to be honest about HAI prevention, and Mike recently blogged about “aspirational goals” and reality. At the end of his post, Mike linked to an inspiring news story about the success being achieved at the City of Hope, among the sickest of patients. A telling quote from this piece demonstrates how “zero talk” can not only motivate, but also demoralize those who are on the front lines of infection prevention:

"It's tough, especially when there is a lot of literature out there that talks about zero infections….I think there should be zero infections. But not all health care-associated infections are preventable.”

As if on cue, I got an e-mail today from Bard Access Systems APIC, announcing the roll-out of a new website entitled, “I Believe in Zero CLABSIs”. Zero is no longer an “aspirational goal” for Bard Access Systems APIC, but a very concrete one:

“We not only believe in Zero CLABSIs — we know it is possible, and we are confident that the tools and resources contained on this website will provide you with the framework you need to help your facility BELIEVE and ACHIEVE ZERO CLABSIs.”

If APIC is unwilling or unable to speak honestly about HAIs, they will eventually lose credibility with their members who fight daily to prevent them. Furthermore, insisting that zero is already achievable weakens the rationale to perform the kind of groundbreaking translational research that is needed to push CLABSI rates ever closer to an irreducible minimum. Why investigate novel approaches to prevention if we already know how to eliminate every CLABSI?

Breaking down the CLABSI bundle

There is an interesting CLABSI prevention study out this week in PLoSONE (full disclosure: tireless co-blogger and pal Eli is one of the authors). In order to determine how well the CLABSI bundle was being implemented in U.S. ICUs, and which individual elements (or subsets of elements) were most strongly associated with CLABSI reductions, the authors surveyed NHSN hospital practices. They used quarterly ICU-specific CLABSI rates as their outcome measure.

The bottom line: the bundle was associated with lower CLABSI rates only for units that monitored and reported high rates of compliance with at least one element of the bundle out of three (maximum sterile barrier precautions, optimal site selection, and daily assessment of need).

Why would meticulous adherence to any one of these three bundle elements be significantly associated with CLABSI reduction, while meticulous adherence to all the elements was not? I believe it was a simple power issue: too few ICUs (only 38%) had high rates of adherence to the whole bundle. Lack of power could also explain why no single element was statistically-significantly associated with CLABSI reduction.

This study is a good first step toward “breaking down the bundle”, to determine which elements are most important for infection prevention, what compliance measurements are most useful, and (eventually) what components should be added, or subtracted, from existing bundles.

And there will be prizes!

The U.S. Department of Health and Human Services just sent me an e-mail announcing two new national awards to recognize success in “reducing and eliminating central-line associated bloodstream infection and ventilator-associated pneumonia.” The awards are co-sponsored by the Critical Care Societies Collaborative.

The announcement states that the awards are intended to motivate. There should already be several potent motivators at work here (e.g. saving lives, reducing lengths of hospital stay and costs, CMS public disclosure requirements, etc.). But if the prospect of getting a plaque and a free trip to Chicago is what your organization needs to get over the hump, then by all means get to work. I’m also in favor of anything that raises the profile of HAI prevention, so it is good to see on that level.

Speaking of raising profiles, there was a very similar award presented at the Fifth Decennial, to recognize excellent team performance in infection prevention. It would have been nice to see SHEA, APIC and IDSA co-sponsoring this, too.

Award announcement here