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Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center
j o u r n a l o f p a t i e n t s a f e t y & i n f e c t i o n c o n t r o l x x x ( 2 0 1 4 ) 1 e4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jpsic
Original Article
Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center Vibhor Tak a, Purva Mathur a,*, Subodh Kumar b, Babita Gupta c, Amit Gupta b, Sumit Sinha d, Deepak Gupta d, M.C. Misra b a
Department of Laboratory Medicine, JPNA Trauma Centre, AIIMS, New Delhi 110029, India Department of Surgery, JPNA Trauma Centre, AIIMS, New Delhi, India c Department of Anaesthesiology, JPNA Trauma Centre, AIIMS, New Delhi, India d Department of Neurosurgery, JPNA Trauma Center, AIIMS, New Delhi, India b
article info
abstract
Article history:
Background: Central line associated blood stream infections (CLA-BSIs) are a leading cause
Received 21 August 2013
of health care associated infections. There is paucity of data on the actual magnitude of
Accepted 3 December 2013
CLA-BSIs in most hospitals of developing countries due to lack of surveillance. This study reports the impact of an intensive surveillance, training and feedback on the rates of CLA-
Keywords:
BSIs at an Indian trauma center.
Nosocomial blood stream infections
Methods: The study was conducted at a level 1 trauma center from June 2010 to January
CLA-BSI
2013. The clinical details of all patients and microbiology culture reports who were
Secondary bacteremia
admitted for more than 48 h were recorded in a pre-designed pro forma. These details were
ICUs
further entered in an automated software based upon CDC NHSN’s definitions of device
Trauma
associated infections. The CLA-BSI rates in a previous pilot study in 2010 were found to be very high. Intensive surveillance, education and training drive was initiated along with better hand hygiene and device care as a part of hospital infection control measures. Results: During the study period, a total of 2969 patients were followed up for CLA-BSIs. These patients amounted to a total of 27,394 ICU days and 15,443 CVC days. A total of 93 episodes of CLA-BSI occurred during the study, amounting to a CLA-BSI rate of 6.02/1000 CVC days. Staphylococcus aureus (27; 27.5%) was the most common isolate. A total of 101 episodes of secondary BSIs were also observed during the study. Of these, 70 (69%) were secondary to VAP, 18 (18%) were secondary to wound infections and 13 (13%) were secondary to UTI. Of the 92 patients who accounted for the 93 episodes of CLA-BSIs, a total of 20 (21.7%) had a fatal outcome. Conclusions: Thus, with the help of the intensive surveillance, using this software, we have been able to monitor the impact of training, surveillance and interventions on the rates of CLA-BSI, which have reduced from 27.6 to 6/1000 CVC days within a span of 2 years at our
* Corresponding author. Tel.: þ91 26189000extn1169, 26188000extn1169, and 26109000extn1169; fax: 91 11 26106826. E-mail address: [email protected] (P. Mathur). http://dx.doi.org/10.1016/j.jpsic.2013.12.001 2214-207X/Copyright ª 2014, Hospital Infection Society India. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
Please cite this article in press as: Tak V, et al., Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center, Journal of Patient Safety & Infection Control (2014), http://dx.doi.org/10.1016/ j.jpsic.2013.12.001
2
j o u r n a l o f p a t i e n t s a f e t y & i n f e c t i o n c o n t r o l x x x ( 2 0 1 4 ) 1 e4
institute. Although these measures require a dedicated team effort, they are easy and cost effective to implement and can reduce all device associated infections across all types of health care facilities. Copyright ª 2014, Hospital Infection Society India. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
1.
Introduction
Central venous catheters have become indispensable devices for the management of critically ill patients; however, their use is often complicated by central line associated blood stream infections (CLA-BSIs). CLA-BSIs are a leading cause of health care associated infections (HCAIs), accounting for almost 5e6% of them.1 They are associated with increased morbidity, length of stay, mortality and health care costs. Majority of these infections are potentially preventable by better hospital infection control practices. Catheter related BSIs (CRBSI) is a clinical definition, used when diagnosing and treating patients, that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI. It is not typically used for surveillance purposes. It is often problematic to precisely establish if a BSI is a CRBSI due to the clinical needs of the patient (the catheter is not always pulled), limited availability of microbiologic methods, and procedural compliance by direct care personnel (labeling must be accurate). Therefore, simpler definitions like CLA-BSI are often used for surveillance purposes.2 There is a wide variation in the CLA-BSI rates in the developed and developing countries. In the developed countries, there has been a steady decline in the rates of CLA-BSIs due to an integrated surveillance, education and preventive programme. There is paucity of data on the actual magnitude of CLA-BSIs in most hospitals of developing countries due to lack of surveillance.
2.
Aims and objectives
To strengthen education and surveillance activities of CLA-BSI and other health care associated infections at our center and undertake measures to control these infections.
3.
Materials and methods
Prior to 2010, there was no surveillance activity for CLA-BSIs at our center. In 2010 we conducted a pilot study from January to April 2010 to assess the baseline level of CLA-BSI, the rates of which were found out to be 27.6/1000 CVC days.3 This rate was very high as compared to the developed countries. Since then, we have initiated an intensive surveillance of CLA-BSI at our 182 bedded, level 1 trauma center. The foundation of this programme has been based on defining each infection as per the CDC’s definition, tracking the source of BSIs, educating the
health care workers and providing feedbacks of the rates to each unit. The surveillance has been automated with the development of an indigenously developed software, ASHAIN (Automated Surveillance of Hospital Acquired INfections). The software has been designed based upon algorithms according to CDC NHSN’s guidelines to diagnose HCAIs.4 This study reports the impact of an intensive surveillance, training and feedback on the rates of CLA-BSIs. The study was approved by the Institute’s Ethical committee. As part of the surveillance, our six dedicated Hospital Infection Control Nurses visit all ICUs and wards and collect information from each patient, presence of central lines, the date of insertion and removal, adherence to central line bundles, treatment regimens and culture reports of various clinical samples. We also undertake multiple training sessions on hand hygiene, central line bundle practices, standard precautions and hospital infection control for all cadres of health care workers. All new recruits of nursing staff are given weekly lectures for three months on infection prevention. We spread information by putting up hand hygiene and central line bundle posters on walls in all patient care areas. Videos are displayed regarding hand hygiene practices based upon WHO’s five moments of hand hygiene5 in all clinical areas, serving as constant reminders. They are also supplemented by direct one to one reminders by our HICNs to all health care workers (HCWs). The hand hygiene compliance is monitored every week for two hours as per WHO’s recommendations.5 The hand hygiene compliance is also monitored via CCTVs, the monitors of which are installed in the HIC room. The compliance to central line bundles is measured by standard protocols. The central line bundle consists of the following elements: hand hygiene during line insertion and maintenance, maximal barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection with avoidance of the femoral vein for central venous access in adult patients and daily review of line necessity with prompt removal of unnecessary lines.2 Monthly, ward wise reports regarding total number of admissions, device days, compliance to hand hygiene, episodes of CLA-BSIs & bundle compliance rates are prepared and sent to respective administrative heads and nursing superintendents. Feedback and suggestions regarding further necessary preventive actions are constantly provided to various clinical areas. For the purpose of surveillance, the following definitions were used: CLA-BSI was defined as a primary BSI in a patient that had a central line within the 48-h period before the development of the BSI and was not blood stream related to an infection at another site.2,6
Please cite this article in press as: Tak V, et al., Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center, Journal of Patient Safety & Infection Control (2014), http://dx.doi.org/10.1016/ j.jpsic.2013.12.001
3
j o u r n a l o f p a t i e n t s a f e t y & i n f e c t i o n c o n t r o l x x x ( 2 0 1 4 ) 1 e4
Secondary blood stream infection:2,6 Was defined as a culture-confirmed BSI associated with a documented HAI at another site (i.e. met CDC criteria of infection at another site). If the primary infection was cultured, the secondary BSI must have yielded culture of same organism and exhibited same antibiogram as the primary HAI site. The tips of central vascular catheters, if received were processed by the roll plate method of Maki et al.7 However, for the interpretation of CLA-BSI, the result of catheter tips was not taken into consideration. The blood samples were collected in the BacT Alert blood culture bottles according to the manufacturer’s instructions. All samples were processed according to standard methods.8 Identification of bacteria and yeasts was done by the Vitek 2 system (BioMerieux Ltd., France). Antimicrobial susceptibility testing was performed by the disc diffusion method, according to the CLSI guidelines9 and by the VITEK 2 system (BioMerieux Ltd.)
4.
Results
The impact of all these measures was quantified from June, 2010 to January, 2013. The study population consisted of patients admitted to the ICUs of the trauma center for more than 48 h who had a central vascular line during their ICU stay. The data was stratified into three time periods to study the impact of surveillance, training and feedbacks. It was compared to the pilot study,3 when we had no such system in place. During the study period, a total of 3715 patients were admitted to the ICUs of the trauma center, amounting to a total of 28,664 patient days. Of these, 746 patients (20%) stayed in the ICUs for less than 48 h and were therefore excluded from further analysis. The excluded patients were either admitted for post trauma observation/were post-operative and admitted for a short duration or were severely injured, who expired within 48 h of admission. Thus, a total of 2969 patients were followed up for CLABSIs. These patients amounted to a total of 27,394 ICU days. The length of ICU stay of this study population ranged from 3e69 days (median 7 days). The age of the patients ranged from 1 months to 90 years (median 30 years). A total of 2538 (85%) patients were males.
The total CVC days for the study population (n ¼ 2969) during the study period amounted to 15,443 days. A total of 93 episodes of CLA-BSI occurred during the study, amounting to a CLA-BSI rate of 6.02/1000 CVC days. A total of 98 microbes were isolated from the 93 episodes of CLA-BSI. Staphylococcus aureus (27; 27.5%) was the most common isolate, followed by Candida Sp. (16; 16%), Acinetobacter baumannii (15; 15%), Klebsiella pneumoniae (10; 10%), Serratia marcescens (9; 9%), Enterococcus faecium (7; 7%), Pseudomonas aeruginosa (4; 4%), Burkholderia cepacia (4; 4%), Staphylococcus epidermidis (3; 3%), Enterobacter sp. (2; 2%) & Stenotrophomonas maltophilia (1; 1%). Table 1 shows the trend of CLA-BSIs during the past twostudy period at our center and the impact of initiation of an intensive automated surveillance. The hand hygiene compliance and compliance to central line bundle showed a sustained increase from January, 2010 to January, 2013 (Table 1). The CVP tips also grew a similar organism in 32 of the 93 (34%) episodes of CLA-BSI. In other cases, the CVP tips could not be sent as the patients were severely injured and had hemodynamic instability or there was growth of mixture of bacteria or bacterial growth was in insignificant numbers. However, since our study pertained to CLA-BSI (which does not require a catheter tip culture, in contrast to CRBSI), the catheter tip culture results were not taken into consideration for calculation of CLA-BSI rates. A total of 101 episodes of secondary BSIs were also observed during the study. Thus, we observed a higher proportion of secondary BSI as compared to primary BSIs. Of these, 70 (69%) were secondary to VAP, 18 (18%) were secondary to wound infections and 13 (13%) were secondary to UTI. A total of 530 (18%) of the 2969 patients died during their ICU stay. An autopsy was performed on these cases. The recorded primary cause of death in these patients was severe injuries in 334 (63%), complications of trauma in 64 (12%) and infections in 132 patients (25%). A comparison of the percentage mortality in trauma patients and the contribution of infections as cause of mortality during the present study and the same figures during January to April, 2010 is shown in Table 1. Infections contributed to 60% of mortality in the pilot study as compared to 25% during the present study.
Table 1 e Trend of CLA-BSI and impact of preventive interventions from June 2010 to January, 2013. Time period
CVC days Number of episodes of CLA-BSI Rate of CLA-BSI (per 1000 CVC days) Compliance to central line bundle (%) Compliance to hand hygiene (%) Percentage mortality (of the total admitted patients staying beyond 48 h) Infections as cause of mortality (%) a
JanuaryeApril, 2010 (Pilot study)a
June, 2010 eAugust, 2011
September, 2011 eFebruary, 2012
March 2012 eSeptember, 2012
October, 2012 eJanuary, 2013
1808 50 27.6 32 12 28
6073 46 7.5 90 64 17
3414 23 6.7 80.3 67.7 10
4179 17 4.06 84 63 19.4
1777 7 3.9 82 55 17
60
38
28
17
16
Reference.2
Please cite this article in press as: Tak V, et al., Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center, Journal of Patient Safety & Infection Control (2014), http://dx.doi.org/10.1016/ j.jpsic.2013.12.001
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j o u r n a l o f p a t i e n t s a f e t y & i n f e c t i o n c o n t r o l x x x ( 2 0 1 4 ) 1 e4
However, restricting to the patient population in the present study (who developed CLA-BSIs at some point of their ICU stay), of the 92 patients who accounted for the 93 episodes of CLA-BSIs, a total of 20 (21.7%) had a fatal outcome. The recorded cause of death in 15 of these 20 cases (75%) was septicemia; in the remaining five, it was severe injuries. However, of the 15 patients who died due to septicemia, seven also had ventilator associated pneumonia, and one had abdominal wound infection, thus it was difficult to ascertain the attributable mortality of CLA-BSIs.
5.
Discussion
Hospitals in the United States functioning under the CDC’s NHSN network report a mean CLA-BSI rate of 1.5 cases per 1000 CVC days in medical-surgical ICUs and of 2.9 cases per 1000 CVC days in NICUs.10 By contrast, in developing countries, the CLA-BSI rates range from 1.6e44.6 cases per 1000 CVC days in adult and pediatric ICUs and from 2.6e60.0 cases per 1000 CVC days in NICUs.11 In a multinational study of ICUs from 8 developing countries, the incidence of CVC related BSIs was 12.5/1000 catheter days.12 The CLA-BSI rates are higher in limited resource countries due to lack of proper infrastructure for surveillance as well as poor or non-existing infection control practices. Since some BSIs are secondary to other sources other than the central line that may not be easily recognized, the CLA-BSI surveillance definition may overestimate the true incidence of CRBSI. We have employed one HICN dedicated to trace the source of all BSIs in the ICUS and to educate and monitor the compliance to hand hygiene and central line bundle. In all cases of BSIs, culture reports of samples from other sites are compiled and compared with the blood report. If other samples are not received, the HICNs collect samples like urine, wound samples, respiratory samples and a repeat blood sample from peripheral vein. This has reduced the numbers of BSIs being wrongly labeled as CLA-BSI. For the same reason, we have found a larger number of secondary BSIs (101), since the source of BSIs could be traced in those episodes. This is in contrast to many other studies, where primary BSIs form the predominant group.
6.
Conclusions
Data analysis by this indigenous software has significantly reduced the turnover time required for generation of reports of CLA-BSI as compared to manual generation of reports. Thus, with the help of the intensive surveillance, using this software, we have been able to monitor the impact of training, surveillance and interventions on the rates of CLA-BSI, which have reduced from 27.6 to 6/1000 CVC days within a span of 2 years at our institute. We believe that hospitals in developing countries should develop their own modules of prevention, beginning with surveillance and education, followed by implementation of preventive bundles, reminders and feedbacks. Although these measures require a dedicated team effort, they are easy and cost effective to implement and can
reduce all device associated infections across all types of health care facilities. Such simple and effective measures are also needed in our country, which is witnessing high rates of multi- and pan-drug resistant organisms.
Conflicts of interest All authors have none to declare.
Acknowledgment This software was developed through a grant from the Indian Council of Medical Research, New Delhi. We thank the ICMR for their financial support. This study was funded by a grant from the Indian Council of Medical Research. We acknowledge the financial support of ICMR for the performance of this study.
references
1. Damani NN. Manual of Infection Control Procedures. 2nd ed. New York: Cambridge University Press; 2003. 2. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(suppl 1):S1eS34. 3. Gunjiyal J, Thomas SM, Gupta AK, et al. Device associated and multidrug e resistant infections in critically ill trauma patients: towards development of automated surveillance in developing countries. J Hosp Infect. 2011;77:169e185. 4. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309e332. 5. WHO. Guidelines on Hand Hygiene in Health Care. Geneva: WHO Press; 2009. 6. CDC. National Healthcare Safety Network. Device Associated Infections Module. Protocols and Instructions; 2010. Available at: www.cdc.gov/nhsn/psc-da.html http://www.cdc.gov/nhsn/ library.html. 7. Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intra-venous-catheter-related infection. N Engl J Med. 1977;296:1305e1309. 8. Collee JG, Diguid JP, Fraser AG. Mackie and McCartney Practical Medical Microbiology. 14th ed. Edinburgh: Churchill Livingstone; 1996. 9. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing, 19th Informational Supplements, 2009;M100eS16. Wayne, PA, USA: CLSI; 2006. 10. Edwards JR, Peterson KD, Andrus ML, et al. National Healthcare Safety Network (NHSN) report, data summary for 2006, issued June 2007. Am J Infect Control. 2007;35(5):290e301. 11. Rosenthal VD. Central line e associated bloodstream infections in limited-resource countries: a review of the literature. Clin Infect Dis. 2009;49:1899e1907. 12. Rosenthal VD, Maki DG, Salomao R, et al. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med. 2006;145:582e591.
Please cite this article in press as: Tak V, et al., Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center, Journal of Patient Safety & Infection Control (2014), http://dx.doi.org/10.1016/ j.jpsic.2013.12.001
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jpsic
Original Article
Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center Vibhor Tak a, Purva Mathur a,*, Subodh Kumar b, Babita Gupta c, Amit Gupta b, Sumit Sinha d, Deepak Gupta d, M.C. Misra b a
Department of Laboratory Medicine, JPNA Trauma Centre, AIIMS, New Delhi 110029, India Department of Surgery, JPNA Trauma Centre, AIIMS, New Delhi, India c Department of Anaesthesiology, JPNA Trauma Centre, AIIMS, New Delhi, India d Department of Neurosurgery, JPNA Trauma Center, AIIMS, New Delhi, India b
article info
abstract
Article history:
Background: Central line associated blood stream infections (CLA-BSIs) are a leading cause
Received 21 August 2013
of health care associated infections. There is paucity of data on the actual magnitude of
Accepted 3 December 2013
CLA-BSIs in most hospitals of developing countries due to lack of surveillance. This study reports the impact of an intensive surveillance, training and feedback on the rates of CLA-
Keywords:
BSIs at an Indian trauma center.
Nosocomial blood stream infections
Methods: The study was conducted at a level 1 trauma center from June 2010 to January
CLA-BSI
2013. The clinical details of all patients and microbiology culture reports who were
Secondary bacteremia
admitted for more than 48 h were recorded in a pre-designed pro forma. These details were
ICUs
further entered in an automated software based upon CDC NHSN’s definitions of device
Trauma
associated infections. The CLA-BSI rates in a previous pilot study in 2010 were found to be very high. Intensive surveillance, education and training drive was initiated along with better hand hygiene and device care as a part of hospital infection control measures. Results: During the study period, a total of 2969 patients were followed up for CLA-BSIs. These patients amounted to a total of 27,394 ICU days and 15,443 CVC days. A total of 93 episodes of CLA-BSI occurred during the study, amounting to a CLA-BSI rate of 6.02/1000 CVC days. Staphylococcus aureus (27; 27.5%) was the most common isolate. A total of 101 episodes of secondary BSIs were also observed during the study. Of these, 70 (69%) were secondary to VAP, 18 (18%) were secondary to wound infections and 13 (13%) were secondary to UTI. Of the 92 patients who accounted for the 93 episodes of CLA-BSIs, a total of 20 (21.7%) had a fatal outcome. Conclusions: Thus, with the help of the intensive surveillance, using this software, we have been able to monitor the impact of training, surveillance and interventions on the rates of CLA-BSI, which have reduced from 27.6 to 6/1000 CVC days within a span of 2 years at our
* Corresponding author. Tel.: þ91 26189000extn1169, 26188000extn1169, and 26109000extn1169; fax: 91 11 26106826. E-mail address: [email protected] (P. Mathur). http://dx.doi.org/10.1016/j.jpsic.2013.12.001 2214-207X/Copyright ª 2014, Hospital Infection Society India. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
Please cite this article in press as: Tak V, et al., Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center, Journal of Patient Safety & Infection Control (2014), http://dx.doi.org/10.1016/ j.jpsic.2013.12.001
2
j o u r n a l o f p a t i e n t s a f e t y & i n f e c t i o n c o n t r o l x x x ( 2 0 1 4 ) 1 e4
institute. Although these measures require a dedicated team effort, they are easy and cost effective to implement and can reduce all device associated infections across all types of health care facilities. Copyright ª 2014, Hospital Infection Society India. Published by Reed Elsevier India Pvt. Ltd. All rights reserved.
1.
Introduction
Central venous catheters have become indispensable devices for the management of critically ill patients; however, their use is often complicated by central line associated blood stream infections (CLA-BSIs). CLA-BSIs are a leading cause of health care associated infections (HCAIs), accounting for almost 5e6% of them.1 They are associated with increased morbidity, length of stay, mortality and health care costs. Majority of these infections are potentially preventable by better hospital infection control practices. Catheter related BSIs (CRBSI) is a clinical definition, used when diagnosing and treating patients, that requires specific laboratory testing that more thoroughly identifies the catheter as the source of the BSI. It is not typically used for surveillance purposes. It is often problematic to precisely establish if a BSI is a CRBSI due to the clinical needs of the patient (the catheter is not always pulled), limited availability of microbiologic methods, and procedural compliance by direct care personnel (labeling must be accurate). Therefore, simpler definitions like CLA-BSI are often used for surveillance purposes.2 There is a wide variation in the CLA-BSI rates in the developed and developing countries. In the developed countries, there has been a steady decline in the rates of CLA-BSIs due to an integrated surveillance, education and preventive programme. There is paucity of data on the actual magnitude of CLA-BSIs in most hospitals of developing countries due to lack of surveillance.
2.
Aims and objectives
To strengthen education and surveillance activities of CLA-BSI and other health care associated infections at our center and undertake measures to control these infections.
3.
Materials and methods
Prior to 2010, there was no surveillance activity for CLA-BSIs at our center. In 2010 we conducted a pilot study from January to April 2010 to assess the baseline level of CLA-BSI, the rates of which were found out to be 27.6/1000 CVC days.3 This rate was very high as compared to the developed countries. Since then, we have initiated an intensive surveillance of CLA-BSI at our 182 bedded, level 1 trauma center. The foundation of this programme has been based on defining each infection as per the CDC’s definition, tracking the source of BSIs, educating the
health care workers and providing feedbacks of the rates to each unit. The surveillance has been automated with the development of an indigenously developed software, ASHAIN (Automated Surveillance of Hospital Acquired INfections). The software has been designed based upon algorithms according to CDC NHSN’s guidelines to diagnose HCAIs.4 This study reports the impact of an intensive surveillance, training and feedback on the rates of CLA-BSIs. The study was approved by the Institute’s Ethical committee. As part of the surveillance, our six dedicated Hospital Infection Control Nurses visit all ICUs and wards and collect information from each patient, presence of central lines, the date of insertion and removal, adherence to central line bundles, treatment regimens and culture reports of various clinical samples. We also undertake multiple training sessions on hand hygiene, central line bundle practices, standard precautions and hospital infection control for all cadres of health care workers. All new recruits of nursing staff are given weekly lectures for three months on infection prevention. We spread information by putting up hand hygiene and central line bundle posters on walls in all patient care areas. Videos are displayed regarding hand hygiene practices based upon WHO’s five moments of hand hygiene5 in all clinical areas, serving as constant reminders. They are also supplemented by direct one to one reminders by our HICNs to all health care workers (HCWs). The hand hygiene compliance is monitored every week for two hours as per WHO’s recommendations.5 The hand hygiene compliance is also monitored via CCTVs, the monitors of which are installed in the HIC room. The compliance to central line bundles is measured by standard protocols. The central line bundle consists of the following elements: hand hygiene during line insertion and maintenance, maximal barrier precautions upon insertion, chlorhexidine skin antisepsis, optimal catheter site selection with avoidance of the femoral vein for central venous access in adult patients and daily review of line necessity with prompt removal of unnecessary lines.2 Monthly, ward wise reports regarding total number of admissions, device days, compliance to hand hygiene, episodes of CLA-BSIs & bundle compliance rates are prepared and sent to respective administrative heads and nursing superintendents. Feedback and suggestions regarding further necessary preventive actions are constantly provided to various clinical areas. For the purpose of surveillance, the following definitions were used: CLA-BSI was defined as a primary BSI in a patient that had a central line within the 48-h period before the development of the BSI and was not blood stream related to an infection at another site.2,6
Please cite this article in press as: Tak V, et al., Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center, Journal of Patient Safety & Infection Control (2014), http://dx.doi.org/10.1016/ j.jpsic.2013.12.001
3
j o u r n a l o f p a t i e n t s a f e t y & i n f e c t i o n c o n t r o l x x x ( 2 0 1 4 ) 1 e4
Secondary blood stream infection:2,6 Was defined as a culture-confirmed BSI associated with a documented HAI at another site (i.e. met CDC criteria of infection at another site). If the primary infection was cultured, the secondary BSI must have yielded culture of same organism and exhibited same antibiogram as the primary HAI site. The tips of central vascular catheters, if received were processed by the roll plate method of Maki et al.7 However, for the interpretation of CLA-BSI, the result of catheter tips was not taken into consideration. The blood samples were collected in the BacT Alert blood culture bottles according to the manufacturer’s instructions. All samples were processed according to standard methods.8 Identification of bacteria and yeasts was done by the Vitek 2 system (BioMerieux Ltd., France). Antimicrobial susceptibility testing was performed by the disc diffusion method, according to the CLSI guidelines9 and by the VITEK 2 system (BioMerieux Ltd.)
4.
Results
The impact of all these measures was quantified from June, 2010 to January, 2013. The study population consisted of patients admitted to the ICUs of the trauma center for more than 48 h who had a central vascular line during their ICU stay. The data was stratified into three time periods to study the impact of surveillance, training and feedbacks. It was compared to the pilot study,3 when we had no such system in place. During the study period, a total of 3715 patients were admitted to the ICUs of the trauma center, amounting to a total of 28,664 patient days. Of these, 746 patients (20%) stayed in the ICUs for less than 48 h and were therefore excluded from further analysis. The excluded patients were either admitted for post trauma observation/were post-operative and admitted for a short duration or were severely injured, who expired within 48 h of admission. Thus, a total of 2969 patients were followed up for CLABSIs. These patients amounted to a total of 27,394 ICU days. The length of ICU stay of this study population ranged from 3e69 days (median 7 days). The age of the patients ranged from 1 months to 90 years (median 30 years). A total of 2538 (85%) patients were males.
The total CVC days for the study population (n ¼ 2969) during the study period amounted to 15,443 days. A total of 93 episodes of CLA-BSI occurred during the study, amounting to a CLA-BSI rate of 6.02/1000 CVC days. A total of 98 microbes were isolated from the 93 episodes of CLA-BSI. Staphylococcus aureus (27; 27.5%) was the most common isolate, followed by Candida Sp. (16; 16%), Acinetobacter baumannii (15; 15%), Klebsiella pneumoniae (10; 10%), Serratia marcescens (9; 9%), Enterococcus faecium (7; 7%), Pseudomonas aeruginosa (4; 4%), Burkholderia cepacia (4; 4%), Staphylococcus epidermidis (3; 3%), Enterobacter sp. (2; 2%) & Stenotrophomonas maltophilia (1; 1%). Table 1 shows the trend of CLA-BSIs during the past twostudy period at our center and the impact of initiation of an intensive automated surveillance. The hand hygiene compliance and compliance to central line bundle showed a sustained increase from January, 2010 to January, 2013 (Table 1). The CVP tips also grew a similar organism in 32 of the 93 (34%) episodes of CLA-BSI. In other cases, the CVP tips could not be sent as the patients were severely injured and had hemodynamic instability or there was growth of mixture of bacteria or bacterial growth was in insignificant numbers. However, since our study pertained to CLA-BSI (which does not require a catheter tip culture, in contrast to CRBSI), the catheter tip culture results were not taken into consideration for calculation of CLA-BSI rates. A total of 101 episodes of secondary BSIs were also observed during the study. Thus, we observed a higher proportion of secondary BSI as compared to primary BSIs. Of these, 70 (69%) were secondary to VAP, 18 (18%) were secondary to wound infections and 13 (13%) were secondary to UTI. A total of 530 (18%) of the 2969 patients died during their ICU stay. An autopsy was performed on these cases. The recorded primary cause of death in these patients was severe injuries in 334 (63%), complications of trauma in 64 (12%) and infections in 132 patients (25%). A comparison of the percentage mortality in trauma patients and the contribution of infections as cause of mortality during the present study and the same figures during January to April, 2010 is shown in Table 1. Infections contributed to 60% of mortality in the pilot study as compared to 25% during the present study.
Table 1 e Trend of CLA-BSI and impact of preventive interventions from June 2010 to January, 2013. Time period
CVC days Number of episodes of CLA-BSI Rate of CLA-BSI (per 1000 CVC days) Compliance to central line bundle (%) Compliance to hand hygiene (%) Percentage mortality (of the total admitted patients staying beyond 48 h) Infections as cause of mortality (%) a
JanuaryeApril, 2010 (Pilot study)a
June, 2010 eAugust, 2011
September, 2011 eFebruary, 2012
March 2012 eSeptember, 2012
October, 2012 eJanuary, 2013
1808 50 27.6 32 12 28
6073 46 7.5 90 64 17
3414 23 6.7 80.3 67.7 10
4179 17 4.06 84 63 19.4
1777 7 3.9 82 55 17
60
38
28
17
16
Reference.2
Please cite this article in press as: Tak V, et al., Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center, Journal of Patient Safety & Infection Control (2014), http://dx.doi.org/10.1016/ j.jpsic.2013.12.001
4
j o u r n a l o f p a t i e n t s a f e t y & i n f e c t i o n c o n t r o l x x x ( 2 0 1 4 ) 1 e4
However, restricting to the patient population in the present study (who developed CLA-BSIs at some point of their ICU stay), of the 92 patients who accounted for the 93 episodes of CLA-BSIs, a total of 20 (21.7%) had a fatal outcome. The recorded cause of death in 15 of these 20 cases (75%) was septicemia; in the remaining five, it was severe injuries. However, of the 15 patients who died due to septicemia, seven also had ventilator associated pneumonia, and one had abdominal wound infection, thus it was difficult to ascertain the attributable mortality of CLA-BSIs.
5.
Discussion
Hospitals in the United States functioning under the CDC’s NHSN network report a mean CLA-BSI rate of 1.5 cases per 1000 CVC days in medical-surgical ICUs and of 2.9 cases per 1000 CVC days in NICUs.10 By contrast, in developing countries, the CLA-BSI rates range from 1.6e44.6 cases per 1000 CVC days in adult and pediatric ICUs and from 2.6e60.0 cases per 1000 CVC days in NICUs.11 In a multinational study of ICUs from 8 developing countries, the incidence of CVC related BSIs was 12.5/1000 catheter days.12 The CLA-BSI rates are higher in limited resource countries due to lack of proper infrastructure for surveillance as well as poor or non-existing infection control practices. Since some BSIs are secondary to other sources other than the central line that may not be easily recognized, the CLA-BSI surveillance definition may overestimate the true incidence of CRBSI. We have employed one HICN dedicated to trace the source of all BSIs in the ICUS and to educate and monitor the compliance to hand hygiene and central line bundle. In all cases of BSIs, culture reports of samples from other sites are compiled and compared with the blood report. If other samples are not received, the HICNs collect samples like urine, wound samples, respiratory samples and a repeat blood sample from peripheral vein. This has reduced the numbers of BSIs being wrongly labeled as CLA-BSI. For the same reason, we have found a larger number of secondary BSIs (101), since the source of BSIs could be traced in those episodes. This is in contrast to many other studies, where primary BSIs form the predominant group.
6.
Conclusions
Data analysis by this indigenous software has significantly reduced the turnover time required for generation of reports of CLA-BSI as compared to manual generation of reports. Thus, with the help of the intensive surveillance, using this software, we have been able to monitor the impact of training, surveillance and interventions on the rates of CLA-BSI, which have reduced from 27.6 to 6/1000 CVC days within a span of 2 years at our institute. We believe that hospitals in developing countries should develop their own modules of prevention, beginning with surveillance and education, followed by implementation of preventive bundles, reminders and feedbacks. Although these measures require a dedicated team effort, they are easy and cost effective to implement and can
reduce all device associated infections across all types of health care facilities. Such simple and effective measures are also needed in our country, which is witnessing high rates of multi- and pan-drug resistant organisms.
Conflicts of interest All authors have none to declare.
Acknowledgment This software was developed through a grant from the Indian Council of Medical Research, New Delhi. We thank the ICMR for their financial support. This study was funded by a grant from the Indian Council of Medical Research. We acknowledge the financial support of ICMR for the performance of this study.
references
1. Damani NN. Manual of Infection Control Procedures. 2nd ed. New York: Cambridge University Press; 2003. 2. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(suppl 1):S1eS34. 3. Gunjiyal J, Thomas SM, Gupta AK, et al. Device associated and multidrug e resistant infections in critically ill trauma patients: towards development of automated surveillance in developing countries. J Hosp Infect. 2011;77:169e185. 4. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309e332. 5. WHO. Guidelines on Hand Hygiene in Health Care. Geneva: WHO Press; 2009. 6. CDC. National Healthcare Safety Network. Device Associated Infections Module. Protocols and Instructions; 2010. Available at: www.cdc.gov/nhsn/psc-da.html http://www.cdc.gov/nhsn/ library.html. 7. Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for identifying intra-venous-catheter-related infection. N Engl J Med. 1977;296:1305e1309. 8. Collee JG, Diguid JP, Fraser AG. Mackie and McCartney Practical Medical Microbiology. 14th ed. Edinburgh: Churchill Livingstone; 1996. 9. Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing, 19th Informational Supplements, 2009;M100eS16. Wayne, PA, USA: CLSI; 2006. 10. Edwards JR, Peterson KD, Andrus ML, et al. National Healthcare Safety Network (NHSN) report, data summary for 2006, issued June 2007. Am J Infect Control. 2007;35(5):290e301. 11. Rosenthal VD. Central line e associated bloodstream infections in limited-resource countries: a review of the literature. Clin Infect Dis. 2009;49:1899e1907. 12. Rosenthal VD, Maki DG, Salomao R, et al. Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med. 2006;145:582e591.
Please cite this article in press as: Tak V, et al., Impact of an intensive surveillance on central line associated blood stream infections at an Indian trauma center, Journal of Patient Safety & Infection Control (2014), http://dx.doi.org/10.1016/ j.jpsic.2013.12.001