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A comparison of the incidence of midline catheter–associated bloodstream infections to that of central line–associated bloodstream infections in 5 acute care hospitals
ARTICLE IN PRESS American Journal of Infection Control 000 (2019) 1−3
Contents lists available at ScienceDirect
American Journal of Infection Control journal homepage: www.ajicjournal.org
Brief Report
A comparison of the incidence of midline catheter−associated bloodstream infections to that of central line−associated bloodstream infections in 5 acute care hospitals Nancy J. Hogle MPH, RN, CIC a,*, Krystal M. Balzer MSN, RN, CIC a, Barbara G. Ross MS, RN, CIC, FAPIC a, Lorelle Wuerz PhD, RN, VA-BC, NEA-BC b, William G. Greendyke MD a,c, E. Yoko Furuya MD, MS a,c, Matthew S. Simon MD, MS a,d, David P. Calfee MD, MS a,d a
Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, NY Center for Professional Nursing Practice, NewYork-Presbyterian, New York, NY c Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY d Department of Medicine, Weill Cornell Medicine, New York, NY b
Key Words: Intravenous therapy Blood stream infection Bacteremia Intravascular catheter
In a retrospective study conducted over 12 months in a multi-hospital system, the incidence of bloodstream infections associated with midline catheters was not significantly lower than that associated with central venous catheters (0.88 vs 1.10 infections per 1,000 catheter-days). Additional research is needed to further characterize the infectious risks of midline catheters and to determine optimal strategies to minimize these risks. © 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Despite notable success in reducing the incidence of central line− associated bloodstream infections (CLABSIs) over the past several years, CLABSIs continue to be a cause of substantial morbidity, mortality, and excess health care costs in US hospitals.1,2 One important strategy for CLABSI prevention is avoidance of unnecessary use of central lines (CLs).3,4 Midline catheters (MLs) are intravenous (IV) catheters that are inserted into peripheral veins. Although they are of variable length, they are typically longer than standard peripheral IV catheters yet do not enter the center venous system. These catheters may remain in place and functional for longer periods of time than standard peripheral IV catheters; therefore, MLs may be an appropriate alternative to CLs for some patients who do not require central access.5 Currently, surveillance and reporting of midline catheter−associated bloodstream infections (MLABSIs) are not required, in contrast to CLABSI. Some hospitals have reported lower rates of CLABSI following implementation of a ML program; however, few have assessed the incidence of MLABSIs.6,7 Given that hospitals may increasingly use MLs as alternatives to CLs and that the incidence of bloodstream infections (BSIs) associated with the use of MLs has not been thoroughly studied, we sought to determine the incidence of MLABSIs after their introduction in a multi-hospital system. *Address correspondence to Nancy J. Hogle, MPH, Cleveland Clinic, 9500 Euclid Ave, JJN2-200, Cleveland, OH 44195. E-mail address: [email protected] (N.J. Hogle). Conflicts of interest: M.S.S. reports personal fees from Roche Diagnostics, outside the submitted work. All other authors report no conflicts of interest.
METHODS This was a retrospective surveillance study conducted in the 5 acute care hospitals of a large urban medical system from September 2016 to August 2017. The 5 hospitals include 2 large academic tertiary care hospitals, 2 small community hospitals, and an academic pediatric and women’s hospital. Combined, the 5 hospitals have approximately 2,200 staffed beds. This study was approved by the Weill Cornell Medicine Institutional Review Board and the Columbia University Irving Medical Center Institutional Review Board. The hospital system had introduced PowerGlide MLs (Bard Access Systems, Inc.; Salt Lake City, UT) as an option for venous access between June and August 2016. The MLs were ordered by a clinician, placed by trained vascular access personnel, and maintained by either the vascular access team or the patient’s bedside nurse. MLs were placed using a skin prep containing alcohol and chlorhexidine gluconate (CHG), sterile gloves, and sterile techniques, and a Tegaderm CHG dressing (3M; St. Paul, MN) was applied to the insertion site. During the study period, peripherally inserted central catheters were inserted by trained vascular access nurses or physicians in procedural areas (eg, interventional radiologists), and other non-tunneled and tunneled central venous catheters were placed by trained physicians, physician assistants, and nurse practitioners following a standardized protocol across all sites based on current evidencebased practice guidelines.3,4
https://doi.org/10.1016/j.ajic.2019.11.004 0196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
ARTICLE IN PRESS N.J. Hogle et al. / American Journal of Infection Control 00 (2019) 1−3
2
Fig 1. ML utilization ratio by month among the 5 participating hospitals combined. ML, midline catheter.
Table 1 Cumulative incidence of MLABSIs across the 5 participating hospitals Hospital
MLABSIs (n)
ML-days (n)
MLABSI rate per 1,000 ML-days
A B C D E Overall
1 8 0 14 0 23
388 10,127 546 14,438 261 26,063
2.58 0.79 0.0 0.97 0.0 0.88
ML, midline catheter; MLABSI, midline catheter−associated bloodstream infection.
Data were collected using hospital electronic medical records. CLABSI and MLABSI cases were identified as part of routine surveillance for health care−associated infections conducted by trained infection preventionists at the participating hospitals. Surveillance for CLABSIs was performed using definitions provided by the Centers for Disease Control and Prevention’s National Healthcare Safety Network.8 MLABSI was similarly defined as a primary BSI that occurred in a patient with a ML that had been in place for more than 2 calendar days prior to the date of the laboratory-confirmed BSI. Primary BSIs identified in patients who had both a ML and a CL were counted as CLABSIs. All potential CLABSI and MLABSI events identified by the infection preventionists were independently reviewed by a hospital epidemiologist to confirm that surveillance definitions were applied correctly and consistently. CLABSI and MLABSI incidence was calculated as the number of CLABSIs or MLABSIs divided by the number of catheter-days multiplied by 1,000. Catheter utilization rates for CLs and MLs were calculated as the number of catheter-days divided by the number of patient-days within a given time period. The National Healthcare Safety Network incidence density rate comparison calculator was used to determine if there was a significant difference between the incidence of MLABSIs and that of CLABSIs during the observation period.
RESULTS During the 12-month study period, there were 165,166 CL-days and 26,063 ML-days among all 5 hospitals. Overall catheter utilization was 0.21 for CLs and 0.034 for MLs. Between September 2016 and August 2017, ML utilization increased from approximately 0.03 to 0.045 (Fig 1). ML use was greatest at the 2 large academic hospitals (hospitals B and D in Table 1), corresponding to approximately
45-100 ML insertions per month at hospital B and 120-160 ML insertions per month at hospital D. Among the 5 hospitals, 23 MLABSIs were identified during the study period for an overall MLABSI incidence of 0.88 per 1,000 ML-days. The cumulative incidence of MLABSIs at each of the 5 hospitals is shown in Table 1. The incidence of MLABSIs did not differ significantly among the hospitals. During the same period, 178 CLABSIs were identified, resulting in a CLABSI incidence of 1.10 per 1,000 CL-days. The difference between the incidence of MLABSIs and that of CLABSIs was not statistically significant (P = .37). DISCUSSION Avoiding the unnecessary use of CLs is an important strategy for CLABSI prevention. MLs are increasingly being used as an alternative to CLs to prevent CLABSIs and, ideally, to reduce the overall risk of catheter-associated BSIs. In our study population, the incidence of MLABSIs was approximately 20% lower than that of CLABSIs, but this difference was not statistically significant. These findings suggest that the incidence of MLABSIs is not negligible and that midline catheters do not eliminate the risk of catheter-associated BSIs. A recent study by deVries et al7 reported no MLABSIs over a 2-year period. Our findings differ from theirs, and we offer several possible explanations. First, although both were small studies, the deVries study was much smaller in that it observed a total of 5,430 ML days, approximately one-fifth the number of ML days included in our study. Next, they used a different ML catheter and different infection prevention practices (eg, maximal sterile barriers for insertion, a different CHG-containing dressing).7 One or more of these factors may have contributed to the differences in outcomes observed in the 2 studies. This study has several limitations. First, we used standardized surveillance definitions for CLABSIs, which may have over- or underestimated the true rate of catheter-related bloodstream infections. Second, the study period was relatively brief with relatively few BSI events, resulting in insufficient power to detect statistical significance in the small but potentially clinically relevant differences between the CLABSI and MLABSI rates. Although the study was conducted in both large and small hospitals, as well as a freestanding pediatric and women’s hospital, all of the hospitals were part of the same health care system; thus, the findings may not be generalizable to other settings. Finally, we did not assess or control for differences in
ARTICLE IN PRESS N.J. Hogle et al. / American Journal of Infection Control 00 (2019) 1−3
patient-level factors (eg, severity of illness, medical comorbidities) that may have influenced the risk for BSIs or determined the type of catheter (CL or ML) selected. CONCLUSIONS We found that the incidence of MLABSIs was not significantly different from that of CLABSIs. Hospitals using midline catheters should consider including MLABSI surveillance as part of an overall vascular access safety program. Additional research is needed to further characterize the infectious risks of midline catheters and to determine optimal strategies to minimize these risks. Acknowledgments Thank you to our contributors, who made this work possible: Janett Pike, Jeff Karp, Adam Gouveia, Kathryn Albert, Lilibeth Andrada, Jean-Marie Cannon, John D’Agostino, Christine Hatola, Jennifer Holohan, Diane Mangino, Maria Messina, Patrice Russell, Nancy Schneider, Jillian Scarr, Kindra White, and Krista Wilson.
3
References 1. Centers for Disease Control and Prevention. Vital signs: central line-associated blood stream infections−United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep 2011;60:243-8. 2. Centers for Disease Control and Prevention. Data summary of HAIs in the US: assessing progress 2006−2016. Available from: https://www.cdc.gov/hai/data/ archive/data-summary-assessing-progress.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhai%2Fsurveillance%2Fdata-reports%2Fdata-summary-assessingprogress.html. Accessed November 20, 2019. 3. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:753-71. 4. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Summary of recommendations: guidelines for the prevention of intravascular catheterrelated infections. Clin Infect Dis 2011;52:e162-93. 5. Chopra V, Flanders SA, Saint S, Woller SC, O’Grady NP, Safdar N, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med 2015;163(Suppl 6):S1-4. 6. Pathak R, Patel A, Enuh H, Adekunle O, Shrisgantharajah V, Diaz K. The incidence of central line-associated bacteremia after the introduction of midline catheters in a ventilator unit population. Infect Dis Clin Pract (Baltim Md) 2015;23:131-4. 7. deVries M, Lee J, Hoffman L. Infection free midline catheter implementation at a community hospital (2 years). Am J Infect Control 2019;47:1118-21. 8. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) patient safety component manual. https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. Accessed November 20, 2019.
Contents lists available at ScienceDirect
American Journal of Infection Control journal homepage: www.ajicjournal.org
Brief Report
A comparison of the incidence of midline catheter−associated bloodstream infections to that of central line−associated bloodstream infections in 5 acute care hospitals Nancy J. Hogle MPH, RN, CIC a,*, Krystal M. Balzer MSN, RN, CIC a, Barbara G. Ross MS, RN, CIC, FAPIC a, Lorelle Wuerz PhD, RN, VA-BC, NEA-BC b, William G. Greendyke MD a,c, E. Yoko Furuya MD, MS a,c, Matthew S. Simon MD, MS a,d, David P. Calfee MD, MS a,d a
Department of Infection Prevention and Control, NewYork-Presbyterian Hospital, New York, NY Center for Professional Nursing Practice, NewYork-Presbyterian, New York, NY c Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY d Department of Medicine, Weill Cornell Medicine, New York, NY b
Key Words: Intravenous therapy Blood stream infection Bacteremia Intravascular catheter
In a retrospective study conducted over 12 months in a multi-hospital system, the incidence of bloodstream infections associated with midline catheters was not significantly lower than that associated with central venous catheters (0.88 vs 1.10 infections per 1,000 catheter-days). Additional research is needed to further characterize the infectious risks of midline catheters and to determine optimal strategies to minimize these risks. © 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
Despite notable success in reducing the incidence of central line− associated bloodstream infections (CLABSIs) over the past several years, CLABSIs continue to be a cause of substantial morbidity, mortality, and excess health care costs in US hospitals.1,2 One important strategy for CLABSI prevention is avoidance of unnecessary use of central lines (CLs).3,4 Midline catheters (MLs) are intravenous (IV) catheters that are inserted into peripheral veins. Although they are of variable length, they are typically longer than standard peripheral IV catheters yet do not enter the center venous system. These catheters may remain in place and functional for longer periods of time than standard peripheral IV catheters; therefore, MLs may be an appropriate alternative to CLs for some patients who do not require central access.5 Currently, surveillance and reporting of midline catheter−associated bloodstream infections (MLABSIs) are not required, in contrast to CLABSI. Some hospitals have reported lower rates of CLABSI following implementation of a ML program; however, few have assessed the incidence of MLABSIs.6,7 Given that hospitals may increasingly use MLs as alternatives to CLs and that the incidence of bloodstream infections (BSIs) associated with the use of MLs has not been thoroughly studied, we sought to determine the incidence of MLABSIs after their introduction in a multi-hospital system. *Address correspondence to Nancy J. Hogle, MPH, Cleveland Clinic, 9500 Euclid Ave, JJN2-200, Cleveland, OH 44195. E-mail address: [email protected] (N.J. Hogle). Conflicts of interest: M.S.S. reports personal fees from Roche Diagnostics, outside the submitted work. All other authors report no conflicts of interest.
METHODS This was a retrospective surveillance study conducted in the 5 acute care hospitals of a large urban medical system from September 2016 to August 2017. The 5 hospitals include 2 large academic tertiary care hospitals, 2 small community hospitals, and an academic pediatric and women’s hospital. Combined, the 5 hospitals have approximately 2,200 staffed beds. This study was approved by the Weill Cornell Medicine Institutional Review Board and the Columbia University Irving Medical Center Institutional Review Board. The hospital system had introduced PowerGlide MLs (Bard Access Systems, Inc.; Salt Lake City, UT) as an option for venous access between June and August 2016. The MLs were ordered by a clinician, placed by trained vascular access personnel, and maintained by either the vascular access team or the patient’s bedside nurse. MLs were placed using a skin prep containing alcohol and chlorhexidine gluconate (CHG), sterile gloves, and sterile techniques, and a Tegaderm CHG dressing (3M; St. Paul, MN) was applied to the insertion site. During the study period, peripherally inserted central catheters were inserted by trained vascular access nurses or physicians in procedural areas (eg, interventional radiologists), and other non-tunneled and tunneled central venous catheters were placed by trained physicians, physician assistants, and nurse practitioners following a standardized protocol across all sites based on current evidencebased practice guidelines.3,4
https://doi.org/10.1016/j.ajic.2019.11.004 0196-6553/© 2019 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
ARTICLE IN PRESS N.J. Hogle et al. / American Journal of Infection Control 00 (2019) 1−3
2
Fig 1. ML utilization ratio by month among the 5 participating hospitals combined. ML, midline catheter.
Table 1 Cumulative incidence of MLABSIs across the 5 participating hospitals Hospital
MLABSIs (n)
ML-days (n)
MLABSI rate per 1,000 ML-days
A B C D E Overall
1 8 0 14 0 23
388 10,127 546 14,438 261 26,063
2.58 0.79 0.0 0.97 0.0 0.88
ML, midline catheter; MLABSI, midline catheter−associated bloodstream infection.
Data were collected using hospital electronic medical records. CLABSI and MLABSI cases were identified as part of routine surveillance for health care−associated infections conducted by trained infection preventionists at the participating hospitals. Surveillance for CLABSIs was performed using definitions provided by the Centers for Disease Control and Prevention’s National Healthcare Safety Network.8 MLABSI was similarly defined as a primary BSI that occurred in a patient with a ML that had been in place for more than 2 calendar days prior to the date of the laboratory-confirmed BSI. Primary BSIs identified in patients who had both a ML and a CL were counted as CLABSIs. All potential CLABSI and MLABSI events identified by the infection preventionists were independently reviewed by a hospital epidemiologist to confirm that surveillance definitions were applied correctly and consistently. CLABSI and MLABSI incidence was calculated as the number of CLABSIs or MLABSIs divided by the number of catheter-days multiplied by 1,000. Catheter utilization rates for CLs and MLs were calculated as the number of catheter-days divided by the number of patient-days within a given time period. The National Healthcare Safety Network incidence density rate comparison calculator was used to determine if there was a significant difference between the incidence of MLABSIs and that of CLABSIs during the observation period.
RESULTS During the 12-month study period, there were 165,166 CL-days and 26,063 ML-days among all 5 hospitals. Overall catheter utilization was 0.21 for CLs and 0.034 for MLs. Between September 2016 and August 2017, ML utilization increased from approximately 0.03 to 0.045 (Fig 1). ML use was greatest at the 2 large academic hospitals (hospitals B and D in Table 1), corresponding to approximately
45-100 ML insertions per month at hospital B and 120-160 ML insertions per month at hospital D. Among the 5 hospitals, 23 MLABSIs were identified during the study period for an overall MLABSI incidence of 0.88 per 1,000 ML-days. The cumulative incidence of MLABSIs at each of the 5 hospitals is shown in Table 1. The incidence of MLABSIs did not differ significantly among the hospitals. During the same period, 178 CLABSIs were identified, resulting in a CLABSI incidence of 1.10 per 1,000 CL-days. The difference between the incidence of MLABSIs and that of CLABSIs was not statistically significant (P = .37). DISCUSSION Avoiding the unnecessary use of CLs is an important strategy for CLABSI prevention. MLs are increasingly being used as an alternative to CLs to prevent CLABSIs and, ideally, to reduce the overall risk of catheter-associated BSIs. In our study population, the incidence of MLABSIs was approximately 20% lower than that of CLABSIs, but this difference was not statistically significant. These findings suggest that the incidence of MLABSIs is not negligible and that midline catheters do not eliminate the risk of catheter-associated BSIs. A recent study by deVries et al7 reported no MLABSIs over a 2-year period. Our findings differ from theirs, and we offer several possible explanations. First, although both were small studies, the deVries study was much smaller in that it observed a total of 5,430 ML days, approximately one-fifth the number of ML days included in our study. Next, they used a different ML catheter and different infection prevention practices (eg, maximal sterile barriers for insertion, a different CHG-containing dressing).7 One or more of these factors may have contributed to the differences in outcomes observed in the 2 studies. This study has several limitations. First, we used standardized surveillance definitions for CLABSIs, which may have over- or underestimated the true rate of catheter-related bloodstream infections. Second, the study period was relatively brief with relatively few BSI events, resulting in insufficient power to detect statistical significance in the small but potentially clinically relevant differences between the CLABSI and MLABSI rates. Although the study was conducted in both large and small hospitals, as well as a freestanding pediatric and women’s hospital, all of the hospitals were part of the same health care system; thus, the findings may not be generalizable to other settings. Finally, we did not assess or control for differences in
ARTICLE IN PRESS N.J. Hogle et al. / American Journal of Infection Control 00 (2019) 1−3
patient-level factors (eg, severity of illness, medical comorbidities) that may have influenced the risk for BSIs or determined the type of catheter (CL or ML) selected. CONCLUSIONS We found that the incidence of MLABSIs was not significantly different from that of CLABSIs. Hospitals using midline catheters should consider including MLABSI surveillance as part of an overall vascular access safety program. Additional research is needed to further characterize the infectious risks of midline catheters and to determine optimal strategies to minimize these risks. Acknowledgments Thank you to our contributors, who made this work possible: Janett Pike, Jeff Karp, Adam Gouveia, Kathryn Albert, Lilibeth Andrada, Jean-Marie Cannon, John D’Agostino, Christine Hatola, Jennifer Holohan, Diane Mangino, Maria Messina, Patrice Russell, Nancy Schneider, Jillian Scarr, Kindra White, and Krista Wilson.
3
References 1. Centers for Disease Control and Prevention. Vital signs: central line-associated blood stream infections−United States, 2001, 2008, and 2009. MMWR Morb Mortal Wkly Rep 2011;60:243-8. 2. Centers for Disease Control and Prevention. Data summary of HAIs in the US: assessing progress 2006−2016. Available from: https://www.cdc.gov/hai/data/ archive/data-summary-assessing-progress.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhai%2Fsurveillance%2Fdata-reports%2Fdata-summary-assessingprogress.html. Accessed November 20, 2019. 3. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, et al. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35:753-71. 4. O’Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Summary of recommendations: guidelines for the prevention of intravascular catheterrelated infections. Clin Infect Dis 2011;52:e162-93. 5. Chopra V, Flanders SA, Saint S, Woller SC, O’Grady NP, Safdar N, et al. The Michigan Appropriateness Guide for Intravenous Catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med 2015;163(Suppl 6):S1-4. 6. Pathak R, Patel A, Enuh H, Adekunle O, Shrisgantharajah V, Diaz K. The incidence of central line-associated bacteremia after the introduction of midline catheters in a ventilator unit population. Infect Dis Clin Pract (Baltim Md) 2015;23:131-4. 7. deVries M, Lee J, Hoffman L. Infection free midline catheter implementation at a community hospital (2 years). Am J Infect Control 2019;47:1118-21. 8. Centers for Disease Control and Prevention. National Healthcare Safety Network (NHSN) patient safety component manual. https://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. Accessed November 20, 2019.