I N F E C T I O N C O N T R O L AND H O S P I T A L E P I D E M I O L O G Y MAY 2 0 1 0 , VOL. 3 1 , N O .

CONCISE COMMUNICATION

Analysis of Central Line-Associated related BSIs (CLRBSIs). CLRBSI was defined according to the
Centers for Disease Control and Prevention definition4 as
Bloodstream Infections in the Intensive bacteremia or candidemia in a patient who had a positive
Care Unit after Implementation blood culture result with a sample drawn from a peripheral
of Central Line Bundles vein, clinical manifestations of infection, and no obvious
source of infection other than a central line. Semiquanti-
Emily K. Shuman, MD; Laraine L. Washer, MD; tative or quantitative central line tip culture or a differential
Jennifer L. Arndt, MS, CIC; period of central line blood culture positivity versus periph-
Christy A. Zalewski, MPH, CIC; Robert C. Hyzy, MD; eral blood culture positivity of greater than 2 hours was also
Lena M. Napolitano, MD; Carol E. Chenoweth, MD required. CLABSI was defined according to the previously
mentioned NHSN definition4 as a laboratory-confirmed BSI
Central line-associated bloodstream infections (CLABSIs) have been in a patient with a central line in place within 48 hours be-
reduced in number but not eliminated in our intensive care units fore onset of infection. Secondary BSIs (designated by our
with use of central line bundles. We performed an analysis of re- infection control professionals as BSIs involving the same
maining CLABSIs. Many bloodstream infections that met the def- organism with the same antibiogram isolated from anoth-
inition of CLABSI had sources other than central lines or represented er clinical site of infection) were excluded.
contaminated blood samples. Medical records of patients with CLABSIs were examined
Infect Control Hosp Epidemiol 2010; 31(5):551-553further for potential causes by 2 infectious diseases physicians.
Review by a third infectious diseases physician was performed
After implementation of a bundle of measures to reduce cen- for discordant results. Reviewing physicians were not blinded
tral line infections,1"3 we have reduced the number of central to the opinions of the infection control professionals or other
line-associated bloodstream infections (CLABSIs) but have physicians. Criteria for determining sources of CLABSIs are
not eliminated them in our intensive care units (ICUs). One outlined in Table 1. Enterococci were considered possible
5
concern is that the National Healthcare Safety Network blood sample contaminants on the basis of previous data.
(NHSN) definition for CLABSI,4 which is used by most in- CLRBSIs were determined to be infections due to central lines
stitutions, is not specific to central line infections. We re- and were not evaluated further for source. Both CLABSIs and
viewed the remaining CLABSIs in our ICUs to propose pos- CLRBSIs were examined to determine types of central lines
sible interventions. In particular, we examined CLABSIs to present and organisms involved.
determine if some of these were from sources other than
central lines.

METHODS RESULTS
This retrospective observational study was conducted in two The number of CLABSIs decreased in both ICUs (Figure 1).
20-bed adult ICUs (the Critical Care Medicine Unit [CCMU] During the study period, there were 2,239 CCMU admissions
and the Surgical ICU [SICU]) at an 809-bed tertiary care hos- (11,578 central line-days) and 2,576 SICU admissions (10,857
pital. A bundle of measures to reduce the number of central central line-days). There were 30 BSIs in the CCMU and 8
line infections was implemented in March 2004 in the CCMU in the SICU, with overall rates of 2.5 BSIs/1,000 central line-
and in June 2005 in the SICU. The bundle included education days for the CCMU and of 0.7 BSIs/1,000 central line-days
of nurses and physicians, use of line insertion carts, use of for the SICU. Ten BSIs in the CCMU (33%) were CLRBSIs,
checklists to ensure adherence to guidelines, the stopping of and 20 (67%) were CLABSIs. All 8 BSIs in the SICU (100%)
procedures when guidelines are violated, and daily assessment were CLABSIs.
of ongoing need for central lines.1'2 Additional preventive According to the physician review of the 20 CLABSIs in
measures include skin preparation with 2% chlorhexidine the CCMU, 9 (45%) had central line sources, 9 (45%) were
gluconate and 70% isopropyl alcohol solution (ChloraPrep) the result of contaminated blood samples, and 2 (10%) were
and use of chlorhexidine gluconate and silver sulfadiazine- transient postoperative BSIs. The 2 reviewing physicians
coated catheters (Arrowgard Plus). agreed on the source of BSI in all but 2 CCMU cases (10%).
Cases were identified from microbiology laboratory, in- Of the 9 patients with CLABSIs attributed to contaminated
fection control, and medical records from November 2005 blood samples, 8 (89%) were given antimicrobials by their
through September 2007. Two dedicated infection control physicians. Of the 8 CLABSIs in the SICU, 5 (62.5%) had
professionals (1 for each ICU) designated nonsecondary intra-abdominal sources, 2 (25%) had central line sources,
bloodstream infections (BSIs) as CLABSIs or central line- and 1 (12.5%) was from an unknown non-central line source.
552 I N F E C T I O N CONTROL AND H O S P I T A L E P I D E M I O L O G Y MAY 2 0 1 0 , V O L . 3 1 , N O . 5

TABLE 1. Criteria for Determining Sources of Central Line-Associated Bloodstream Infections (CLABSIs)
Source Criteria
Central line Either meets Centers for Disease Control and Prevention definition for CLABSI4 or meets previ-
ous National Healthcare Safety Network definition for CLABSI4 and has no other source of
infection identified on physician review
Contaminated blood sample Single positive blood culture result with a typical skin colonizer (including enterococci) in a pa-
tient with no signs of infection5
Transient postoperative BSI Single positive blood culture result within 24 hours after surgery at a site where a patient was
known to be colonized with the same organism (eg, methicillin-resistant Staphylococcus aureus
[MRSA] bacteremia after lung transplantation in a patient with MRSA tracheal colonization)
Intra-abdominal source BSI with typical bowel organism(s) in a patient with a history of recent abdominal surgery or
known intra-abdominal process
Unknown non-central line source Primary BSI with an organism atypical for a central line source but with no other obvious
source of infection
NOTE. BSI, bloodstream infection.

The 2 reviewing physicians agreed on the source of BSI in useful as a public reporting measure in the setting of in-
all SICU cases. Overall, 17 (61%) of 28 CLABSIs in the 2 creasing pressure to "get to zero."
ICUs had sources of infection from other than central lines Our results suggest that interventions to improve aseptic
or from contaminated blood samples. blood sample collection could have a substantial impact on
A total of 19 patients in the CCMU and 2 patients in the further reducing CLABSI rates in our ICUs, where most blood
SICU had BSIs attributed to central lines (either CLRBSIs or samples are drawn from central lines by nursing staff.6 In
CLABSIs from central line sources). Among these patients, addition, although many BSIs in our study were from sources
the type of central line most commonly used was a periph- other than central lines, there were also many BSIs that did
erally inserted central catheter (PICC), in 13 CCMU patients originate from central lines, and we identified possible in-
(68%) and 2 SICU patients (100%). The second most com- terventions for further reducing the number of these infec-
mon type of central line was a nontunneled hemodialysis tions. Maki et al7 found that both PICCs and nontunneled
catheter, in 7 CCMU patients (36.8%). hemodialysis catheters are associated with a high risk of in-
Organisms recovered from CCMU patients with BSIs at- fection in the ICU setting. In our study, most of the patients
tributed to central lines (n = 19) included 8 isolates of en- with BSIs attributed to central lines had PICCs, and many
terococci (of which 7 were vancomycin resistant), 6 of co- had nontunneled hemodialysis catheters. At our hospital,
agulase-negative staphylococci, 6 of gram-negative bacteria, PICCs are inserted by staff from a dedicated vascular access
3 of Candida species, and 2 of Staphylococcus aureus. Six BSIs service, and hemodialysis catheters are typically inserted by
attributed to central lines (32%) had polymicrobial findings. nephrologists rather than ICU staff. Placement and handling
Organisms isolated from SICU patients with BSIs attributed of these types of central lines may be an important target for
to central lines (n = 2) were Candida species (n = 1) and intervention to further reduce CLABSI rates.
coagulase-negative staphylococci (n = 1). Of the 9 BSIs in Finally, we found that vancomycin-resistant enterococci
the CCMU attributed to blood sample contamination, 6
(67%) were due to vancomycin-resistant enterococci.

6
5
DISCUSSION t
Bundles of measures have been effective in reducing the num- & 4H
ber of CLABSIs in our ICUs, but CLABSIs persist at lower
rates. We investigated the possibility that the NHSN definition
1
o
for CLABSI may not be specific enough to allow for elimi- 8. 2
a)
nation of central line infections in all ICUs. In our ICUs,
55 1
infectious diseases physicians believed that more than half
l
BD
the time, CLABSIs originated either from other than a central
line or from contaminated blood samples. Because the NHSN 0 2004 2005 2006 2007
definition of CLABSI is meant to be used for surveillance
purposes, it is intentionally sensitive at the expense of spec- FIGURE i. Central line-associated bloodstream infection (BSI)
ificity. Thus, although the NHSN definition may be useful rates in the Critical Care Medicine Unit (CCMU) and Surgical In-
for benchmarking within and between institutions, it is less tensive Care Unit (SICU), 2004-2007.
 ANALYSIS OF CLABSIS 553

were the most common cause of BSIs attributed to central Received July 28, 2009; accepted October 26, 2009; electronically published
lines, as well as the most commonly isolated organisms in March 24, 2010.
Presented in part: 18th Annual Scientific Meeting of the Society for Health-
contaminated blood samples. It has been shown that there is care Epidemiology of America; Orlando, Florida; April 6, 2008 (Abstract
a high rate of skin colonization among patients with van- 114).
comycin-resistant enterococci bacteremia and that many of © 2010 by The Society for Healthcare Epidemiology of America. All rights
these episodes of bacteremia clear spontaneously, which is reserved. 0899-823X/2010/3105-0020$15.00. DOI: 10.1086/652157
suggestive of blood sample contamination.8 This reminds us
of the need to adhere to standard infection control practices,
including hand hygiene and the use of gowns and gloves when
indicated, to further reduce CLABSI rates. Additional mea- REFERENCES
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ACKNOWLEDGMENTS
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Address reprint requests to Emily K. Shuman, MD, 3119 Taubman Center, patient safety component protocol. 2008. http://www.cdc.gov/nhsn. Ac-
1500 E Medical Center Dr, Ann Arbor, MI 48109-5378 (emilyks@umich.edu). cessed October 19, 2009.