Adherence to guidelines and central-line-associated bloodstream infection occurrence during insertion and maintenance of intravascular catheters: evidence from 20 tertiary hospitals.

OBJECTIVE: To investigate adherence to intravascular catheter (IVC) insertion and maintenance guidelines in Chinese tertiary hospitals. METHODS: A cross-sectional questionnaire survey of adult inpatients with IVC placements was conducted from July to September 2022 in 20 tertiary hospitals in China. One clinical staff member from each department in each hospital was assigned to participate in the survey. Questionnaires were uniformly collected and reviewed after three months. RESULTS: This study included 1815 cases (62.69%) of central venous catheter, 471 cases (16.27%) of peripherally inserted central catheter, 461 cases (15.92%) of PORT, and 147 cases (5.08%) of haemodialysis catheter insertions. Statistically significant differences in compliance were observed across the four IVC types, specifically in relation to the insertion checklist, standard operating procedure, and insertion environment (P<0.05). Practice adherence during IVC maintenance differed significantly across the four IVC types in aspects such as availability of IVC maintenance verification forms, daily scrubbing of the catheterized patients, and catheter connection methods (P<0.05). A total of 386 (13.34%) patients developed fever, 1086 (37.53%) were treated with therapeutic antibiotics, 16 (0.55%) developed central-line-associated bloodstream infections, two (0.07%) developed local skin infections, and six (0.21%) developed deep vein thrombosis. CONCLUSIONS: Adherence to guidelines regarding insertion and maintenance differed across the four IVC types; there is a gap between the recommended measures and the actual operation of the guidelines. Therefore, it is necessary to further enhance training and develop checklists to prevent central-line-associated bloodstream infections.

Impact of care bundle audit on compliance to device care bundles and device associated infections in the Critical Care Unit of a tertiary care hospital, Southern India - A before-after interventional study.

BACKGROUND: A care bundle comprises a set of evidence-based practices in patient care that are grouped together with the assumption that these practices when performed together will result in better clinical outcomes than when these practices are performed separately. Care bundles for devices when implemented effectively can bring about a reduction in device associated infection rates. METHODS: The study was conducted in three phases, 1 month pre-interventional and interventional phases and 11 months of post-interventional phase in a critical care unit. Compliance to care bundles were recorded by direct observation during daily audit rounds. An educational intervention addressing the healthcare workers regarding bundle care approach was conducted and supplemented with bedside "audit and feedback" during the interventional phase. Audit was conducted in the post-interventional period to study the trend of device associated infections and compliance rates. RESULTS: An increasing trend of month-wise compliance rates to the device care bundles were observed. The month-wise Ventilator Associated Events rates showed a decreasing trend. In the post-interventional phase, the average Catheter-associated Urinary Tract Infection, Central Line Associated Bloodstream Infection and Ventilator Associated Events rates showed a reduction from their respective baseline rates for the study setting. CONCLUSIONS: An educational intervention targeted at the healthcare workers along with daily audit of care bundle practices in the critical care setting led to an increase in the compliance to device care bundles and a reduction in the incidence of Catheter-associated Urinary Tract Infection, Central Line Associated Bloodstream Infection and Ventilator Associated Events rates in the critical care setting.

Impact of intermittent versus continuous infusions on central line-associated bloodstream infection risk in haemato-oncology patients: a quasi-experimental study.

BACKGROUND: Continuous fluid infusions delivered between therapies by piggy-back systems avoid disconnection and reconnection of central venous catheters (CVCs), thereby reducing opportunities for line contamination. However, the impact of continuous versus intermittent infusions on central line-associated bloodstream infections (CLABSIs) is unknown. AIM: To investigate the effect of temporary infusion interruption and line disconnection, with or without use of a 70% isopropyl alcohol cap (IPA-C) on CLABSI rates in haematology patients. METHODS: Quasi-experimental study in two haemato-oncology units. At baseline (P1, September 2020 to August 2021), continuous intravenous piggy-back infusions were mandatory. In a first intervention phase (P2, September 2021 to August 2022), infusion disconnections were implemented with use of a 70% isopropyl alcohol cap (IPA-C) for passive decontamination. In a second intervention phase (P3, September 2022 to August 2023), infusion disconnections continued without the use of IPA-C. Rates of CLABSI were compared across the three intervention periods using segmented Poisson regression. FINDINGS: A total of 11,039 catheter-days across 764 CVCs and 16,226 patient-days were included. Twenty-one CLABSIs were recorded across all intervention periods. Compared with P1, incidence rate ratios (IRRs) for CLABSI did not significantly change in P2 (IRR 0.76 (95% CI 0.27-2.15)) and P3 (IRR 0.79 (95% CI 0.28-2.22)). No CVCs were removed due to occlusion during the study period. Five of 21 CLABSIs were polymicrobial, and coagulase-negative staphylococci were isolated in 19/21 cases (90%). CONCLUSION: Interruption of continuous infusions in haemato-oncology patients with a CVC was not associated with a substantial change in CLABSI rates, whether or not an IPA-C was used.

Incidence, Risk Factors, and Outcomes of Central Line-Associated Bloodstream Infections in Trauma Patients.

Introduction: Central line-associated blood stream infection (CLABSI) is a hospital-acquired infection (HAI) associated with increased morbidity and mortality among the general patient population. However, few studies have evaluated the incidence, outcomes, and risk factors for CLABSI in trauma patients. This study aimed to identify the rate of positive (+)CLABSI in trauma patients and risk factors associated with (+)CLABSI. Methods: The 2017-2021 Trauma Quality Improvement Program database was queried for trauma patients aged ≥18 years undergoing central-line placement. We compared patients with (+)CLABSI vs. (-)CLABSI patients. Bivariate and multivariable logistic regression analyses were performed. Results: From 175,538 patients undergoing central-line placement, 469 (<0.1%) developed CLABSI. The (+)CLABSI patients had higher rates of cirrhosis (3.9% vs. 2.0%, p = 0.003) and chronic kidney disease (CKD) (4.3% vs. 2.6%, p = 0.02). The (+)CLABSI group had increased injury severity score (median: 25 vs. 13, p < 0.001), length of stay (LOS) (median 33.5 vs. 8 days, p < 0.001), intensive care unit LOS (median 21 vs. 6 days, p < 0.001), and mortality (23.7% vs. 19.6%, p = 0.03). Independent associated risk factors for (+)CLABSI included catheter-associated urinary tract infection (CAUTI) (odds ratio [OR] = 5.52, confidence interval [CI] = 3.81-8.01), ventilator-associated pneumonia (VAP) (OR = 4.43, CI = 3.42-5.75), surgical site infection (SSI) (OR = 3.66, CI = 2.55-5.25), small intestine injury (OR = 1.91, CI = 1.29-2.84), CKD (OR = 2.08, CI = 1.25-3.47), and cirrhosis (OR = 1.81, CI = 1.08-3.02) (all p < 0.05). Conclusion: Although CLABSI occurs in <0.1% of trauma patients with central-lines, it significantly impacts LOS and morbidity/mortality. The strongest associated risk factors for (+)CLABSI included HAIs (CAUTI/VAP/SSI), specific injuries (small intestine), and comorbidities. Providers should be aware of these risk factors with efforts made to prevent CLABSI in these patients.

Central Venous Catheter Consideration in Pediatric Oncology: A Systematic Review and Meta-analysis From the American Pediatric Surgical Association Cancer Committee.

BACKGROUND: Tunneled central venous catheters (CVCs) are the cornerstone of modern oncologic practice. Establishing best practices for catheter management in children with cancer is essential to optimize care, but few guidelines exist to guide placement and management. OBJECTIVES: To address four questions: 1) Does catheter composition influence the incidence of complications; 2) Is there a platelet count below which catheter placement poses an increased risk of complications; 3) Is there an absolute neutrophil count (ANC) below which catheter placement poses an increased risk of complications; and 4) Are there best practices for the management of a central line associated bloodstream infection (CLABSI)? METHODS: Data Sources: English language articles in Ovid Medline, PubMed, Embase, Web of Science, and Cochrane Databases. STUDY SELECTION: Independently performed by 2 reviewers, disagreements resolved by a third reviewer. DATA EXTRACTION: Performed by 4 reviewers on forms designed by consensus, quality assessed by GRADE methodology. RESULTS: Data were extracted from 110 manuscripts. There was no significant difference in fracture rate, venous thrombosis, catheter occlusion or infection by catheter composition. Thrombocytopenia with minimum thresholds of 30,000-50,000 platelets/mcl was not associated with major hematoma. Limited evidence suggests a platelet count <30,000/mcL was associated with small increased risk of hematoma. While few studies found a significant increase in CLABSI in CVCs placed in neutropenic patients with ANC<500Kcells/dl, meta-analysis suggests a small increase in this population. Catheter removal remains recommended in complicated or persistent infections. Limited evidence supports antibiotic, ethanol, or hydrochloric lock therapy in definitive catheter salvage. No high-quality data were available to answer any of the proposed questions. CONCLUSIONS: Although over 15,000 tunneled catheters are placed annually in North America into children with cancer, there is a paucity of evidence to guide practice, suggesting multiple opportunities to improve care. LEVEL OF EVIDENCE: III. This study was registered as PROSPERO 2019 CRD42019124077.

ddPCR enables rapid detection of bloodstream infections in patients on home parenteral nutrition: A prospective cohort study.

INTRODUCTION: Chronic intestinal failure patients (CIF) require a central venous access device (CVAD) to administer parenteral nutrition. Most serious complication related to a CVAD is a central line-associated bloodstream infection (CLABSI). The golden standard to diagnose a CLABSI are blood cultures, however, they may require 1-5 days before getting a result. Droplet digital polymerase chain reaction (ddPCR) for the detection of pathogen 16S/28S rRNA is a novel culture-independent molecular technique that has been developed to enhance and expedite infection diagnostics within two and a half hours. In this study, we prospectively compared ddPCR with blood cultures to detect pathogens in whole blood. METHODS: We included adult CIF patients with a clinical suspicion of CLABSI in this prospective single-blinded clinical study. Blood cultures were routinely collected and subsequently two central samples from the CVAD and two peripheral samples from a peripheral venous access point. Primary outcome was the sensitivity and specificity of ddPCR. RESULTS: In total, 75 patients with 126 suspected CLABSI episodes were included, with 80 blood samples from the CVAD and 114 from peripheral veins. The central ddPCR samples showed a sensitivity of 91% (95%CI 77-98), and specificity of 96% (95%CI 85-99). Peripheral ddPCR samples had a sensitivity of 63% (95%CI 46-77) and specificity of 99% (95%CI 93-100). CONCLUSION: ddPCR showed a high sensitivity and specificity relative to blood cultures and enables rapid pathogen detection and characterization. Clinical studies should explore if integrated ddPCR and blood culture outcomes enables a more rapid pathogen guided CLABSI treatment and enhancing patient outcomes.

Evaluating the outcome of a bundle with 11 components and the INICC multidimensional approach in decreasing rates of central line-associated bloodstream infections across nine Asian countries.

BACKGROUND: Central line-associated bloodstream infection (CLABSI) rates in intensive care units (ICUs) across Latin America exceed those in high-income countries significantly. METHODS: We implemented the INICC multidimensional approach, incorporating an 11-component bundle, in 122 ICUs spanning nine Asian countries. We computed the CLABSI rate using the CDC/NSHN definition and criteria. The CLABSI rate per 1000 CL-days was calculated at baseline and throughout different phases of the intervention, including the 2nd month, 3rd month, 4-16 month, and 17-29 month periods. A two-sample t-test was employed to compare baseline CLABSI rates with intervention rates. Additionally, we utilized a generalized linear mixed model with a Poisson distribution to analyze the association between exposure and outcome. RESULTS: A total of 124,946 patients were hospitalized over 717,270 patient-days, with 238,595 central line (CL)-days recorded. The rates of CLABSI per 1000 CL-days significantly decreased from 16.64 during the baseline period to 6.51 in the 2nd month (RR = 0.39; 95% CI = 0.36-0.42; p < 0.001), 3.71 in the 3rd month (RR = 0.22; 95% CI = 0.21-0.25; p < 0.001), 2.80 in the 4-16 month (RR = 0.17; 95% CI = 0.15-0.19; p < 0.001), and 2.18 in the 17-29 month (RR = 0.13; 95% CI = 0.11-0.15; p < 0.001) intervals. A multilevel Poisson regression model demonstrated a sustained, continuous, and statistically significant decrease in ratios of incidence rates, reaching 0.35 (p < 0.0001) during the 17-29 month period. Moreover, the all-cause in-ICU mortality rate significantly decreased from 13.23% to 10.96% (p = 0.0001) during the 17-29 month period. CONCLUSIONS: Our intervention led to an 87% reduction in CLABSI rates, with a 29-month follow-up.

International Nosocomial Infection Control Consortium (INICC) report of health care associated infections, data summary of 45 countries for 2015 to 2020, adult and pediatric units, device-associated module.

BACKGROUND: Reporting on the International Nosocomial Infection Control Consortium study results from 2015 to 2020, conducted in 630 intensive care units across 123 cities in 45 countries spanning Africa, Asia, Eastern Europe, Latin America, and the Middle East. METHODS: Prospective intensive care unit patient data collected via International Nosocomial Infection Control Consortium Surveillance Online System. Centers for Disease Control and Prevention/National Health Care Safety Network definitions applied for device-associated health care-associated infections (DA-HAI). RESULTS: We gathered data from 204,770 patients, 1,480,620 patient days, 936,976 central line (CL)-days, 637,850 mechanical ventilators (MV)-days, and 1,005,589 urinary catheter (UC)-days. Our results showed 4,270 CL-associated bloodstream infections, 7,635 ventilator-associated pneumonia, and 3,005 UC-associated urinary tract infections. The combined rates of DA-HAIs were 7.28%, and 10.07 DA-HAIs per 1,000 patient days. CL-associated bloodstream infections occurred at 4.55 per 1,000 CL-days, ventilator-associated pneumonias at 11.96 per 1,000 MV-days, and UC-associated urinary tract infections at 2.91 per 1,000 UC days. In terms of resistance, Pseudomonas aeruginosa showed 50.73% resistance to imipenem, 44.99% to ceftazidime, 37.95% to ciprofloxacin, and 34.05% to amikacin. Meanwhile, Klebsiella spp had resistance rates of 48.29% to imipenem, 72.03% to ceftazidime, 61.78% to ciprofloxacin, and 40.32% to amikacin. Coagulase-negative Staphylococci and Staphylococcus aureus displayed oxacillin resistance in 81.33% and 53.83% of cases, respectively. CONCLUSIONS: The high rates of DA-HAI and bacterial resistance emphasize the ongoing need for continued efforts to control them.

Neighborhood Income Is Associated with Health Care Use in Pediatric Short Bowel Syndrome.

OBJECTIVE: To evaluate associations between neighborhood income and burden of hospitalizations for children with short bowel syndrome (SBS). STUDY DESIGN: We used the Pediatric Health Information System (PHIS) database to evaluate associations between neighborhood income and hospital readmissions, readmissions for central line-associated bloodstream infections (CLABSI), and hospital length of stay (LOS) for patients <18 years with SBS hospitalized between January 1, 2006, and October 1, 2015. We analyzed readmissions with recurrent event analysis and analyzed LOS with linear mixed effects modeling. We used a conceptual model to guide our multivariable analyses, adjusting for race, ethnicity, and insurance status. RESULTS: We included 4289 children with 16 347 hospitalizations from 43 institutions. Fifty-seven percent of the children were male, 21% were Black, 19% were Hispanic, and 67% had public insurance. In univariable analysis, children from low-income neighborhoods had a 38% increased risk for all-cause hospitalizations (rate ratio [RR] 1.38, 95% CI 1.10-1.72, P = .01), an 83% increased risk for CLABSI hospitalizations (RR 1.83, 95% CI 1.37-2.44, P < .001), and increased hospital LOS (ß 0.15, 95% CI 0.01-0.29, P = .04). In multivariable analysis, the association between low-income neighborhoods and elevated risk for CLABSI hospitalizations persisted (RR 1.70, 95% CI 1.23-2.35, P < .01, respectively). CONCLUSIONS: Children with SBS from low-income neighborhoods are at increased risk for hospitalizations due to CLABSI. Examination of specific household- and neighborhood-level factors contributing to this disparity may inform equity-based interventions.

Cost-utility analysis of 4% tetrasodium ethylenediaminetetraacetic acid, taurolidine, and heparin lock to prevent central line-associated bloodstream infections in children with intestinal failure.

BACKGROUND: Central line-associated bloodstream infections (CLABSI) are a serious complication in children with intestinal failure. This study assessed the incremental costs of 4% tetrasodium ethylenediaminetetraacetic acid (EDTA) compared with taurolidine lock and heparin lock per quality-adjusted life-year (QALY) gained in children with intestinal failure from the healthcare payer and societal perspective. METHODS: A Markov cohort model of a 1-year-old child with intestinal failure was simulated until the age of 17 years (time horizon), with a cycle length of 1 month. The health outcome measure was QALYs, with results expressed in terms of incremental costs and QALYs. Model parameters were obtained from published literature and institutional data. Deterministic, probabilistic, and scenario sensitivity analyses were performed. RESULTS: 4% Tetrasodium EDTA was dominant (more effective and less expensive) compared with taurolidine and heparin, yielding an additional 0.17 QALYs with savings of CAD$88,277 compared with heparin, and an additional 0.06 QALYs with savings of CAD$52,120 compared with taurolidine lock from the healthcare payer perspective. From the societal perspective, 4% tetrasodium EDTA resulted in savings of CAD$90,696 compared with heparin and savings of CAD$36,973 compared with taurolidine lock. CONCLUSIONS: This model-based analysis indicates that 4% tetrasodium EDTA can be considered the optimal strategy compared with taurolidine and heparin in terms of cost-effectiveness. The decision uncertainty can be reduced by conducting further research on the model input parameters. An expected value of perfect information analysis can identify what model input parameters would be most valuable to focus on.

Coronavirus disease 2019 (COVID-19) impact on central-line-associated bloodstream infections (CLABSI): a systematic review.

Introduction: Central line-associated bloodstream infections (CLABSI) are an important clinical and public health issue, impacted by the purported increase in healthcare-associated infections (including CLABSI) during the COVID-19 pandemic. This review evaluates the impact of COVID-19 on CLABSI at a global level, to determine risk factors, effective preventive measures and microbiological epidemiology. Methods: A systematic literature review was performed using a PECO framework, with COVID-19 infection as the exposure measure and CLABSI rates as the main outcome of interest, pre- and during the pandemic. Results: Overall, most studies (17 of N=21) found a significant increase in CLABSI incidence/rates during the pandemic. Four studies showed a reduction (N=1) or no increase (N=3). High workload, redeployment, and 'overwhelmed' healthcare staff were recurrent risk-factor themes, likely to have negatively influenced basic infection control practices, including compliance with hand hygiene and line care bundles. Microbiological epidemiology was also impacted, with an increase in enterococcal infections and other pathogens. Conclusion: The COVID-19 pandemic significantly impacted CLABSI incidence/rates. Observations from the different studies highlight significant gaps in healthcare associated infections (HCAI) knowledge and practice during the pandemic, and the importance of identifying preventive measures effective in reducing CLABSI, essential to health system resilience for future pandemics. Central to this are changes to CLABSI surveillance, as reporting is not mandatory in many healthcare systems. An audit tool combined with regular assessments of the compliance with infection control measures and line care bundles also remains an essential step in the prevention of CLABSI.

Impact of COVID-19 Pandemic on Healthcare-Associated Infections: A Systematic Review and Meta-Analysis.

This study investigated how the Coronavirus Disease 2019 (COVID-19) pandemic has affected the rate of healthcare-associated infections (HAIs). PubMed, Scopus and Google Scholar were searched to identify potentially eligible studies published from December 2019 to September 2022. A random effect model was used to determine the changes in the rate of HAIs during the pandemic. Thirty-seven studies, mostly from the United States (n = 13), were included. Fifteen studies described how the pandemic affected the rate of CLABSIs and CAUTIs, and eight of them showed a significant increase in CLABSIs. The risk of CLABSIs and CDIs was 27% (pooled odds ratio [OR]: 0.73; confidence interval [CI]: 0.61-0.89; p < 0.001) and 20% (pooled OR: 1.20; CI: 1.10-1.31; p < 0.001) higher during the pandemic compared to before the COVID-19 pandemic period, respectively. However, the overall risk of HAIs was unaffected by the pandemic (pooled OR: 1.00; 95 CI: 0.80-1.24; p = 0.990). Furthermore, there were no significant changes in the risk of CAUTIs (pooled OR: 1.01; 95 CI: 0.88-1.16; p = 0.890), and SSIs (pooled OR: 1.27; CI: 0.91-1.76; p = 0.16) between the two periods. The COVID-19 pandemic had no effect on the overall risk of HAIs among hospitalized patients, but an increased risk of CLABSIs and CDI were observed during the pandemic. Therefore, more stringent infection control and prevention measures and prudent interventions to promote the rational use of antibiotics are warranted across all healthcare facilities to reduce the burden of HAIs.

Reducing the rate of central line-associated bloodstream infections; a quality improvement project.

BACKGROUND: The burden of central line-associated bloodstream infections is significant and has negative implications for healthcare, increasing morbidity and mortality risks, increasing inpatient hospital stays, and increasing the cost of hospitalization. Efforts to reduce the incidence of central line-associated bloodstream infections have utilized quality improvement projects that implement, measure, and monitor outcomes. However, variations in location, healthcare organization, patient risks, and practice gaps are key to the success of interventions and approaches. This study aims to evaluate interventions of a quality improvement project on the reduction of central line-associated bloodstream infection rates at a university teaching hospital. METHODS: This was a retrospective review of a quality improvement project that was implemented using the Plan-Do-Study-Act quality improvement cycle. Active surveillance of processes and outcomes was performed in the critical care areas; compliance to central line care bundles, and central line-associated bloodstream infections. Interrupted time series was used to analyze trends pre and post-intervention and regression modeling to estimate data segments preceding and succeeding the interventions. RESULTS: There were 350 central line insertions, 3912 catheter days, and 20 central line-associated bloodstream infection events during the intervention period. Compliance with central line care bundles was at 94%. There was a trend in the reduction of central line-associated bloodstream infections by 18% that did not reach statistical significance (p = 0.252). CONCLUSIONS: Improvement projects to reduce central line-associated bloodstream infections face challenges and complexities associated with implementing interventions in real-world healthcare settings. There is a great need to continuously monitor, evaluate, readjust, and adapt interventions to achieve desired results, sustain improvements in patient outcomes, and investigate reasons for non-adherence as keys to achieving desired outcomes.

Central Line-Associated Bloodstream Infections: Effect of Patient and Pathogen Factors on Outcome.

Introduction: Patients on central lines are often having multiple morbidities, and invasive devices provide a niche for biofilm formation, which makes central line-associated bloodstream infections (CLABSIs), a serious concern in health-care settings, as the infections difficult to treat. In this study, we evaluated the common bacteria causing CLABSI, and various patient and pathogen factors affecting the clinical outcome. Methods: In the prospective observational study, patients diagnosed with CLABSI were recruited. Extensive clinical, microbiological, and other laboratory workup was done, and observations were recorded. Congo red agar method, tube test, and microtiter plate assay were used for eliciting the biofilm-forming attributes of the bacterial pathogens. Results: Klebsiella pneumoniae was responsible for 48% of CLABSI, followed by Coagulase-negative Staphylococci (16%) and Staphylococcus aureus and Acinetobacter baumannii (12% each). Fifty-six percent of the isolates produced biofilms. The median (interquartile range) duration of hospital stay till death or discharge was 30 (20, 43) days. The all-cause mortality was 44%. Patients having a deranged liver function on the day of diagnosis (P value for total bilirubin 0.001 and for aspartate transaminase 0.02), and those infected with multidrug-resistant organisms (P value = 0.04) had significantly poor prognosis. The difference in the demographic, clinical, laboratory profile, and outcome of patients infected with biofilm producers and nonproducers was not found to be statistically significant. Conclusion: The study throws light on various host and pathogen factors determining the cause and outcome of CLABSI patients. To the best of our knowledge, this is the first study trying to decipher the role of biofilm formation in the virulence of pathogens and the prognosis of CLABSI.

"Nurse-The Archer" Fighting Against the Hidden Enemy.

Background and aim: The coronavirus disease-2019 (COVID-19) pandemic is a global threat spreading like a wildfire and taking the world by its storm. It has challenged the healthcare delivery systems and disrupted them in a way no one ever imagined before. We at Apollo Hospitals, Chennai, Tamil Nadu, India received many patients in the COVID critical care unit (CCU) and found a gradual lack of bundle care compliance resulting in an upsurge of central line-associated bloodstream infection (CLABSI) amid the patients. Materials and methods: A qualitative research approach and quasi-experimental research design were selected to assess the knowledge of the 150 frontline COVID CCU nurses regarding the CLABSI bundle and its prevention strategies. Results: This study revealed that 57% [mean (M) = 12.6; standard deviation (SD) = 2.37] of nurses had inadequate knowledge of the CLABSI bundle and its prevention strategies, in the pretest and scored 80% (M = 6.7; SD = 2.28) in the post-test, with "t" = 22.06 at p < 0.00001 after the hands-on training. The percentage of compliance to CLABSI bundle care increased to 83% and thereafter in an increasing trend. This was clearly evident through the reduction in the preventable CLABSI rate among critically ill COVID-19 patients. Conclusion: Nurses are on the frontline in preventing and controlling healthcare-associated infections (HAIs). Fighting with all the visible and invisible challenges, our research focused on hands-on training for frontline warriors to adhere to the CLABSI bundle care which drove us to the reduction in preventable CLABSI rate in our hospital through improved CLABSI bundle compliance. How to cite this article: Premkumar S, Ramanathan Y, Varghese JJ, Morris B, Nambi PS, Ramakrishnan N, et al. "Nurse-The Archer" Fighting Against the Hidden Enemy. Indian J Crit Care Med 2023;27(4):246-253.

Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections over 18 years in 281 ICUs of 9 Asian countries.

BACKGROUND: Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors (RF) in Asia. METHODS: From 03/27/2004 to 02/11/2022, we conducted a multinational multicenter prospective cohort study in 281 ICUs of 95 hospitals in 44 cities in 9 Asian countries (China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam). For estimation of CLABSI rate we used CL-days as denominator and number of CLABSI as numerator. To estimate CLABSI RF for we analyzed the data using multiple logistic regression, and outcomes are shown as adjusted odds ratios (aOR). RESULTS: A total of 150,142 patients, hospitalized 853,604 days, acquired 1514 CLABSIs. Pooled CLABSI rate per 1000 CL-days was 5.08; per type of catheter were: femoral: 6.23; temporary hemodialysis: 4.08; jugular: 4.01; arterial: 3.14; PICC: 2.47; subclavian: 2.02. The highest rates were femoral, temporary for hemodialysis, and jugular, and the lowest PICC and subclavian. We analyzed following variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization ratio, CL-type, tracheostomy use, hospitalization type, ICU type, facility ownership and World Bank classifications by income level. Following were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 4% daily (aOR = 1.04; 95% CI = 1.03-1.04; p < 0.0001); number of CL-days before CLABSI acquisition, rising risk 5% per CL-day (aOR = 1.05; 95% CI 1.05-1.06; p < 0.0001); medical hospitalization (aOR = 1.21; 95% CI 1.04-1.39; p = 0.01); tracheostomy use (aOR = 2.02;95% CI 1.43-2.86; p < 0.0001); publicly-owned facility (aOR = 3.63; 95% CI 2.54-5.18; p < 0.0001); lower-middle-income country (aOR = 1.87; 95% CI 1.41-2.47; p < 0.0001). ICU with highest risk was pediatric (aOR = 2.86; 95% CI 1.71-4.82; p < 0.0001), followed by medical-surgical (aOR = 2.46; 95% CI 1.62-3.75; p < 0.0001). CL with the highest risk were internal-jugular (aOR = 3.32; 95% CI 2.84-3.88; p < 0.0001), and femoral (aOR = 3.13; 95% CI 2.48-3.95; p < 0.0001), and subclavian (aOR = 1.78; 95% CI 1.47-2.15; p < 0.0001) showed the lowest risk. CONCLUSIONS: The following CLABSI RFs are unlikely to change: country income level, facility-ownership, hospitalization type, and ICU type. Based on these findings it is suggested to focus on reducing LOS, CL-days, and tracheostomy; using subclavian or PICC instead of internal-jugular or femoral; and implementing evidence-based CLABSI prevention recommendations.

Disseminated cutaneous Mycobacterium chelonae infection secondary to an indwelling catheter in an immunocompetent host.

Background: Mycobacterium chelonae is a species of nontuberculous mycobacteria that typically causes localized cutaneous disease in immunocompetent hosts. There have been few reports of disseminated infections in immunocompetent individuals which have often been associated with invasive medical procedures. Case Presentation: In this report, we describe a 43-year-old immunocompetent female with an implanted venous access device who presented with skin lesions increasing in size and frequency over the course of five months despite antimicrobial therapy. A diagnosis was not made until mycobacterial culture from a skin biopsy grew M. chelonae. Conclusion: Disseminated cutaneous M. chelonae infection can be a rare complication of indwelling venous catheterization among immunocompetent patients.

Nurses' Perceptions of Adherence to the Central Line Maintenance Bundle: Linkages to Thoughts, Emotions, and Behavior.

The U.S. Centers for Disease Control established the central line maintenance care bundle in 2011, yet nurses' adherence to all seven components remains challenging. The specific aim of this study was to explore and understand intensive care nurses' perceptions and beliefs regarding central line maintenance, bundle care elements, and associated adherence. This qualitative study used a phenomenological approach. Three main themes emerged as follows: (1) thoughts about the ability to adhere to the central line bundle created feelings about central line maintenance care, (2) feelings about the nurses' ability to adhere to the central line bundle influenced behaviors, and (3) behaviors for central line bundle adherence reinforced thoughts. Each theme had several subthemes. Organizations must assess and mitigate the unique cognitive and behavioral factors that affect nurses' adherence to the central line-associated bloodstream infection (CLABSI) maintenance bundle. In addition, nursing adherence requires knowledge of CLABSI rates and direct care nurse involvement in identifying solutions.

Infections in Critically Ill Children.

Health care-associated infections (HAI) directly influence the survival of children in pediatric intensive care units (PICU), the most common being central line-associated bloodstream infection (CLABSI) 25-30%, followed by ventilator-associated pneumonia (VAP) 20-25%, and others such as catheter-associated urinary tract infection (CAUTI) 15%, surgical site infection (SSI) 11%. HAIs complicate the course of the disease, especially the critical one, thereby increasing the mortality, morbidity, length of hospital stay, and cost. The incidence of HAI in Western countries is 6.1-15.1% and in India, it is 10.5 to 19.5%. The advances in healthcare practices have reduced the incidence of HAIs in the recent years which is possible due to strict asepsis, hand hygiene practices, surveillance of infections, antibiotic stewardship, and adherence to bundled care. The burden of drug resistance and emerging infections are increasing with limited antibiotics in hand, is still a dreadful threat. The most common manifestation of HAIs is fever in PICU, hence the appropriate targeted search to identify the cause of fever should be done. Proper isolation practices, judicious handling of devices, regular microbiologic audit, local spectrum of organisms, identification of barriers in compliance of hand hygiene practices, appropriate education and training, all put together in an efficient and sustained system improves patient outcome.

Assessment of Knowledge, Attitude, and Adherence to National Guidelines for Preventing Central Line-Associated Bloodstream Infections Among ICU Nurses of Adult Patients in Jeddah, Saudi Arabia: A Cross-Sectional Survey.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) pose a significant burden on patient outcomes in intensive care units (ICUs). Adherence to evidence-based guidelines for CLABSI prevention is crucial in reducing healthcare-associated infections. This study aimed to assess the knowledge, attitude, and practice adherence to national guidelines for preventing CLABSIs among adult ICU nurses in Ministry of Health (MOH) hospitals in Jeddah, Saudi Arabia.  Methods: This cross-sectional survey included all adult ICU nurses with a minimum of one year of experience from the four major MOH hospitals in Jeddah with operational adult ICUs. A self-administered online questionnaire was utilized for data collection. Descriptive statistics, t-tests, ANOVA, and Pearson correlation were employed for data analysis.  Results: A total of 203 nurses completed the questionnaire (response rate: 91.5%). The overall knowledge score was 71%. Only 20% of nurses answered over 90% of the knowledge questions correctly, and merely 8% answered all questions correctly. Higher knowledge levels were significantly associated with older age, longer ICU nursing experience, higher education, holding a head nurse position, and attending educational courses on CLABSI prevention. Regarding attitudes, 58% of respondents had a positive perception of guideline utility for CLABSI prevention. In terms of adherence, the overall score was 65%, with only 5% reporting complete adherence to evidence-based practices for preventing CLABSIs.  Conclusion: This study highlights knowledge gaps, suboptimal adherence, and the need for targeted interventions to enhance nurses' understanding of and adherence to evidence-based guidelines for preventing CLABSIs among adult ICU nurses in Jeddah's MOH hospitals. Enhancing knowledge, attitudes, and practice adherence is crucial for reducing CLABSI risks and improving patient outcomes. Further research investigating the factors influencing nurses' knowledge, acceptance, and application of evidence-based guidelines is warranted to inform the development of tailored interventions and educational strategies.