Risk factors for recurrent central line-associated bloodstream infections in a pediatric intensive care unit

Turkish Journal of Medical Sciences http://journals.tubitak.gov.tr/medical/ Research Article Turk J Med Sci (2017) 47: 1128-1136 © TÜBİTAK doi:10.3906/sag-1602-4 Risk factors for recurrent central line-associated bloodstream infections in a pediatric intensive care unit 1, 2 1 2 3 1 Rana İŞGÜDER *, İlker DEVRİM , Gökhan CEYLAN , Ahu KARA , Gamze GÜLFİDAN , Hasan AĞIN 1 Department of Pediatric Intensive Care Unit, Dr. Behçet Uz Children’s Hospital, İzmir, Turkey 2 Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children’s Hospital, İzmir, Turkey 3 Department of Microbiology, Dr. Behçet Uz Children’s Hospital, İzmir, Turkey Received: 01.02.2016 Accepted/Published Online: 25.04.2017 Final Version: 23.08.2017 Background/aim: It is recommended that a central venous catheter (CVC) be removed if central line-associated bloodstream infection (CLABSI) has been diagnosed. The objective of this retrospective study was to evaluate the risk factors for recurrent CLABSI in reinserted catheters in a pediatric intensive care unit. Materials and methods: Patients with recurrent and nonrecurrent CLABSI were compared in terms of the catheter exchange interval, the interval between negative blood culture and reinsertion of the CVC, and the pre-/reinsertion treatment duration. Results: Thirty-one patients with initial CLABSI had reinserted CVCs, and 12 (38.7%) of these patients were diagnosed with recurrent CLABSI. In the recurrent group, the catheter exchange interval, the interval between negative blood culture and reinsertion of the second CVC, and pre-/reinsertion treatment duration were found to be shorter. Logistic regression analysis revealed that if the interval between negative blood culture and reinsertion of the second CVC was shorter than 4 days, recurrent CLABSI risk increased by 1.7-fold (P = 0.021). Sterile gauze-dressed patients had shorter cumulative catheter surveys than the polyurethane-dressed patients (P = 0.005). Conclusion: Using transparent polyurethane dressings instead of sterile gauze for maintaining the CVC and delaying the reinsertion procedure for at least 4 days after the negative culture might be helpful in preventing recurrent CLABSI. Key words: Central line-associated bloodstream infections, risk factors for recurrence, pediatric intensive care unit 1. Introduction Central venous catheters (CVCs) are essential for the management of children in intensive care units. CVCs are not only useful for the administration of medications, blood products, parenteral nutrition, and fluid therapy; they are also essential for invasive procedures such as hemodynamic monitorization and plasmapheresis. One of the most important complications of CVCs are central line-associated bloodstream infections (CLABSIs), which are associated with high morbidity and mortality in addition to increased medical costs due to longer hospital stays and the use of more expensive antimicrobial drugs (1–3). Once a CLABSI is suspected, general recommendations include removal of the catheter for nontunneled CVCs (4,5). However, in practical clinical settings, a substantial number of patients with CLABSIs require reinsertion of their CVCs since these patients still require reliable persistent venous lines for their ongoing therapy. Data related to the risk factors associated with recurrent * Correspondence: 1128 CLABSI following catheter removal and reinsertion are limited to a few studies, most of which focused on adult patients only (6–8). In this study, we focused on the risk factors of the recurrence of CLABSI in a retrospective cohort of children in a pediatric intensive care unit (PICU) following catheter reinsertion. 2. Materials and methods 2.1. Study population, hospital setting, and inclusion/ exclusion criteria In this retrospective study, the clinical data of patients between the ages of 1 month old and 18 years old and hospitalized at the PICU of Dr. Behçet Uz Children’s Research and Training Hospital from July 2012 to July 2014 were collected. Dr. Behçet Uz Children’s Hospital is a tertiary-care pediatric teaching hospital. At the time of the study, the PICU had 24 beds and 772 patients were hospitalized annually there. The study was approved by the institutional research board. İŞGÜDER et al. / Turk J Med Sci A retrospective cohort of patients with CLABSIs was formed by using clinical data. Among the patients with CLABSI, those who had had a reinserted, nontunneled CVC formed the study group. Clinical findings and microbiological data were analyzed for the risk of recurrent CLABSI in this group. Patients who had more than one CVC at the same time or whose CVC duration was shorter than 48 h were excluded from the study. Patients with persistent CLABSI were also not enrolled in this study. 2.2. Central venous catheter insertion technique For the catheterization process, 1, 2, or 3 lumen polyurethane nontunneled temporary catheters (B. Braun, Melsungen, Germany) were chosen. None of them were antimicrobial-impregnated catheters. Before the implementation process and according to the guidelines of the Centers for Disease Control and Prevention (CDC), hand hygiene was ensured and powder-free sterile gloves, a mask, a cap, and a sterile scrub suit were worn (4). For skin antisepsis, 10% povidone iodine or 2% chlorhexidine solutions were used. The entire body of the patient, with the exception of the intervention site, was covered with sterile drapes. Catheters were inserted using the Seldinger technique. For the dressing of the catheter site, the first choice was a transparent polyurethane cover (Tegaderm, 3M Medical, St Paul, MN, USA) and whenever that was not possible sterile gauze was used instead. The transparent polyurethane cover was changed every 7 to 10 days, and sterile gauzes were changed every 2 days. In our clinic, the infection control committee performs regular education sessions about catheter insertion, followup processes, disinfection during the maintenance of catheters, and hand hygiene for all employees. We did not use the guidewire exchange technique for implementation of new catheters in our PICU. 2.3. Microbiologic criteria The definition of CLABSI was based on the new CDC definitions (9). 2.3.1. Definition of CLABSI CLABSI is defined as a laboratory-confirmed bloodstream infection (LCBI) for which the central line (CL) has been in place for >2 calendar days from the date of the event, with the day of device placement being day 1 and the CL having been in place on the date of the event or the day before. If the CL was in place for >2 calendar days and was then removed, the LCBI criteria must be fully met on the day of discontinuation or the next day. If the patient is admitted or transferred to a facility with a CL in place (e.g., tunneled or implanted central line), and that is the patient’s only central line, the day of first access as an inpatient is considered day 1. “Access” is defined as line placement, infusion, or withdrawal thro (...truncated)