COVID-19 Pandemic, CLABSI, and CAUTI: The Urgent Need to Refocus on Hardwiring Prevention Efforts

Abstract Background: The coronavirus disease 2019 (COVID-19) pandemic has had a considerable impact on US hospitalizations, affecting processes and patient population. Methods: We evaluated the impact of COVID-19 pandemic in 78 US hospitals on central line associated bloodstream infections (CLABSI) and catheter associated urinary tract infections (CAUTI) events 12 months pre-COVID-19 and 6 months during COVID-19 pandemic. Results: There were 795,022 central line-days and 817,267 urinary catheter-days over the two study periods. Compared to pre-COVID-19 period, CLABSI rates increased during the pandemic period from 0.56 to 0.85 (51.0%) per 1,000 line-days (p<0.001) and from 1.00 to 1.64 (62.9%) per 10,000 patient-days (p<0.001). Hospitals with monthly COVID-19 patients representing >10% of admissions had a NHSN device standardized infection ratio for CLABSI that was 2.38 times higher compared to those with <5% prevalence during the pandemic period (p=0.004). Coagulase-negative staphylococcus CLABSI increased by 130% from 0.07 to 0.17 events per 1,000 line-days (p<0.001), and Candida sp. by 56.9% from 0.14 to 0.21 per 1,000 line-days (p=0.01). In contrast, no significant changes were identified for CAUTI (0.86 vs. 0.77 per 1,000 catheter-days; p=0.19). Conclusions: The COVID-19 pandemic was associated with substantial increases in CLABSI but not CAUTI events. Our findings underscore the importance of hardwiring processes for optimal line care, and regular feedback on performance to maintain a safe environment.

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Effect of Removing Contact Precautions for Multidrug-Resistant Organisms on Hospital Infections in a Pediatric Health System

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.742 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s199-s200

Author(s):

Matthew Linam ◽

Dorian Hoskins ◽

Preeti Jaggi ◽

Mark Gonzalez ◽

Renee Watson ◽

...

Keyword(s):

Hand Hygiene ◽

Antibiotic Stewardship ◽

Infection Prevention ◽

Tertiary Care ◽

Bloodstream Infections ◽

Central Line ◽

Contact Precautions ◽

Stewardship Program ◽

Tract Infections ◽

The Impact

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.Funding: NoneDisclosures: None

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The case for a population standardized infection ratio (SIR): A metric that marries the device SIR to the standardized utilization ratio (SUR)

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2019.175 ◽

2019 ◽

Vol 40 (9) ◽

pp. 979-982 ◽

Cited By ~ 1

Author(s):

Mohamad G. Fakih ◽

Ren-Huai Huang ◽

Angelo Bufalino ◽

Thomas Erlinger ◽

Lisa Sturm ◽

...

Keyword(s):

Urinary Catheter ◽

Bloodstream Infections ◽

Central Line ◽

Hospital Performance ◽

Relative Increase ◽

Risk Of Infection ◽

High Performing ◽

Utilization Ratio ◽

Device Use ◽

Tract Infections

AbstractBackground:The device standardized infection ratio (SIR) is used to compare unit and hospital performance for different publicly reported infections. Interventions to reduce unnecessary device use may select a higher-risk population, leading to a paradoxical increase in SIR for some high-performing facilities. The standardized utilization ratio (SUR) adjusts for device use for different units and facilities.Methods:We calculated the device SIR (calculated based on actual device days) and population SIR (defined as Σ observed events divided by Σ predicted events based on predicted device days), adjusting for the facility SUR for both central-line–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) in 84 hospitals from a single system for calendar years 2016 and 2017.Results:The central-line SUR was 1.02 for 801,172 central-line days, with a device SIR of 0.76 and a population SIR of 0.78, a 1.6% relative increase. On the other hand, the urinary catheter SUR was 0.90 for 757,504 urinary catheter days, with a device SIR of 0.84 and a population SIR of 0.76, a 10.0% relative decrease. The cumulative attributable difference for CAUTI to a target SIR of 1 was −135.4 for the device SIR compared to −203.66 for the population SIR, a 50.8% increase in prevented events.Conclusion:Population SIR accounts for predicted device utilization; thus, it is an attractive metric with which to address overall risk of infection or harm to a patient population. It also reduces the risk of selection bias that may impact the device SIR with interventions to reduce device use.

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Impact of modified CDC/NHSN surveillance definition on the incidence of CAUTI: a study from an Indian tertiary care hospital

Journal of Infection Prevention ◽

10.1177/1757177420982048 ◽

2020 ◽

pp. 175717742098204

Author(s):

Bijayini Behera ◽

Jayanti Jena ◽

Ashoka Mahapatra ◽

Jyoti Biswala

Keyword(s):

Tertiary Care ◽

Bloodstream Infections ◽

Central Line ◽

Care Hospital ◽

Candida Spp ◽

Surgical Intensive Care ◽

Control And Prevention ◽

The Mean ◽

Tract Infections ◽

The Impact

Introduction: Catheter-associated urinary tract infections (CAUTIs) are one of the most common infections encountered in healthcare settings. Candida spp. were excluded as the causative agents of CAUTIs as per Centres for Disease Control and Prevention (CDC) and National Healthcare Safety Network (NHSN) definitions in 2015. Aim: To determine the impact of the 2015 definition change on the CAUTI rate of patients admitted to medical and surgical intensive care units (ICUs) of a tertiary care and teaching hospital in India. Method: CAUTI rates were compared in both the ICUs over a period of two years with inclusion and exclusion of Candida spp. Results: Out of the total 116 CAUTI episodes during the study period, a mean of 9.08 CAUTIs per 1000 catheter days were observed in both the ICUs when Candida spp. were included, but the mean CAUTI rate was reduced to 4.78/1000 catheter days when Candida spp. were excluded. Discussion/Conclusion: The mean CAUTI rate decreased by 46.03% solely by excluding Candida spp. This significant reduction in CAUTI rates may be applicable to institutions having high rates of candiduria in catheterised patients, but may not be applicable in centres where the incidence of candiduria is already low. Disregarding Candida as a causative agent of CAUTI did not impact rates of central line-associated bloodstream infections during the study period.

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593. Burden of Healthcare-Associated Infections among Hospitalized Infants within Community Hospitals

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.662 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S279-S280

Author(s):

Ibukunoluwa C Akinboyo ◽

Rebecca R Young ◽

Michael J Smith ◽

Becky A Smith ◽

Sarah S Lewis ◽

...

Keyword(s):

Infection Control ◽

Neonatal Intensive Care ◽

Bloodstream Infections ◽

Central Line ◽

Control Network ◽

Healthcare Associated Infections ◽

Community Hospitals ◽

Tract Infections ◽

Healthcare Associated ◽

The Impact

Abstract Background Healthcare-associated infections (HAI) remain the leading cause of morbidity and mortality among hospitalized children. Within community hospitals with targeted infection prevention efforts, participation in an infection control network has led to significant decreases in device or procedure-related infections among adult patients. The impact of these interventions has not been assessed in pediatric patients admitted to community hospitals. Methods We conducted a retrospective cohort study to describe the burden of HAI among hospitalized infants (< 1 year old) within 53 community hospitals participating in the Duke Infection Control Outreach Network (DICON) from 2013–2018. We determined the frequency of device-related HAI, central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI) and hospital-associated pneumonia or ventilator-associated events (HAP/VAE) using National Healthcare Safety Network (NHSN) definitions; and the burden of HAIs among neonatal intensive care units (NICU) and non-NICU centers. The trend of HAI was analyzed with Spearman’s correlation. Results Thirty hospitals reported 150 HAI among 141 infants over the 6-year period. Median (IQR) time to infection was 10 (4, 20) days after admission. Hospitals with a NICU (15) reported more HAI (median 5, (IQR: 3, 12)) than hospitals without a NICU (median 2 (IQR: 1, 2)) (P = 0.031). CLABSI represented 35% of HAI, HAP/VAE were 23% and CAUTI were 12%. The most frequently isolated primary organism for all HAI was Escherichia coli (22 HAI, 15%) which was also isolated in 39% of CAUTI. Methicillin-resistant and methicillin-susceptible Staphylococcus aureus (S. aureus) were the most commonly isolated organisms among CLABSI (17%) and HAP/VAE (33%). Nine centers with ≥4 years of NICU and Central line (CL) use data reported a median (IQR) rate of 1.2 (0, 2.4) CLABSIs/1,000 central line days. There was no change in median CLABSI rate over time (P = 0.47), Figure 1. Conclusion CLABSI, most commonly caused by S. aureus, represented the majority of HAI reported from hospitalized infants within community hospitals participating in an infection control network. Further research into device utilization practices may inform future interventions to reduce HAI. Disclosures All authors: No reported disclosures.

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Impact of a hospital-wide huddle on device utilisation and infection rates: a community hospital’s journey to zero

Journal of Infection Prevention ◽

10.1177/1757177420939239 ◽

2020 ◽

Vol 21 (6) ◽

pp. 228-233

Author(s):

Alfredo J Mena Lora ◽

Mirza Ali ◽

Candice Krill ◽

Sherrie Spencer ◽

Eden Takhsh ◽

...

Keyword(s):

Infection Prevention ◽

Cost Savings ◽

Bloodstream Infections ◽

Central Line ◽

Culture Of Safety ◽

Before And After ◽

Quasi Experimental ◽

Tract Infections ◽

Healthcare Associated ◽

The Impact

Background: Device utilisation ratios (DUR) correlate with device-associated complications and rates of infection. We implemented a hospital-wide Daily Interdisciplinary Safety Huddle (DISH) with infection control and device components. The aim of this study was to evaluate the impact of DISH on DURs and rates of infection for indwelling urinary catheters (IUC) and central venous catheters (CVC). Methods: A quasi-experimental study assessing DURs and rates of infection before and after implementation of DISH. At DISH, usage of IUC and CVC is reported by managers and the infection preventionist reviews indications and plans for removal. Data before and after implementation were compared. Paired T-test was used to assess for differences between both groups. Results: DISH was successfully implemented at a community hospital. The average DUR for IUC in intensive care unit (ICU) and non-ICU settings was reduced from 0.56 to 0.35 and 0.27 to 0.12, respectively. CVC DUR decreased from 0.29 to 0.26 in the ICU and 0.14 to 0.12 in non-ICU settings. Catheter-associated urinary tract infections (CAUTIs) decreased by 87% and central line-associated bloodstream infections (CLABSIs) by 96%. Conclusion: DISH was associated with hospital-wide reductions in DUR and device-associated healthcare-associated infections. Reduction of CLABSIs and CAUTIs had estimated cost savings of $688,050. The impact was more profound in non-ICU settings. To our knowledge, an infection prevention hospital-wide safety huddle has not been reported in the literature. DISH increased device removal, accountability and promoted a culture of safety.

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Chlorhexidine Bathing Effects on Health-Care-Associated Infections

Biological Research For Nursing ◽

10.1177/1099800416654013 ◽

2016 ◽

Vol 19 (2) ◽

pp. 123-136 ◽

Cited By ~ 7

Author(s):

Janette Denny ◽

Cindy L. Munro

Keyword(s):

Health Care ◽

Bacterial Colonization ◽

Bloodstream Infections ◽

Surgical Site Infections ◽

Central Line ◽

Good Evidence ◽

Health Care Associated Infections ◽

Meta Analyses ◽

Tract Infections ◽

The Impact

Background: Health-care-associated infections (HAIs), infections that patients contract during the course of their hospitalization, are receiving a growing amount of attention. Heavy skin bacterial colonization aids in the transmission and development of HAIs. Nurses frequently use bathing with chlorhexidine gluconate (CHG) to reduce patients’ cutaneous microbial burden. This intervention has been shown to have promising but mixed results in the prevention of HAIs. Purpose: This article reviews the literature for evidence on the impact of CHG bathing on HAIs. Method: A literature search was conducted to identify peer-reviewed studies and meta-analyses that examined the impact of CHG bathing on HAIs using PubMed and CINAHL with the following search terms: CHG bathing AND healthcare associated infections, surgical site infections ( SSIs), central line associated bloodstream infections ( CLABSIs), ventilator-associated pneumonias ( VAP), catheter-associated urinary-tract infections ( CAUTIs), and Clostridium difficile-associated disease. The initial search identified 23 articles for review. Additional studies were identified by searching references used in original studies or review articles on this topic. Principle findings: There is good evidence to support incorporating a CHG bathing regimen to reduce the incidence of CLABSIs, SSIs, vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA) HAIs. Conclusion: As CHG becomes a standard practice to prevent HAIs, it is important to monitor for adverse reactions and evidence of resistance/susceptibility.

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A Decade in Trying to Increase Hand Hygiene—Finally Success

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.592 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s93-s94

Author(s):

Linda Huddleston ◽

Sheila Bennett ◽

Christopher Hermann

Keyword(s):

Hand Hygiene ◽

Hand Hygiene Compliance ◽

Compliance Rate ◽

Bloodstream Infections ◽

Central Line ◽

Second Phase ◽

Two Phase ◽

Hygiene Compliance ◽

Tract Infections ◽

The Voice

Background: Over the past 10 years, a rural health system has tried 10 different interventions to reduce hospital-associated infections (HAIs), and only 1 intervention has led to a reduction in HAIs. Reducing HAIs is a goal of nearly all hospitals, and improper hand hygiene is widely accepted as the main cause of HAIs. Even so, improving hand hygiene compliance is a challenge. Methods: Our facility implemented a two-phase longitudinal study to utilize an electronic hand hygiene reminder system to reduce HAIs. In the first phase, we implemented an intervention in 2 high-risk clinical units. The second phase of the study consisted of expanding the system to 3 additional clinical areas that had a lower incidence of HAIs. The hand hygiene baseline was established at 45% for these units prior to the voice reminder being turned on. Results: The system gathered baseline data prior to being turned on, and our average hand hygiene compliance rate was 49%. Once the voice reminder was turned on, hand hygiene improved nearly 35% within 6 months. During the first phase, there was a statistically significant 62% reduction in the average number of HAIs (catheter associated urinary tract infections (CAUTI), central-line–acquired bloodstream infections (CLABSIs), methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant organisms (MDROs), and Clostridiodes difficile experienced in the preliminary units, comparing 12 months prior to 12 months after turning on the voice reminder. In the second phase, hand hygiene compliance increased to >65% in the following 6 months. During the second phase, all HAIs fell by a statistically significant 60%. This was determined by comparing the HAI rates 6 months prior to the voice reminder being turned on to 6 months after the voice reminder was turned on. Conclusions: The HAI data from both phases were aggregated, and there was a statistically significant reduction in MDROs by 90%, CAUTIs by 60%, and C. difficile by 64%. This resulted in annual savings >$1 million in direct costs of nonreimbursed HAIs.Funding: NoneDisclosures: None

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Comparison of Metrics Used to Track CLABSIs and CAUTIs Across a Regional Network

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.710 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s178-s179

Author(s):

Sonali Advani ◽

Becky Smith ◽

Jessica Seidelman ◽

Nicholas Turner ◽

Christopher Hostler ◽

...

Keyword(s):

Negative Correlation ◽

Urine Culture ◽

Bloodstream Infections ◽

Central Line ◽

Regional Network ◽

Community Hospitals ◽

Scatter Plots ◽

Preventable Harm ◽

Device Use ◽

Tract Infections

Background: The standardized infection ratio (SIR) is the nationally adopted metric used to track and compare catheter-associated urinary tract infections (CAUTIs) and central-line– associated bloodstream infections (CLABSIs). Despite its widespread use, the SIR may not be suitable for all settings and may not capture all catheter harm. Our objective was to look at the correlation between SIR and device use for CAUTIs and CLABSIs across community hospitals in a regional network. Methods: We compared SIR and SUR (standardized utilization ratio) for CAUTIs and CLABSIs across 43 hospitals in the Duke Infection Control Outreach Network (DICON) using a scatter plot and calculated an R2 value. Hospitals were stratified into large (>70,000 patient days), medium (30,000–70,000 patient days), and small hospitals (<30,000 patient days) based on DICON’s benchmarking for community hospitals. Results: We reviewed 24 small, 11 medium, and 8 large hospitals within DICON. Scatter plots for comparison of SIRs and SURs for CLABSIs and CAUTIs across our network hospitals are shown in Figs. 1 and 2. We detected a weak positive overall correlation between SIR and SUR for CLABSIs (0.33; R2 = 0.11), but no correlation between SIR and SUR for CAUTIs (−0.07; R2 = 0.00). Of 15 hospitals with SUR >1, 7 reported SIR <1 for CLABSIs, whereas 10 of 13 hospitals with SUR >1 reported SIR <1 for CAUTIs. Smaller hospitals showed a better correlation for CLABSI SIR and SUR (0.37) compared to medium and large hospitals (0.19 and 0.22, respectively). Conversely, smaller hospitals showed no correlation between CAUTI SIR and SUR, whereas medium and larger hospitals showed a negative correlation (−0.31 and −0.39, respectively). Conclusions: Our data reveal a weak positive correlation between SIR and SUR for CLABSIs, suggesting that central line use impacts CLABSI SIR to some extent. However, we detected no correlation between SIR and SUR for CAUTIs in smaller hospitals and a negative correlation for medium and large hospitals. Some hospitals with low CAUTI SIRs might actually have higher device use, and vice versa. Therefore, the SIR alone does not adequately reflect preventable harm related to urinary catheters. Public reporting of SIR may incentivize hospitals to focus more on urine culture stewardship rather than reducing device utilization.Funding: NoneDisclosures: None

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Implementation of a Female External Urinary Catheter Reduces Indwelling Urinary Catheter Use and Catheter-Associated Urinary Tract Infections

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.1158 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s482-s483

Author(s):

Paul Gentile ◽

Jesse Jacob ◽

Shanza Ashraf

Keyword(s):

Urinary Tract ◽

Urinary Tract Infections ◽

Urinary Catheter ◽

Improve Patient Safety ◽

Academic Medical Center ◽

Secondary Outcome ◽

Successful Implementation ◽

Urinary Catheters ◽

Tract Infections ◽

The Impact

Background: Using alternatives to indwelling urinary catheters plays a vital role in reducing catheter-associated urinary tract infections (CAUTIs). We assessed the impact of introducing female external catheters on urinary catheter utilization and CAUTIs. Methods: In a 500-bed academic medical center, female external catheters were implemented on October 1, 2017, with use encouraged for eligible females with urinary incontinence but not meeting other standard indications for urinary catheters. Nurses were educated and trained on female external catheter application and maintenance, and infection prevention staff performed surveillance case reviews with nursing and medical staff. We determined the number of catheter days for both devices based on nursing documentation of device insertion or application, maintenance, and removal. We used the CAUTI and DUR (device utilization ratio) definitions from the CDC NHSN. Our primary outcomes were changes in DUR for both devices 21 months before and 24 months after the intervention in both intensive care units (ICUs) and non-ICU wards. We used a generalized least-squares model to account for temporal autocorrelation and compare the trends before and after the intervention. Our secondary outcome was a reduction in CAUTIs, comparing females to males. Results: In total, there were 346,213 patient days in 35 months. The mean rate of patient days per month increased from 7,436.4 to 7,601.9 after the implementation of female external catheters, with higher catheter days for both urinary catheters (18,040 vs 19,625) and female external catheters (22 vs 12,675). After the intervention, the DUR for female external catheters increased (0 vs 0.07; P < .001) and for urinary catheters the DUR decreased (0.12 vs 0.10; P < .001) (Fig. 1). A reduction in urinary catheter DUR was observed in ICUs (0.29 vs 0.27; P < .001) but not wards (0.08 vs 0.08; P = NS) (Fig. 2). Of the 39 CAUTIs, there was no significant overall change in the rate per 1,000 catheter days (1.22 vs 0.87; P = .27). In females (n = 20 CAUTI), there was a 61% reduction in the CAUTI rate per 1,000 catheter days (0.78 vs 0.31; P = .02), but no significant change in the rate in males (0.44 vs 0.56; P = .64). The CAUTI rate per 1,000 catheter days among females decreased in the ICUs (1.14 vs 0.31; P = .04) but not in wards (0.6 vs 0.33; P = .96). Conclusions: In a setting with a baseline low UC DUR, successful implementation of female external catheters further modestly reduced UC DUR and was associated with a 61% decrease in CAUTI among females in the ICU but not in wards. Further interventions to better identify appropriate patients for female external catheters may improve patient safety and prevent patient harm.Funding: NoneDisclosures: None

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Review of Best Practices for CLABSI Prevention and the Impact of Recent Legislation on CLABSI Reporting

SAGE Open ◽

10.1177/2158244016677747 ◽

2016 ◽

Vol 6 (4) ◽

pp. 215824401667774 ◽

Cited By ~ 1

Author(s):

Benjamin Woodward ◽

Reba Umberger

Keyword(s):

Best Practices ◽

Healthcare Providers ◽

Bloodstream Infections ◽

Central Line ◽

Mandatory Reporting ◽

Future Research ◽

Common Source ◽

Healthcare Associated Infection ◽

Extrinsic Factors ◽

The Impact

Central line-associated bloodstream infections (CLABSI) are a very common source of healthcare-associated infection (HAI). Incidence of CLABSI has been significantly reduced through the efforts of nurses, healthcare providers, and infection preventionists. Extrinsic factors such as recently enacted legislation and mandatory reporting have not been closely examined in relation to changes in rates of HAI. The following review will examine evidence-based practices related to CLABSI and how they are reported, as well as how the Affordable Care Act, mandatory reporting, and pay-for-performance programs have affected these best practices related to CLABSI prevention. There is a disconnect in the methods and guidelines for reporting CLABSI between these programs, specifically among local monitoring agencies and the various federal oversight organizations. Future research will focus on addressing the gap in what defines a CLABSI and whether or not these programs to incentivize hospital to reduce CLABSI rates are effective.

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