Re: Assessment of CLABSI’s

[Pauline Bass]

Thanks to those that responded to the online survey. 44 responses were received but 24 completed the survey completely (there were some comments on the quality of the questions, so I suppose some may have started but didnt like the questions). This included responses from all states and territories, with 77% from ICPs. More than half had been working in infection control for more than 5 years.

Case – A patient with 60% burns had a Enterobacter bacteraemia after a prolonged hospital stay. A central line was in place. The patient had clinically infected burns with tissue cultures growing multiple organisms (but not enterobacter) on the day of the bacteraemia.
Issue – Can the bacteraemia be ascribed to a clinical source without microbiological evidence?
Proportion calling this case a CLABSI – 93%
Case – A patient has Pseudomonas grown from a single blood culture taken from a central line. No peripheral culture is taken. The patient was admitted 5 days ago for a head injury and has a central line in situ. The patient was not febrile or septic at the time of the culture and was not started on antibiotics.
Issue – Does a positive blood culture from a central line only constitute a bacteraemia?
Proportion calling this case a CLABSI – 52%
Case – A patient grew VRE from a single peripheral culture. A CVC in situ, 5 days after an amputation for gangrene. A tissue culture was positive 5 days prior to the bacteraemia in the amputation specimen. Cultures from the amputation stump taken on the day of the bacteraemia and 5 days later grew yeast only, and 7 days later grew VRE. The patient subsequently had further surgery for gangrene 2 months later.
Issue – Can the bacteraemia be ascribed to another site even if cultures were not positive until several days later?
Proportion calling this case a CLABSI – 25%
Case – A patient is undergoing treatment for acute myeloid leukaemia and has chemotherapy induced mucositis (mouth ulcers, nausea, vomiting). She has a Hickmans line in situ. Blood taken peripherally grows enterococcus on multiple occasions.
Issue – Does mucositis (based on clinical assessment) constitute another site of infection?
Proportion calling this case a CLABSI – 56%
Case – A patient grew an enterococcus from a single peripheral blood culture. The patient was in ICU for severe pneumonia but was clinically improving (extubated the day before, no longer febrile, white cell count decreasing). A comment is written in the notes by the ID physician saying “enterococcus – probable contaminant”.
Issue – Does a clinical diagnosis of contamination override the case definition?
Proportion calling this case a CLABSI -24%

13 comments were received. Some issues raised included:

Acknowledgement that these cases are difficult
The use of an indeterminate or unknown category at some hospitals
Insufficient clinical details to make the call (taking into account neutropenic status, other organisms, exit site status)
Consulting with clinicians to help make the decision

I personally would have said that clinically, none of the cases were a line-related bacteraemia, but all met the strict definition of a CLABSI (except perhaps the mucositis case). Clearly, Ive been overcalling them.

Although this small survey may not be representative of all ICPs, we need a better definition of a CLABSI that is reproducible and validly reflects the preventable ones. Moreover, criterion 1 of the CLABSI is probably the simplest of all the NHSN definitions. Others have raised similar issues (Sexton, ICHE, 2010, from where case 5 is derived) and previous published data suggests that the assessment of CLABSI (Worth L, AJIC 2009) and superficial infection following CAGS (Friedman ICHE 2007) are not reliable.

I wonder what proportion of the variation in infection rates we see between hospitals is due to variation in how these definitions are interpreted?

Thanks

Pauline Bass on behalf of Allen Cheng

Pauline Bass
Infection Prevention Nurse Consultant
Infection Prevention and Healthcare Epidemiology
Alfred Health
p.bass@alfred.org.au
—
Allen Cheng
MBBS, FRACP, MPH, PhD

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