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PHC 231

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1. Discuss Central Line-Associated Bloodstream Infection (CLABI) "or" Ventilator-Associated Pneumonia (VAP) outbreak in long-term acute care hospital settings. Address the following in your report:

1. Characterize the epidemiology and microbiology
2. Describe the agent and identify the host and the environment that is favorable for the infection.
3. Discuss how the infections spread and the types of prevention and control measures
4. Identify a population and develop a hypothesis about possible causes in a testable format with standard statistical notation (the null and the alternative)
5. Explain how you would choose controls to test this hypothesis?

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Introduction

A central line-associated bloodstream infection (CLABSI) is a serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line

1)Epidemiology

CLABSIs lead to prolonged hospital stays and increase health care costs and mortality. An estimated 250,000 bloodstream infections occur annually, and most are related to the presence of intravascular devices. In the United States, the CLABSI rate in intensive care units (ICU) is estimated to be 0.8 per 1000 central line days. International Nosocomial Infection Control Consortium (INICC) surveillance data from January 2010 through December 2015 (703 intensive care units in 50 countries) reported a CLABSI rate of 4.1 per 1000 central line days. Many central lines are found outside the ICUs. In one study, 55% of ICU patients and 24% of non-ICU patients had central lines. However, as more patients are located outside of the ICU, 70% of hospitalized patients with central venous catheters were outside the ICU. CLABSI rates outside ICUs are assumed to be similar tolike those within ICUs.[5].

Microbology

Organisms isolated from blood cultures among subjects with community-onset CLABSI or hospital-onset CLABSI were classified as Gram-positive bacteria, Gram-negative bacteria, or yeast.

Based on the National Healthcare Safety Network (NHSN) data from January 2006 to October 2007 the order of selected pathogens associated with causing CLABSI are as follows.                Gram-positive organisms (staphylococci, 34.1%; enterococci, 16%; and Staphylococcus aureus, 9.9%) are the most common, followed by gram negatives (Klebsiella, 5.8%; Enterobacter, 3.9%; Pseudomonas, 3.1%; E.coli, 2.7%; Acinetobacter 2.2%), Candida species (11.8%).

Pseudomonas is commonly seen in association with neutropenia, severe illness, or known prior colonization. Candida is associated with the following risk factors: femoral catheterization, TPN, prolonged administration of broad-spectrum antibiotics, hematologic malignancy, or solid organ or hematopoietic stem cell transplantation.
Certain bacteria such as staphylococci, Pseudomonas and Candida produce extracellular polysaccharide [slime (biofilm)] which favor increased virulence, adherence to catheter surface and resistance to antimicrobial therapy

Describe Agent

• Staphylococci are spherical Gram-positive bacteria, which are immobile and form grape-like clusters. They form bunches because they divide in two planes as opposed to their close relatives streptococci which, although they are similarly shaped, form chains because they divide only in one plane
• Klebsiella is a genus of Gram-negative, oxidase-negative, rod-shaped bacteria with a prominent polysaccharide-based capsule.
• Pseudomonas aeruginosa is a gram-negative, rod-shaped, asporogenous, and monoflagellated bacterium that has an incredible nutritional versatility

Host factors

Host factors that increase the risk of CLABSI are chronic illnesses (hemodialysis, malignancy, gastrointestinal tract disorders, pulmonary hypertension), immune compromised states (bone marrow transplant, end-stage renal disease, diabetes mellitus), malnutrition, total parenteral nutrition (TPN), extremes of age, loss of skin integrity (burns), prolonged hospitalization before line insertion catheter type, catheter location (femoral line has the highest, followed by internal jugular, then subclavian), conditions of insertion (emergent versus elective, use of full barrier precautions versus limited), catheter site care, and skill of the catheter inserter.

Environmental Factors

   An outbreak occurred at a Japanese Tertiary Care Center, was caused by 2 different clones of M. mucogenicum as well as M. canariasense. M. mucogenicum. The outbreak resulted from contaminated hospital equipment and contaminated tap water.

Another study Between July 2011 and April 2012, 16 RGM isolates were identified among 15 hematopoietic cell transplant patients, compared with none in the preceding year. After environmental samples were initially grown on media for heterotrophic counts and further speciated, RGM species were identified in the hospital water supply.

Also, Contaminated intravenous materials or hospital equipment may lead to CLABSI.

Spread of infection

There are many ways that contamination can occur of the central line and cause a central line-related infection. These include:

• Contamination on insertion
• The patient’s skin flora
• The healthcare worker
• CVAD hub colonization
• Contaminated infusion or components of IV set
• Hematogenous spread from other sites (e.g. through the bloodstream from another infection)
• Non-intact dressing

Central venous catheters disrupt the integrity of the skin, making infection with bacteria or fungi possible. A central line–associated bloodstream infection (CLABSI) may spread to the bloodstream and cause hemodynamic changes and organ dysfunction, possibly leading to death.

Prevention Guidelines During Insertion

Recent data reveal no difference in the infection rate based on the insertion catheter site. The following are some key components of a prevention program, abstracted from an extensive list provided by the CDC and IDSA.[8][9][6]

1. Hand hygiene by washing hands with soap and water or with alcohol-based gels or foams. Gloves do not obviate the need for hand hygiene.
2. Strict aseptic technique by using maximal sterile barrier precautions, including a full-body drape when inserting central venous catheters.
3. Use of 2% chlorhexidine skin preparations for disinfecting/ cleaning skin before insertion.
4. Ultrasound guidance by an experienced provider for placement to circumvent mechanical complications and reduce the number of attempts.
5. Avoid the femoral vein as a choice for central line placement, and prefer the subclavian vein when possible for non-tunneled catheters.
6. Promptly remove any central line that is no longer required.
7. Replace central lines placed during an emergency (asepsis not assured) as soon as possible or at least within 48 hours.
8. Use a checklist.

Prevention Guidelines During Maintenance

1. Disinfect the catheter hubs, injection ports, and connections before accessing the line.
2. Replace administration sets other than sets used for lipids or blood products every 96 hours.
3. Assess the need for the central line daily.

What can patients do to help prevent CLABSI?

• Research the hospital, if possible, to learn about its CLABSI rate.
• Speak up about any concerns so that healthcare personnel are reminded to follow the best infection prevention practices.
• Ask a healthcare provider if the central line is absolutely necessary. If so, ask them to help you understand the need for it and how long it will be in place.
• Pay attention to the bandage and the area around it. If the bandage comes off or if the bandage or area around it is wet or dirty, tell a healthcare worker right away.
• Don’t get the central line or the central line insertion site wet.
• Tell a healthcare worker if the area around the catheter is sore or red or if the patient has a fever or chills.
• Do not let any visitors touch the catheter or tubing.
• The patient should avoid touching the tubing as much as possible.
• In addition, everyone visiting the patient must wash their hands—before and after they visit.

4) Identify a population and develop a hypothesis about possible causes in a testable format with standard statistical notation (the null and the alternative)

• Population: Pediatric chest patients with CVCs receiving inpatient care at king khaled Hospital Cancer Center between May 2015 and May 2016.
• Hypothesis: if antibiotic therapy is related to CLABI then patients who are treated by antibiotics will have an increased risk for developing CLABI
• Alternative hypothesis: Antibiotic therapy increase risk of CLABSI.
• Null Hypothesis: Antibiotic therapy doesn’t increase risk of CLABSI.

5) Explain how you would choose controls to test this hypothesis?

• When selecting controls, you should make sure that they must come from the same base population as the cases. You should also make sure that the controls must be samples independent of exposure status. Both the exposed and unexposed controls must have the same probability of selection.
• Individual MATCHING (in this approach, for each case selected, a control is selected who is similar to the case in terms of the specific variables of concern)).

• Cases include those pediatric chest patients with a diagnosis of pneumonia with CVC who had a CLABSI between May 2015 and May 2016.
• Eligible controls include those pediatric chest patients with a CVC who didn’t have CLABSI.   

Answer 1

• a.) CLABI rate is 0.8 per 1000 central-line days, According to INICC the CLABI rates goes to 4.1 central-line days

  Microbiological aspect-

  ​​​​​​

  Organism	Percentage Infection
  Staphylococcus aureus	22.0
  Coagulase-negative staphylococcus	37.0
  Yeasts	9.3
  Enteric Gram-negative bacilli	12.4
  Enterococci and streptococci	4.9
  Pseudomonas	5.5
  Other	8.9

  b.) Agent - Staphylococcus Aureus, Coagulase negative Staphylococcus,Yeast , Streptococci

  Host- Chronic illness (malignancy, hemodialysis, gastrointestinal tract disorders), immune compromised states (bone marrow transplant, end-stage renal disease, diabetes mellitus), malnutrition, prolonged hospitalization before line insertion, catheter type, catheter size, catheter site care, etc.

  Environment- Contamination of  the insertion, the patient's skin flora, contamination of the components of IV sets, poor patient hygiene, impaired skin integrity, prolonged duration of the catheter, etc.

  c.) The spread of the Infection occurs directly from central Catheter line to Heart and then it Can reach to any organ as the Heart Pumps Blood to all the Organs of Body and it can cause bacteremia and sepsis.

  Prevention and Control of this Bacteremia is by Prophylactic and Empericial Microbial Therapy and Removal Of Catheter if the Infection persists is the Best Way out For Treatment.