2011 CLABSI Master Class

Monitoring of CVC-associated bloodstream infections in Victorian hospitals

VICNISS Coordinating Centre

Outline

• VICNISS CLABSI surveillance module• NHSN CLABSI surveillance – revisions• CLABSI rates in Victoria – how do we compare?• Prevention of CLABSI – what does the literature

say?• CLIP surveillance – VICNISS pilot results• Ensuring accuracy & reproducibility• Case studies for discussion

VICNISS & the CLABSI module

VICNISS• Coordinating Centre

– commenced collecting hospital acquired infection data in 2002

• Quarterly data submission– large & small acute public hospitals

– private hospitals

• CDC – NHSN (NNIS)

• Collate, analyse & report ‘hospital rates vs. State rate’; notify CEOs and DoH if significantly high rates identified

VICNISS surveillance modules

• SSI• ICU CLABSI• ICU VAP• Haemodialysis• Surgical prophylactic antibiotics• + Type 2 process & outcomes

CLABSI – a significant outcome

• Mortality– attributable mortality 12-25%

• Increased LOS– 2.4 ICU days– 6.1-7.5 hospital days

• Healthcare costs– US $11-25000 Higuera F et al. ICHE 2007

Warren DK et al. Crit Care Med 2006

Posa PJ et al. AACN Adv Crit Care 2006

Siempos II et al. Crit Care Med 2009

Tacconelli E et al. J Hosp Infect 2009

CLABSI case definitions: clinical

• Numerous• Applications: diagnostic dilemmas, clinical

trials• Specialised laboratory testing methods:

– catheter tip cultures– quantitative blood and catheter tip cultures– differential time to positivity

Clinical definitions: heterogeneity

Diagnostic criteria

‘Definite’ •Same organism cultured from catheter tip & blood(using DTP or quantitative catheter & peripheral cultures)

‘Probable’ •Local infection at insertion site and organism cultured from blood

•Remission of previously refractory fever within 48 hours of catheter removal with organism cultured from blood.

‘Possible’ •Pathogen cultured in blood that is typically implicated in causing catheter-related infections (e.g. S. aureus, Candida)

•Organism cultured from blood and no other focus identified in a patient with an indwelling CVC

Fatkenheuer G, et al. Ann Hematol. 2003

CLABSI case definition: surveillance

• Uniform & standardised• Applications:

– public health reporting– IC monitoring

• Feasible to apply across range of healthcare facilities

• Laboratory and clinical criteria

NHSNCLABSI surveillance definition for benchmarking

Edwards JR, et al. Am J Infect Control 2009

Monitoring in infection controlCLABSI surveillance definition to monitor an

intervention

Pronovost PJ, et al. N Engl J Med 2006

NHSN CLABSI surveillance – revisions

The question of definition*

Case-definition criteria NNISNHS

N

Recognised pathogen in 1 or more blood cultures Y Y

Skin contaminant in 2 or more blood cultures drawn on separate occasions Y Y

Skin contaminant in 1 blood culture, where clinician institutes appropriate antimicrobial therapy

Y N

*case-definition for CLABSI, adult patients

NNIS/NHSN CLABSI rates*Surveillance period

ICU type Jan ‘02-Jun ‘04 Jan ‘06-Dec ‘06 Jan ‘06-Dec ‘07

Cardiothoracic 3.0 1.6 1.4

Medical 5.1 2.9 2.4

Medical/surgical

- major teaching 3.9 2.4 2.0

- all others 3.3 2.2 1.5

Surgical 4.4 2.7 2.3

Trauma 6.0 4.6 4.0

inclusive of criterion 2b & 3b2b & 3b removed

*published pooled mean ratesNNIS Report, Am J Infect Control 2004

Edwards JA, et al. Am J Infect Control 2007

Edwards JA, et al. Am J Infect Control 2008

CLABSI rates - Victoria

pooled mean: 6.05/1000 CVC days

pooled mean: 2.06/1000 CVC days

Updated NHSN definition:1 July 2008

CLABSI aetiology following definition change

• VICNISS reporting period 2002-2008– CNS 36.6%– MRSA 17.4%– enterococci 9.6%

• VICNISS reporting period 2008-2011– CNS 12.3%– MRSA 11.3%– enterococci 26.2%

NHSN CLABSI definitionmodifications: June 2011

• ‘skin contaminants’ → ‘common commensals’– revised & expanded organism list

• Relatedness of infecting organisms– susceptibility profile not required– genus/species sufficient

Modifying a case-definitionconsiderations for a surveillance strategy

• Comparison with historical data• Establishing a new baseline for trend analysis• Confidence intervals• Evidence for prevention & treatment strategies• Consider as ‘new’ infection

CLABSI rates in Victoria – how do we compare?

National trends: CLABSI

Currently available reports:

• WA– 7 contributing hospitals– peripherally- and centrally-inserted devices reported

separately

• SA– 12 contributing hospitals– all bloodstream infections; denominator ‘bed days’

Healthcare Infection Surveillance WA (HISWA)

Aggregate ICU CLABSI rate = 0.77/1000 CVC days(Q1 2011)

http://www.public.health.wa.gov.au/

SA Healthcare associated BSI report

www.health.sa.gov.au

International data: CLABSINHSN rates by ICU type

Edwards JR, et al. Am J Infect Control 2009

Prevention of CLABSI – what does the literature say?

Prevention of CLABSIinterventions with proven efficacy

• Education– physicians & nursing staff

• Anatomical site– subclavian < jugular < femoral

• Skin asepsis– alcoholic chlorhexidine gluconate

• Maximal barrier precautions

Lobo RD, et al. Am J Infect Control 2005Eggimann P, et al. Ann Intern Med 2005

Hamilton HC, et al. Cochrane database Syst Rev 2007

Pratt RJ, et al. J Hosp Infect 2007

Raad II, et al. infect Control Hosp Epidemiol 1994

Impregnated & coated devices

• Chlorhexidine-silver sulfadiazine and minocycline-rifampicin impregnated devices reduce colonisation & CLABSI

• CDC guidelines recommend if CLABSI rates are high

• Threshold CLABSI rates not proposed (cost-benefit demonstrated for use of chlorhexidine-and-silver-sulfadiazine–impregnated catheters if CLABSI > 2%).

Hockenhul JC, et al. Crit Care Med 2009Casey AL, et al. Lancet Infect Dis 2008

Maki DG, et al. Ann Intern Med 1997

The ‘beneficial bundle’

• Strategy/intervention consisting of a series of components– each component evidence-based & demonstrated

impact– process measures

• Implementation– feasible– achieved by multi-faceted strategy – education,

credentialing, product selection

Bloodstream infections in ICUUS experience with ‘bundle intervention’

• Bloodstream infections associated with CVCs are preventable

• Bundle comprised of 5 interventions:– maximal barrier precautions– hand washing– avoidance of femoral site– removal of unnecessary devices– chlorhexidine for skin asepsis

• Significant & sustained impact in reducing rates of infection at multiple US centres

Pronovost PJ, et al. N Engl J Med 2006

Zero tolerance?

• Proposal for zero tolerance of CLABSI rates – simple hospital performance indicator

• Modification in case-definition will reduce CLABSI rates

• Other contributing factors:– barrier precautions, hand-hygiene, skin preparation,

removal of unnecessary devices, avoidance of femoral site

– education, simulator training, credentialing of HCW

CLIP surveillance – VICNISS pilot results

ICU ‘bundle intervention’a lesson for Victorian centres

• Variable uptake of ICU bundle in Australian centres

• Victorian centres with high rates of infection - bundle components used by VICNISS as basis for recommendations

• VICNISS literature review of evidence-based bundle components (2009)

• Australian & NZ Intensive Care Society (ANZICS) collaboration & support for implementation

CLABSI: process monitoring

• Central line insertion practices (CLIP)– HICPAC CVC insertion guidelines– Surveillance module: NHSN– Reporting commenced 2008

• CLABSI prevention bundle– hand hygiene– appropriate skin asepsis– dry antiseptic before skin puncture– maximal barrier precautions (cap, sterile gown,

gloves, mask, full drape)

NHSN CLIP datapreliminary findings

• Mar 2008 – Sep 2009• 72,216 CVC insertions, 744 healthcare facilities• Majority in ICU (84%), and upper extremity

devices (62%)• 6,356 (8.8%) did not adhere to bundle:

– 16% did not perform hand hygiene– 20% did not use appropriate skin antiseptic– 21% did not allow antiseptic to dry– 60% did not adhere to maximal barrier precautions

• cap omitted in 63%• full patient drape omitted in 34%

Allen-Bridson K, et al. SHEA 2010, abstract 686

CLIP data: Victorian experience

• Pilot study, Jan – June 2011• 4 Victorian centres participating in CLABSI

surveillance• Audit of CVC insertion practices in ICU• Minimum 3 month continuous audit period• Assessment of compliance with NHSN bundle• Evaluation of feasibility of data collection

CLIP data: Victorian experience

A role for CLABSI process monitoring in Victoria?

• Following pilot – ongoing participation requested• Proposed scope for CLABSI process monitoring

in Victoria:– Optional surveillance module for healthcare facilities

currently participating in CLABSI surveillance (periodic/continuous)

– If higher than expected CLABSI rates at a single centre

– Monitoring in non-ICU environments, where CLABSI may be less frequent or more difficult to monitor (interventional radiology, ward, other)

• CLIP module available 10/2011

Ensuring accuracy & reproducibility

Validation of CLABSI data (VICNISS)

• Accuracy of data important for benchmarking & longitudinal analysis, but few validation studies performed by non-US centres

• Review of hospital medical records comparing reported surveillance data with gold standard– 6 Victorian centres, Jan-Dec 2006– Gold standard = blinded assessment by trained

VICNISS ICC– NNIS case-definition

McBryde ES, et al. Infect Control Hosp Epidemiol 2009

Outcomes

• Total 398 bacteraemias, 81 reported as CLABSI. Sample set of 46 reported CLABSIs and 62 not reported as CLABSIs

• 67% inter-rater agreement with VICNISS review

• PPV 59% (43-73%), NPV 73% (60-83%)

• Sensitivity 35% (23-48%), specificity 87% (82-92%)

• Hypothetical sensitivity 50% [NHSN]

Reproducibility of CLABSI dataVICNISS

• Questionnaire review of Victorian ICCs assessing reproducibility of case-definition when compared to international gold standard– 18/21 VICNISS centres, 2006– 11-item questionnaire, classification of clinical cases

(CLABSI/not CLABSI)– NNIS case-definition– Gold standard = blinded CDC staff specialist

Worth LJ, et al. Am J Infect Control 2009

Assessment tool: an example

A patient with sub-arachnoid haemorrhage is admitted to hospital directly into ICU and a CVC is inserted. The patient becomes febrile after 24 hrs, with no localising symptoms or signs. Blood culture taken at 24 hrs isolates Staphylococcus aureus, and treatment with intravenous flucloxacillin is commenced:

⃞� this is an ICU-acquired CLABSI⃞� this is not an ICU-acquired CLABSI

Outcomes

• Overall concordance with external comparator 57.1% (range 16.7-94.4%)

• Mean concordance higher for 1A hospitals compared with non-1A (60.6 vs. 55.3%)

• Proportion of congruently classified cases, by NNIS criteria: criterion 1, 52.8%; criterion 2a, 83.3%; criterion 2b, 58.3%

• Hypothetical concordance 62.5% [NHSN]

Enhancing CLABSI surveillance

• Credentialing tool for IC staff– on-line, periodic, rotation of content

• VICNISS website– FAQs, case studies

• Other– education opportunities– multi-disciplinary engagement; collaboration with

ANZICS ‘CLAB’ project

Case studies for discussion

Scenario 1

• Trauma patient, day 18 post MVA

• Blood cultures collected at the same time:– from PICC - Enterobacter gergoviae – from peripheral site – no growth

Scenario 2

• Patient with 60% burns.

• After prolonged hospital stay, central line in situ, – blood culture: Enterobacter spp.

• On same day as blood culture - patient had clinically infected burns with tissue cultures growing multiple organisms (not Enterobacter).

Scenario 3

• Patient admitted 5 days ago following head injury.

• Central line in situ. • Single blood culture from central venous line -

Pseudomonas spp. • No peripheral blood culture taken. • The patient was not febrile or septic at the

time of the culture and was not commenced on antibiotics.

Scenario 4

28 Apr Admitted to hospital

1 May Admitted to ICU

2 CVC inserted (2200)

3 Blood culture (0600) - Acinetobacter spp

Tracheal aspirate - MSSA

4 Notes: "febrile, ? Source GNB on blood culture”

7 ID documented “Acinetobacter cause of line sepsis” CXR essentially clear 3 - 7 May

8 CXR increasing consolidation, collapse in the LLL & increasing consolidation R) lung base

Acinetobacter spp isolated from tracheal aspirate

Scenario 5

• A patient grew an Enterococcus spp from a single peripheral blood culture.

• Patient in ICU for severe pneumonia but was clinically improving (extubated the day before, no longer febrile, white cell count decreasing).

• Medical History - ID physician notes: “Enterococcus - probable contaminant".

Scenario 6

• A patient is undergoing treatment for acute myeloid leukaemia

– has chemotherapy-induced mucositis (mouth ulcers, nausea, vomiting).

– Hickman line in situ

– blood culture taken peripherally - Enterococcus spp• multiple occasions.

Gut source or CLABSI?

• Gram-negative bacteraemia (or fungaemia) in ICU patients may occur either because of translocation of microorganisms from oedematous, abnormal, or adynamic segments of bowel or because of microscopic or macroscopic defects in the bowel wall.

• Absence of proof (of an established infection at a site other than a central vascular catheter as a source of bacteraemia) cannot be cited as proof of absence.

CLABSI due to Enterococci?

• The issue of using a single blood culture positive for enterococci as evidence of a laboratory-confirmed case of CLABSI is not a trivial.

– Evidence that Enterococci are frequent contaminants of blood cultures is compelling.

– Infectious diseases specialists routinely perform a repeat blood culture as a first step to assess patients who have a single blood culture positive for Enterococci. If the repeat culture result is negative, most infectious diseases specialists would conclude that the single positive blood culture result represents contamination.

CLABSI surveillance definition2 proposed changes

• Inclusion of an “indeterminate source” for some BSIs, and

• Acknowledgement that a single blood culture positive for Enterococci has little clinical significance, similar to the interpretation of a single blood culture positive for CNS.

• CLABSIs could be divided into 3 categories:– primary– secondary, or– indeterminate source.

• Acceptance of an “indeterminate source” category for some patients with BSI would allow hospital epidemiologists to acknowledge that we can not determine the source of every infection with certainty.

Scenario 7

• Patient with relapsed acute myeloid leukaemia presented with documented febrile neutropenia.

• CVC in situ.

• Streptococcus viridians spp grown from two separate blood draws.

Aerococcus species Staphylococcus auricularisAerococcus urinae Staphylococcus capitis ss capitisAerococcus viridans Staphylococcus capitis ss unspecifiedBacillus cereus Staphylococcus capitis ss urealyticusBacillus species (not B. anthracis) Staphylococcus coagulase negativeBacillus subtilis Staphylococcus cohniiCorynebacterium aquaticum Staphylococcus epidermidisCorynebacterium bovis Staphylococcus gallinarumCorynebacterium cystitidis Staphylococcus haemolyticusCorynebacterium glutamicum Staphylococcus hominisCorynebacterium group G-2 Staphylococcus lentusCorynebacterium jeikeium Staphylococcus lugdunensisCorynebacterium kutscheri Staphylococcus saccharolyticusCorynebacterium matruchotii Staphylococcus saprophyticusCorynebacterium minutissimum Staphylococcus schleiferiCorynebacterium mycetoides Staphylococcus sciuriCorynebacterium pilosum Staphylococcus simulans

Corynebacterium pseudodiphtheriticum Staphylococcus species

Corynebacterium pseudotuberculosis Staphylococcus warneriCorynebacterium renale Staphylococcus xylosusCorynebacterium species Streptococcus anginosusCorynebacterium striatum Streptococcus bovisCorynebacterium ulcerans Streptococcus mitisCorynebacterium urealyticum Streptococcus mutansCorynebacterium xerosis Streptococcus salivariusDiphtheroids Streptococcus viridans speciesGram-positive cocci unspecified Micrococcus species Propionibacterium acnes Propionibacterium avidum Propionibacterium granulosumPropionibacterium lymphophilumPropionibacterium propionicumPropionibacterium speciesRhodococcus equiRhodococcus species

Common commensals, NHSN, 2011

Scenario 8

• Haematology patient with refractory B-cell lymphoma.

• Day 3 post allograft - blood cultures from both Hickman lumens and peripherally - E. coli .

• Patient has an anal fissure. CT scan: no abscess.

• Ongoing abdominal pain, – Laparotomy 1 week earlier - NAD.– Abdominal pain still under investigation.

• Hickman was not removed by the treating team, TPN was ongoing.

Case 9

• A patient with CVC in situ for 9 days becomes febrile1/5 - E. coli is isolated in blood culture2/5 - Klebsiella pneumoniae is isolated in blood culture

• Chest X-ray is clear and no organism is isolated from urine. No other primary source of infection is identified.

Case 10

• In the setting of fever, a patient with CVC in situ isolates Staphylococcus epidermidis from a single blood culture.

• The treating clinician commences vancomycin for targeted therapy.