Clinical Pearls & Morning Reports

Posted by Carla Rothaus, MD

Published September 20, 2023


How much did the incidence of central line—associated bloodstream infections increase during the Covid-19 pandemic?

Central line–associated bloodstream infection (CLABSI) may increase antibiotic exposure, the hospital stay, health care costs, and the risk of death. Read the NEJM Review Article here.

Clinical Pearls

Q: What organization provides surveillance for CLABSI?

A: The National Healthcare Safety Network (NHSN) has served for decades as the foundation of CLABSI surveillance. The NHSN defines CLABSI as a laboratory-confirmed bloodstream infection in a patient who has had a central venous catheter in place for more than 48 hours before the date on which blood was drawn for culture, if no other source of bacteremia or fungemia is identified.

Q: Have efforts to prevent CLABSI been successful in the United States?

A: Over the past 20 years, substantial efforts have been made by several governmental, public health, and professional organizations to sponsor and promote evidence-based guidelines for strategies to prevent CLABSI. These efforts have been credited for successfully reducing the incidence of CLABSI in ICUs, acute care units, burn units, neonatal ICUs, and oncology units nationwide.

Morning Report Questions

Q: How much did the incidence of CLABSI increase during the Covid-19 pandemic?

A: Despite success in reducing the incidence of CLABSI in recent decades, we should be circumspect, given that both 20 years of reductions in the incidence of CLABSI and our ability to collect surveillance data vanished during the first 3 months of the Covid-19 pandemic. The system we have in place for the prevention of CLABSI is clearly fragile and vulnerable to stress in the health care environment, particularly stress on the provider component of clinical care. Since patient and provider risk factors for the development of CLABSI were substantially altered during the height of the Covid-19 pandemic, it is not surprising to see an increase in the incidence of CLABSI. What is surprising, however, is how quickly and how high the incidence of CLABSI rose during the pandemic, with one study reporting an increase by 325%. The Covid-19 pandemic revealed other vulnerabilities in the CLABSI-prevention system when the NHSN stopped collecting data from January through June 2020 because of the strains of the pandemic and the limited number of infection-prevention professionals who were available. Application of the complicated CLABSI definitions used by the NHSN requires a substantial amount of education and training. Thus, substituting new persons for the infection-prevention professionals who had been assigned to other priorities was nearly impossible.

Q: What kinds of changes to our current CLABSI surveillance and preventive practices does the author suggest?

A: The inadequate number of infection-prevention professionals during the pandemic highlights the need for a new and simpler definition of CLABSI that allows for computerized capture of CLABSI rates with the use of artificial intelligence and the electronic health record. Combining a simpler definition with an electronic solution could achieve high reliability during all conditions of health care delivery. Although consistent reinforcement of preventive practices such as checklists is effective, it relies on limited staff who may have competing priorities when the health care system is strained. It is time to consider combining routine use of all available CLABSI preventive strategies that do not depend on providers in order to be effective. Relying more firmly on the use of forms of technology that have been shown to be effective when used in CLABSI-prevention programs — such as antiseptic-impregnated catheters, chlorhexidine-impregnated dressings, and alcohol-bathed protective caps for every central catheter that is placed — may be a reasonable approach, even if it is not known whether each intervention is necessary. Building redundancy into the infection-prevention system increases reliability and resilience.

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