|Year : 2011 | Volume
| Issue : 2 | Page : 169-171
Central venous catheter-related blood stream infection rate in critical care units in a tertiary care, teaching hospital in Mumbai
K Chopdekar, C Chande, S Chavan, P Veer, V Wabale, K Vishwakarma, A Joshi
Department of Microbiology, Grant Medical College and Sir J.J. Hospital, Mumbai - 400 008, India
|Date of Submission||09-Feb-2011|
|Date of Acceptance||09-Apr-2011|
|Date of Web Publication||2-Jun-2011|
Department of Microbiology, Grant Medical College and Sir J.J. Hospital, Mumbai - 400 008
Source of Support: None, Conflict of Interest: None
Blood stream infections related to central venous catheterization are one of the major device-associated infections reported. Patients admitted in critical care units requiring central venous catheterization and presenting with signs of septicemia during catheterization period were investigated for catheter-related blood stream infections (CRBSI). The CRBSI rate was 9.26 per 1000 catheter days in general with highest rate in neonatal intensive care unit (27.02/1000 days). Site of insertion of catheter and duration of catheterization did not show the influence on the CRBSI rate. Coagulase-negative Staphylococci were the predominant cause. Mortality of 33% was observed in patients with CRBSI. Since central venous catheters are increasingly being used in the critical care, regular surveillance for infection associated them are essential.
Keywords: Central venous catheter, blood stream infections
|How to cite this article:|
Chopdekar K, Chande C, Chavan S, Veer P, Wabale V, Vishwakarma K, Joshi A. Central venous catheter-related blood stream infection rate in critical care units in a tertiary care, teaching hospital in Mumbai. Indian J Med Microbiol 2011;29:169-71
|How to cite this URL:|
Chopdekar K, Chande C, Chavan S, Veer P, Wabale V, Vishwakarma K, Joshi A. Central venous catheter-related blood stream infection rate in critical care units in a tertiary care, teaching hospital in Mumbai. Indian J Med Microbiol [serial online] 2011 [cited 2018 Dec 13];29:169-71. Available from: http://www.ijmm.org/text.asp?2011/29/2/169/81796
| ~ Introduction|| |
Central venous catheter (CVC) is often used as a portal for the delivery of medications, parenteral nutrition, collection of blood samples and monitoring hemodynamic variables in critically ill patients. Noninfectious and infectious complications are frequently reported with central venous catheterization.  Blood stream infections related to central venous catheterization constitute one of the major nosocomial device associated infections. ,, For the surveillance of device-associated infections, the data needs to be expressed as the number of device-associated infections per 1000 device days as per the recommendations from the Center for Disease Control and Prevention, USA.  Very few published studies reporting rate of BSI related to CVC in pediatric and adult critical care units are available in the Indian literature. ,
| ~ Material and Methods|| |
The study was conducted in a tertiary care hospital with 1400 bed capacity. The patients requiring CVCs admitted in adult intensive care units (Medical and Surgical, Bed size - 27), pediatric intensive care unit (bed size 14) and neonatal intensive care unit (bed size 40) during the study period (December 2008 to November 2009) were included in the study. Patient presenting with clinical symptoms and signs of septicemia after central venous catheterization were surveyed for blood stream infections. Data pertaining to age, sex, clinical diagnosis, site of insertion of CVC, treatment received, duration of CVC catheterization, duration of hospitalization and clinical outcome were recorded in each patient.
The catheter tip culture was done in all the patients at the time of removal of catheter. Semiquantitative method used by Maki et al.  was followed for catheter tip culture. Isolation of >15 CFU was taken as cut-off for positive tip culture.
Peripheral blood cultures were collected from the patients with clinical evidence of sepsis. For this 1 to 5 ml blood was collected under aseptic precautions in Hartley's blood culture broth and cultures were processed by standard microbiological methods.  Bacterial isolates recovered from the blood cultures and corresponding tip cultures were subjected to antibiotic sensitivity testing as per CLSI 2009 guidelines.  CRBSI was defined as a positive blood culture obtained from a peripheral vein with clinical evidence of sepsis and with no apparent source of septicemia except tip and catheter tip colonization with same organism as in blood culture. 
| ~ Results and Discussion|| |
During the study period, 85 CVCs were used in 78 patients in various critical care units who developed signs of septicemia during catheterization period. The maximum patients requiring CVCs were from pediatric ICU [Table 1]. Eleven culture-proven blood stream infections occurred in 78 patients of which six were classified as CVC-related blood stream infections as per the definition.  The average CRBSI rate was 9.26 per 1000 catheter days ranging from 8.64 per 1000 catheter days in PICU to maximum rate of 27.02 per 1000 catheter days in NICU. In adult CCU, medical ICU has much lower CRBSI as compared to surgical ICU. CRBSI rate varies considerably in the different studies. ,, National nosocomial infection surveillance system of the Center for Disease Control and Prevention, Atlanta, USA, reports a CRBSI rate of 5.8 per 1000 catheter days.  As the patients receiving critical care were on the antibiotic treatment, the rate of CRBSI in the present study is likely to be influenced by this factor. Since most of the Indian data has not been expressed in terms of device utilization frequencies as the denominator, comparison with other studies in nosocomial infection surveillance becomes difficult. The two sites, femoral (74 catheters) and subclavian (11 catheters) employed for the placement of catheters showed CRBSI of 6.7% (5/74) and 9% (1/11), respectively. The site of insertion did not appear to influence the rate of CRBSI in this study. Femoral site has been reported to be the safest site by many workers. 
|Table 1: Catheter-related blood stream infection rates in different critical care units|
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For interpretation of catheter tip colonization, criteria suggested by Maki et al. was used.  A total of 49 (57.6%) catheter tips were colonized with bacteria and fungi. The microbial pattern of catheter colonization revealed maximum colonization with Candida spp. all belonging to non-albicans type [Table 2].
Catheter colonization did not appear to have direct bearing on blood stream infection (P-value 0.59, Fisher test, not significant). The predictive value of positive tip culture for diagnosis of CRBSI was found to be very low (0.1224). Hence antibiotic treatment based on the positive tip culture does not appear to be justified. No relation was observed by us with the duration of catheterization and CRBSI.
Coagulase-negative Staphylococci were the major (50%) cause of CRBSI followed by Klebsiella pneumoniae, Pseudomonas aeruginosa and non-albicans Candida spp. in one case each. All these four organisms are known to produce biofilms, which are reported to be universally present on CVCs.  All the bacterial isolates were multidrug-resistant showing resistant to more than two different classes of antibiotics. The antibiogram of these isolates also matched with the corresponding isolates from the catheter.
Mortality in CRBSI was observed in 33.3% cases compared to 20% mortality in cases of BSI in catheterized patients not related to CVC. CRBSI are reported to be associated with attributable mortality in the range of 10% to 25%. 
Since CVCs are increasingly being used in the critical care and have direct bearing on the mortality and morbidity and cost of treatment in the catheterized patients, regular surveillance needs to be undertaken for the formulation of appropriate infection control practices.
| ~ Acknowledgments|| |
We thank Dr. Abhiram Kasbe, Associate Professor, Department of Preventive and Social Medicine from T.N. Medical College, B.Y.L.Ch. Hospital, Mumbai, for his help in providing statistical analysis of our data.
| ~ References|| |
|1.||Rao S, Alladi A, Das K, Cruz AJ. Medium and long term central venous access in children. Indian Pediatr 2003;40:41-4. |
|2.||Sachdev A, Gupta D, Soni A, Chugh K. Central venous catheter colonization and related bacteremia in pediatric intensive care unit. Indian Pediatr 2002;39:752-60. |
|3.||Salzman MB, Rubin LG. Intravenous catheter related infections. Adv Pediatr Infect Dis 1995;10:337-68. |
|4.||National Nosocomial Infections Surveillance (NNIS) System report, data summary from January 1990 - May 1999, issued June 1999. Am J Infect Control 1999;27:520-32. |
|5.||Maki DG, Weise CE, Sarfin HW. A semiquantitative culture method for identifying intravenous catheter related infection. N Engl J Med 1977;296:1305-9. |
|6.||Winn WS, Allen SD, Janda WM, Konemam EW, Procop GW, Schreckenberger PC. Charts. In: Darcy P, Pterson N, Montalbano J, editors. Koneman's Color Atlas and Textbook of Diagnostic Microbiology. 6th Ed. Philadelphia: Lippincott; 1997. p. 1442-535. |
|7.||Clinical and Laboratory Standard Institute (CLSI): Performance standards for antimicrobial susceptibility testing. 18 th International Supplement. CLSI document M 100- 18. Wayne, Pennsylvania; 2008. |
|8.||Collignon PG, Soni N, Pearson IY, Woods WP, Munro R, Sorrell TC. Is semiquantitative culture of cenral vein catheter tips useful in the diagnosis of catheter associated bacteremia? J Clin Microbiol 1986;24:532-5. |
|9.||Center for Disease Control and Prevention. Reduction in central line associated bloodstream infections among patients in intensive care - Pennsylvania, April 2001 - March 2005. MMWR Morb Mortal Wkly Rep 2005;54:1013-6. |
|10.||Kokare CR, Chakraborty S, Khopade AN, Mahadik KR. Biofilm: Importance and Application. Indian J Biotechnol 2009;8:159-68. |
[Table 1], [Table 2]
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