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How Should Surveillance Systems Account for Concurrent Intravascular Catheters?

How Should Surveillance Systems Account for Concurrent Intravascular Catheters? Invited Commentary | Infectious Diseases Leonard A. Mermel, DO, ScM The risk of central venous catheter (CVC)-associated bloodstream infections has decreased Related article dramatically. The same may not be true for infections associated with short-term peripheral venous Author affiliations and article information are catheters. The effects of future preventive efforts should be measured using data derived from listed at the end of this article. evidence-based surveillance programs. Dube et al describe a multicenter, retrospective cohort study that assessed the risk of central line–associated bloodstream infection (CLABSI) associated with concurrent CVCs. Analyzing a propensity-adjusted cohort of 11 796 hospitalized patients by status of concurrent CVCs, the authors found that the likelihood of a patient developing CLABSI, after adjustment for confounders, was increased by 62% when they had 2 concurrent CVCs for more than two-thirds of their overall CVC dwell time. In a CVC survival analysis, the daily excess CLABSI risk associated with a concurrent CVC was approximately 80% after adjusting for confounders. Dube et al are not the first to measure the risk of CLABSI among patients with concurrent catheters; others have also found that concurrent catheters are independently associated with increased 3-9 CLABSI risk (Table). Regarding surveillance, adding concurrent CVC days to the denominator reduces the measured incidence of CLABSI. Concurrent CVC days are not accounted for in the US Table. Association of Concurrent Catheters With CLABSI Risk C-Ds, All Simultaneous C-Ds, All CVCs and C-Ds, Simultaneous Arterial Risk of Catheter Colonization Source Study Design 1CVC CVCs Catheters Risk of CLABSI or CLABSI 4 a a Aslakson et al, Single center, prospective, 485 745, PICCs 1293 NA NA 2011 cross-sectional study among excluded patients in the ICU Legriel et al, Single center, prospective, Yes No Yes NA Odds ratio, 30.3 (95% CI, 2011 cross-sectional study among 3.0-311.0) for simultaneous patients in the ICU presence of 3 catheters; odds ratio, 5.1 (95% CI, 1.7-14.9) for average number of catheters by exposure day during ICU stay Scheithauer et al, Single center, prospective, 14 080 22 944 NA Incidence rate ratio, 3.6 (95% CI, NA 2013 cross-sectional study among 2.6-5.1) for simultaneous presence patients in the ICU of >1 CVC; incidence rate ratio, 0.81 (95% CI, 0.79-0.83) when simultaneous CVC days included in denominator Concannon et al, Single center, case-control Yes Yes No Odds ratio, 3.4 (95% CI, 1.7-6.9) NA 2014 study for simultaneous presence of >1 CVC Talbot et al, Single center, retrospective 170 254 184 645 NA CLABSI rates decreased 4%-12% NA 2015 cohort study among patients in when simultaneous CVC days the ICU and not in the ICU included in denominator Couk et al, Multicenter, retrospective 156 574 180 950 Odds ratio, 5.8 (95% CI, 4.1-8.1) NA 2019 cohort study among patients in for concurrent CVC at any point the ICU and not in the ICU during hospitalization; CLABSI rates decreased 25% in ICU and 6% outside ICU when simultaneous CVC days included in denominator Dube et al, Multicenter, retrospective Yes Yes No Adjusted risk ratio, 1.62 (95% CI, NA 2020 cohort study among patients in 1.10-2.33) among patients with 2 the ICU and not in the ICU CVCs for more than two-thirds of their CVC days Abbreviations: C-D, catheter day; CLABSI, central line–associated bloodstream infection; Analysis performed with univariate analysis. CVC, central venous catheter; ICU, intensive care unit; NA, not applicable; PICC, c Analysis performed with Poisson regression. peripherally inserted central catheter. Analysis performed with multiple logistic regression. No CLABSIs noted during study. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(3):e200400. doi:10.1001/jamanetworkopen.2020.0400 (Reprinted) March 4, 2020 1/3 JAMA Network Open | Infectious Diseases How Should Surveillance Systems Account for Concurrent Intravascular Catheters? Centers for Disease Control and Prevention National Healthcare Safety Network; this may partially explain the higher incidence of CLABSI in some tertiary-care academic centers. Without adjustment for this important risk factor, these centers are more likely to incur financial penalties because CLABSI is a component of the formula used in the Hospital-Associated Condition Reduction Program. Based on the totality of data in the peer-reviewed literature, concurrent CVCs are a modifiable CLABSI risk factor and adding concurrent CVC days to the Centers for Disease Control and Prevention National Healthcare Safety Network surveillance system will help ensure hospitals are treated equally regarding this modifiable risk factor. However, this may have the unintended consequence of lowering the threshold to maintain such catheters when not absolutely necessary for patient care. Thus, it will be essential to raise awareness of the risk posed by concurrent CVCs. The study by Dube et al demonstrates that it is time to reassess our national surveillance program regarding CLABSI. The evidence is clear that concurrent CVCs must be accounted for. In a 2011 study, concurrent catheters included CVCs and arterial catheters; whether surveillance using concurrence should include CVCs and arterial catheters should be addressed in future investigations. Additionally, as we focus our prevention efforts on CLABSI, we should remember that all intravascular devices, including short-term peripheral venous catheters, pose a risk of life- threatening infection. Short-term peripheral venous catheters may pose an even greater threat, given that hospitals are pushed to remove CVCs to reduce CLABSI risk, but they do so by replacing CVCs with short-term peripheral catheters for many patients. It is hoped that future surveillance programs will include the risk to our patients from these catheters as well. ARTICLE INFORMATION Published: March 4, 2020. doi:10.1001/jamanetworkopen.2020.0400 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Mermel LA. JAMA Network Open. Corresponding Author: Leonard A. Mermel, DO, ScM, Division of Infectious Diseases, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 (lmermel@lifespan.org). Author Affiliations: Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Division of Infectious Diseases, Rhode Island Hospital, Providence; Department of Epidemiology and Infection Control, Rhode Island Hospital, Providence. Conflict of Interest Disclosures: Dr Mermel reported serving as a consultant or as a member of the scientific advisory committee of Leonard-Meron Biosciences, Citius Pharmaceuticals, Marvao Medical Devices, PuraCath Medical, Bard Access, and Nobio. REFERENCES 1. Weiner LM, Fridkin SK, Aponte-Torres Z, et al. Vital signs: preventing antibiotic-resistant infections in hospitals: United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(9):235-241. doi:10.15585/mmwr.mm6509e1 2. Mermel LA. Short-term peripheral venous catheter-related bloodstream infections: a systematic review. Clin Infect Dis. 2017;65(10):1757-1762. doi:10.1093/cid/cix562 3. Dube WC, Jacob JT, Zheng Z, et al. Comparison of rates of central line–associated bloodstream infections in patients with 1 vs 2 central venous catheters. JAMA Netw Open. 2020;3(3):e200396. doi:10.1001/jamanetworkopen. 2020.0396 4. Aslakson RA, Romig M, Galvagno SM, et al. Effect of accounting for multiple concurrent catheters on central line–associated bloodstream infection rates: practical data supporting a theoretical concern. Infect Control Hosp Epidemiol. 2011;32(2):121-124. doi:10.1086/657941 5. Legriel S, Mongardon N, Troché G, Bruneel F, Bédos JP. Catheter-related colonization or infection in critically ill patients: is the number of simultaneous catheters a risk factor? Am J Infect Control. 2011;39(1):83-85. doi:10.1016/ j.ajic.2010.07.012 6. Scheithauer S, Häfner H, Schröder J, et al. Simultaneous placement of multiple central lines increases central line–associated bloodstream infection rates. Am J Infect Control. 2013;41(2):113-117. doi:10.1016/j.ajic.2012.02.034 JAMA Network Open. 2020;3(3):e200400. doi:10.1001/jamanetworkopen.2020.0400 (Reprinted) March 4, 2020 2/3 JAMA Network Open | Infectious Diseases How Should Surveillance Systems Account for Concurrent Intravascular Catheters? 7. Concannon C, van Wijngaarden E, Stevens V, Dumyati G. The effect of multiple concurrent central venous catheters on central line–associated bloodstream infections. Infect Control Hosp Epidemiol. 2014;35(9):1140-1146. doi:10.1086/677634 8. Talbot TR, Johnson JG, Anders T, Hayes RM. Comparison of NHSN-defined central venous catheter day counts with a method that accounts for concurrent catheters. Infect Control Hosp Epidemiol. 2015;36(1):107-109. doi:10. 1017/ice.2014.7 9. Couk J, Chernetsky Tejedor S, Steinberg JP, Robichaux C, Jacob JT. Impact of multiple concurrent central lines on central-line-associated bloodstream infection rates. Infect Control Hosp Epidemiol. 2019;40(9):1019-1023. doi: 10.1017/ice.2019.180 10. Al Mohajer M, Joiner KA, Nix DE. Are teaching hospitals treated fairly in the hospital-acquired condition reduction program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.0000000000002399 JAMA Network Open. 2020;3(3):e200400. doi:10.1001/jamanetworkopen.2020.0400 (Reprinted) March 4, 2020 3/3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Network Open American Medical Association

How Should Surveillance Systems Account for Concurrent Intravascular Catheters?

JAMA Network Open , Volume 3 (3) – Mar 4, 2020

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References (12)

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American Medical Association
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Copyright 2020 Mermel LA. JAMA Network Open.
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2574-3805
DOI
10.1001/jamanetworkopen.2020.0400
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Abstract

Invited Commentary | Infectious Diseases Leonard A. Mermel, DO, ScM The risk of central venous catheter (CVC)-associated bloodstream infections has decreased Related article dramatically. The same may not be true for infections associated with short-term peripheral venous Author affiliations and article information are catheters. The effects of future preventive efforts should be measured using data derived from listed at the end of this article. evidence-based surveillance programs. Dube et al describe a multicenter, retrospective cohort study that assessed the risk of central line–associated bloodstream infection (CLABSI) associated with concurrent CVCs. Analyzing a propensity-adjusted cohort of 11 796 hospitalized patients by status of concurrent CVCs, the authors found that the likelihood of a patient developing CLABSI, after adjustment for confounders, was increased by 62% when they had 2 concurrent CVCs for more than two-thirds of their overall CVC dwell time. In a CVC survival analysis, the daily excess CLABSI risk associated with a concurrent CVC was approximately 80% after adjusting for confounders. Dube et al are not the first to measure the risk of CLABSI among patients with concurrent catheters; others have also found that concurrent catheters are independently associated with increased 3-9 CLABSI risk (Table). Regarding surveillance, adding concurrent CVC days to the denominator reduces the measured incidence of CLABSI. Concurrent CVC days are not accounted for in the US Table. Association of Concurrent Catheters With CLABSI Risk C-Ds, All Simultaneous C-Ds, All CVCs and C-Ds, Simultaneous Arterial Risk of Catheter Colonization Source Study Design 1CVC CVCs Catheters Risk of CLABSI or CLABSI 4 a a Aslakson et al, Single center, prospective, 485 745, PICCs 1293 NA NA 2011 cross-sectional study among excluded patients in the ICU Legriel et al, Single center, prospective, Yes No Yes NA Odds ratio, 30.3 (95% CI, 2011 cross-sectional study among 3.0-311.0) for simultaneous patients in the ICU presence of 3 catheters; odds ratio, 5.1 (95% CI, 1.7-14.9) for average number of catheters by exposure day during ICU stay Scheithauer et al, Single center, prospective, 14 080 22 944 NA Incidence rate ratio, 3.6 (95% CI, NA 2013 cross-sectional study among 2.6-5.1) for simultaneous presence patients in the ICU of >1 CVC; incidence rate ratio, 0.81 (95% CI, 0.79-0.83) when simultaneous CVC days included in denominator Concannon et al, Single center, case-control Yes Yes No Odds ratio, 3.4 (95% CI, 1.7-6.9) NA 2014 study for simultaneous presence of >1 CVC Talbot et al, Single center, retrospective 170 254 184 645 NA CLABSI rates decreased 4%-12% NA 2015 cohort study among patients in when simultaneous CVC days the ICU and not in the ICU included in denominator Couk et al, Multicenter, retrospective 156 574 180 950 Odds ratio, 5.8 (95% CI, 4.1-8.1) NA 2019 cohort study among patients in for concurrent CVC at any point the ICU and not in the ICU during hospitalization; CLABSI rates decreased 25% in ICU and 6% outside ICU when simultaneous CVC days included in denominator Dube et al, Multicenter, retrospective Yes Yes No Adjusted risk ratio, 1.62 (95% CI, NA 2020 cohort study among patients in 1.10-2.33) among patients with 2 the ICU and not in the ICU CVCs for more than two-thirds of their CVC days Abbreviations: C-D, catheter day; CLABSI, central line–associated bloodstream infection; Analysis performed with univariate analysis. CVC, central venous catheter; ICU, intensive care unit; NA, not applicable; PICC, c Analysis performed with Poisson regression. peripherally inserted central catheter. Analysis performed with multiple logistic regression. No CLABSIs noted during study. Open Access. This is an open access article distributed under the terms of the CC-BY License. JAMA Network Open. 2020;3(3):e200400. doi:10.1001/jamanetworkopen.2020.0400 (Reprinted) March 4, 2020 1/3 JAMA Network Open | Infectious Diseases How Should Surveillance Systems Account for Concurrent Intravascular Catheters? Centers for Disease Control and Prevention National Healthcare Safety Network; this may partially explain the higher incidence of CLABSI in some tertiary-care academic centers. Without adjustment for this important risk factor, these centers are more likely to incur financial penalties because CLABSI is a component of the formula used in the Hospital-Associated Condition Reduction Program. Based on the totality of data in the peer-reviewed literature, concurrent CVCs are a modifiable CLABSI risk factor and adding concurrent CVC days to the Centers for Disease Control and Prevention National Healthcare Safety Network surveillance system will help ensure hospitals are treated equally regarding this modifiable risk factor. However, this may have the unintended consequence of lowering the threshold to maintain such catheters when not absolutely necessary for patient care. Thus, it will be essential to raise awareness of the risk posed by concurrent CVCs. The study by Dube et al demonstrates that it is time to reassess our national surveillance program regarding CLABSI. The evidence is clear that concurrent CVCs must be accounted for. In a 2011 study, concurrent catheters included CVCs and arterial catheters; whether surveillance using concurrence should include CVCs and arterial catheters should be addressed in future investigations. Additionally, as we focus our prevention efforts on CLABSI, we should remember that all intravascular devices, including short-term peripheral venous catheters, pose a risk of life- threatening infection. Short-term peripheral venous catheters may pose an even greater threat, given that hospitals are pushed to remove CVCs to reduce CLABSI risk, but they do so by replacing CVCs with short-term peripheral catheters for many patients. It is hoped that future surveillance programs will include the risk to our patients from these catheters as well. ARTICLE INFORMATION Published: March 4, 2020. doi:10.1001/jamanetworkopen.2020.0400 Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Mermel LA. JAMA Network Open. Corresponding Author: Leonard A. Mermel, DO, ScM, Division of Infectious Diseases, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903 (lmermel@lifespan.org). Author Affiliations: Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island; Division of Infectious Diseases, Rhode Island Hospital, Providence; Department of Epidemiology and Infection Control, Rhode Island Hospital, Providence. Conflict of Interest Disclosures: Dr Mermel reported serving as a consultant or as a member of the scientific advisory committee of Leonard-Meron Biosciences, Citius Pharmaceuticals, Marvao Medical Devices, PuraCath Medical, Bard Access, and Nobio. REFERENCES 1. Weiner LM, Fridkin SK, Aponte-Torres Z, et al. Vital signs: preventing antibiotic-resistant infections in hospitals: United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(9):235-241. doi:10.15585/mmwr.mm6509e1 2. Mermel LA. Short-term peripheral venous catheter-related bloodstream infections: a systematic review. Clin Infect Dis. 2017;65(10):1757-1762. doi:10.1093/cid/cix562 3. Dube WC, Jacob JT, Zheng Z, et al. Comparison of rates of central line–associated bloodstream infections in patients with 1 vs 2 central venous catheters. JAMA Netw Open. 2020;3(3):e200396. doi:10.1001/jamanetworkopen. 2020.0396 4. Aslakson RA, Romig M, Galvagno SM, et al. Effect of accounting for multiple concurrent catheters on central line–associated bloodstream infection rates: practical data supporting a theoretical concern. Infect Control Hosp Epidemiol. 2011;32(2):121-124. doi:10.1086/657941 5. Legriel S, Mongardon N, Troché G, Bruneel F, Bédos JP. Catheter-related colonization or infection in critically ill patients: is the number of simultaneous catheters a risk factor? Am J Infect Control. 2011;39(1):83-85. doi:10.1016/ j.ajic.2010.07.012 6. Scheithauer S, Häfner H, Schröder J, et al. Simultaneous placement of multiple central lines increases central line–associated bloodstream infection rates. Am J Infect Control. 2013;41(2):113-117. doi:10.1016/j.ajic.2012.02.034 JAMA Network Open. 2020;3(3):e200400. doi:10.1001/jamanetworkopen.2020.0400 (Reprinted) March 4, 2020 2/3 JAMA Network Open | Infectious Diseases How Should Surveillance Systems Account for Concurrent Intravascular Catheters? 7. Concannon C, van Wijngaarden E, Stevens V, Dumyati G. The effect of multiple concurrent central venous catheters on central line–associated bloodstream infections. Infect Control Hosp Epidemiol. 2014;35(9):1140-1146. doi:10.1086/677634 8. Talbot TR, Johnson JG, Anders T, Hayes RM. Comparison of NHSN-defined central venous catheter day counts with a method that accounts for concurrent catheters. Infect Control Hosp Epidemiol. 2015;36(1):107-109. doi:10. 1017/ice.2014.7 9. Couk J, Chernetsky Tejedor S, Steinberg JP, Robichaux C, Jacob JT. Impact of multiple concurrent central lines on central-line-associated bloodstream infection rates. Infect Control Hosp Epidemiol. 2019;40(9):1019-1023. doi: 10.1017/ice.2019.180 10. Al Mohajer M, Joiner KA, Nix DE. Are teaching hospitals treated fairly in the hospital-acquired condition reduction program? Acad Med. 2018;93(12):1827-1832. doi:10.1097/ACM.0000000000002399 JAMA Network Open. 2020;3(3):e200400. doi:10.1001/jamanetworkopen.2020.0400 (Reprinted) March 4, 2020 3/3

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JAMA Network OpenAmerican Medical Association

Published: Mar 4, 2020

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