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Central venous catheter-related bloodstream infection and colonization: the impact of insertion site and distribution of multidrug-resistant pathogens

Central venous catheter-related bloodstream infection and colonization: the impact of insertion... Background: Placement of central-venous catheters (CVCs) is an essential practice in the management of hospital- ized patients, however, insertion at the commonly used sites has often the potential of inducing major complications. Neverthelss, the impact of specific site central line catheter insertion on catheter-associated bloodstream infections (CLABSIs) has not been clarified yet in the literature. Objective: The aim of the study was to compare CLABSIs and catheter colonization rates among the three catheter insertion sites: subclavian (SC), internal jugular (IJ ) and femoral (FEM) in hospitalized patients. Moreover, to analyze the distribution of pathogens and their antimicrobial resistance profiles at these three sites, concurrently. Methods: We performed a retrospective analysis of data collected prospectively from all catheterized patients at a tertiary care Greek hospital from May 2016 to May 2018. Data was collected on 1414 CVCs and 13,054 CVC-days. Results: Τhe incidence of CLABSIs among the three sites was as follows: SC:5.1/1000 catheter/days, IJ: 3.73/1000 catheter/days and FEM: 6.93/1000 catheter/days (p = 0.37). The incidence of colonization was as follows: SC:13.39/1000 catheter/days; IJ:7.34/ 1000 catheter/days; FEM:22.91/1000 catheter/days (p = 0.009). MDROs pre- dominated in both CLABSIs and tip colonizations (59.3 and 61%, respectively) with Acinetobacter baumanii being the predominant pathogen (16/59, 27.1% and 44/144, 30.5%, respectively). The incidence of CLABSIs due to multidrug- resistant organisms (MDROs) was as follows: SC:3.83/1000 catheter days; IJ:1.49/1000 catheter days; FEM:5.86/1000 catheter days (p = 0.04). The incidence of tip colonization by MDROs among the 3 sites was as follows: SC:8.93/1000 catheter/days; IJ:4.48/1000 catheter/days; FEM:12.79/1000 catheter/days (p = 0.06). There was no significant difference in the type of pathogen isolated among site groups for both CLABSIs and tip colonizations. Conclusions: FEM site of catheter insertion was associated with a higher rate of bloodstream infection and catheters’ colonization compared to IJ and SC sites. Furthermore, this survey highlights the changing trend of the distribution of frequent pathogens and resistance patterns towards MDR Gram-negative pathogens, underscoring the need for consistent monitoring of antimicrobial resistance patterns of these specific infections. *Correspondence: atsakris@med.uoa.gr Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527 Athens, Greece Full list of author information is available at the end of the article © The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat iveco mmons .org/licen ses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Pitiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 2 of 8 Keywords: Catheterization, Central venous catheter, Sepsis, Colonization, Bloodstream infection, Insertion site, Catheter Introduction Wayne, USA), are mainly used in our hospital. They are Bloodstream infections (BSI) are a significant cause of preferred exclusively for critically ill patients of ICU due morbidity and increased mortality in healthcare facilities; to their three infusion channels that facilitate the deliv- they are also attributed to an increased length of stay and ery of several parenteral medications and fluids simul - escalating costs [1].Central-line catheter use is a major taneously, but also in the others than ICU units. Double ® ® risk factor for bloodstream infections [2] with more than lumen catheters (Arrow /Teleflex , Wayne, USA), are 250,000 cases of hospital-acquired central line associated also used but in a smaller percentage, particularly in bloodstream infections (CLABSIs) within the United patients that do not require complex therapeutic inter- States annually [3]. Several factors, such as those related ventions. Catheters were inserted at optimal sites. The to the patient (i.e. immunodeficiency, renal replacement choice of the site of insertion was left to the discretion therapy), central-venous catheter (CVC) use (prolonged of the physician caring for the patient. The operators catheterization, type of catheter material, and anatomical were proficient in accessing all three sites. Maximal ster - site of catheter insertion), and healthcare practice (poor ile barrier precautions (large sterile drape; surgical hand barrier methods during catheter insertion and handling) antisepsis; and mask, cap, sterile gloves, and gown) were have been shown to increase the risk of CVC infection used at catheter insertion according to CDC recom- [4]. Regarding the anatomical site of insertion, the actual mendations. Catheters were immediately removed if no risk of infection at the three most commonly used inser- longer needed, or if a catheter-related infection (CRI) tion sites: subclavian (SC), internal jugular (IJ) and femo- was suspected. ral (FEM), remains controversial. Indeed, although earlier studies supported that FEM site access was associated Catheter care with a higher risk of infections, previous studies reported Standardized CVC care was achieved by a highly trained no significant differences in the rate of CLABSIs between nursing staff proficient in all aspects of CVC care. All these three sites, provided that all precaution measures insertion sites were maximally visualized for potential are constantly implemented throughout the hospital dressing contamination. Every couple of days or earlier settings [5]. Furthermore, while it has been suggested if clinically required, the nursing staff changed the dress - that anatomical insertion site may influence the type of ing, cleaned the skin site and the catheter hub with iodine bacteria isolated from catheter tip culture as a cause of solution, and changed the intravenous accessory tubing. CLABSI [6], no studies have compared the three sites in Furthermore, the nursing staff independently enforced terms of the pathogen distribution and resistance profiles sterile insertion technique. of microorganisms isolated. The objective of the present study was to compare Data collection CLABSIs and catheter tip colonization rates among the After insertion, catheters were checked using a check-box three insertion sites in central line catheterized patients form containing the patient’s diagnosis, operator’s name, as well as to analyze and compare distribution of patho- site chosen,date placed and removed, date of intensive gens and resistance profiles among the three groups. care units (ICU) discharge or death, mechanical ventila- tion, arterial catheters, parenteral nutrition, vasopressor Methods support, and daily clinical assessment (e.g., induration, We performed a retrospective analysis of data collected discharge, erythema, and tenderness) of possible catheter prospectively from consecutive admissions to Metropoli- infection. The operator inserting the catheter entered the tan Hospital, a tertiary care hospital in Athens, covering initial data; nurse personnel entered data the following a 24-month period from May 2016 to May 2018. This days while the infection control nurse monitored data observational study was approved by the institutional collection 3–4 times per week. review board. We retrospectively collected study data from three dif- ferent sources where information was completed: 1) ICU database (for demographic and clinical data related to the Selection of insertion sites patient’s admission and clinical course); 2) and 3) Clinical Triple lumen, non-antibiotic impregnated catheters Laboratory and hospital infection control team database ® ® (Arrow model,total provided by Arrow /Teleflex , (for blood culture and antibiotic susceptibility results). P itiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 3 of 8 Indications for catheter removal Catheter/days was defined as the number of CVCs CVCs were removed when a) there was a suspicion of presents among all units’ patients at 08:00 h each morn- infection, b) when the catheter was no longer required, ing. When more than one concurrent CVC was present and c) after 15 days of insertion. Fifteen days’ duration in the patient, they were counted as one CVC. is our institutional policy to avoid catheter infection Primary bloodstream infection was confirmed if either from excess catheter duration [7]; the duration is based criterion 1 or criterion 2 were satisfied: on the incidence of CVC infection from the institu- tion’s infection control program. Occasionally, CVCs 1 Patient had a recognized pathogen cultured from one remained more than 15 days if the risk of obtaining new or more blood cultures venous access was higher than leaving the current CVC 2 If the organism cultured was considered a common in place. skin contaminant (Diphtheroids, Bacillus species, coagulase-negative Staphylococcus or Micrococcus) and patient had at least one of the following signs or Culture techniques symptoms: fever (38 °C) or hypotension and positive All catheters were examined for the presence of patho- laboratory results were not related to an infection at gens either as a routine after removal or after suspicion another site, and at least one of the following: of infection. After disinfecting skin around the CVC entry site, the proximal 4–5 cm part of the tip was cut • Organism cultured from two or more blood cul- off using sterile scissors. The specimen was placed in tures drawn on separate occasions. a sterile container and transported to the microbiol- • Organism cultured from at least one blood cul- ogy laboratory within 15 min at room temperature. The ture from a patient with an intravascular line, and intradermal and intravascular portion of the catheter the physician instituted appropriate antimicrobial was analyzed by the semiquantitative culture technique therapy. described by Maki et  al. [8]. According to Maki’s tech- nique, catheter-tip culture is considered positive in the The clinical status of the patients was assessed daily presence of ≥15 colony-forming units (CFU) growth of by on-site attendings. The insertion sites were exam - any organism. Blood cultures were incubated in Becton ined routinely as part of the clinical assessment. Poten- Dickinson Bactec (BD Bio-sciences, USA) in aerobic tial CVC infection was considered any time an infection and anaerobic broth media. Identification of isolates occurred. and antimicrobial resistance patterns were determined by the VITEK 2Automated Compact System (BioMé- Statistical analysis rieux Co., France). E-test (BioMérieux Co., France) was Characteristics of patients and catheters were described performed as an additional test, in order to confirm as count (percent) or mean value (+/− standard devia- the resistance phenotypes reported by the VITEK Sys- tion) for qualitative and quantitative variables, respec- tem, according to the standard laboratory procedures. tively, and were compared between the three catheters Multidrug-resistant organisms (MDROs) were defined groups using Chi-square or T-test, as appropriate. Non- as species of microorganisms that exhibit antimicrobial normally distributed quantitative variables were resistance to at least one antimicrobial drug in three or expressed as median (interquartile range). The one-way more antimicrobial categories. This definition concerns ANOVA test was used to determine the existence of both gram-positive and gram-negative bacteria [9]. statistical significant difference in CLABSIs, coloni - zation rates, catheter duration at the three insertion Evaluation of CVC infection sites. A p-value of ≤0,05 was considered as statistically The definitions of catheter infection and colonization significant. are based on the Centers for Disease Control blood- stream infection guidelines and the semiquantitative Results culture technique by Maki et al. [8]. A total of 13,054 catheter days and 1414 catheters were Catheter associated BSI (CLABSI) was defined as a analyzed. Of them, 249 (3136 catheter days) were of SC laboratory confirmed BSI (a positive blood culture with site, 945 (8041 catheter days) of IJ site and 220 (1877 no other apparent source of infection) occurring in the catheter days) of FEM site. The mean duration of cath - presence of a CVC or within 48 h of CVC removal. eterization was 12.59 ± 8.32 [95% CI 11.6 to13.6] days for Catheter colonization: The presence of ≥ 15 CFU of SC sites, 8.51 ± 6.45 (95% CI 7.59 to 8.41) days for IJ sites a single organism per catheter if not accompanied by a and 8.53 ± 8.13(95% CI 6.93 to 9.07) days for FEM sites laboratory confirmed BSI of the patient. (p = 0.03, ANOVA). The overall incidence of CLABSIs Pitiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 4 of 8 was 5.32/1000 catheter days, and the overall catheter col- 16.1 ± 10.7 days in CLABSIs cases and 14. ± 9.7 days in onization rate was 12.48/1000 catheter days. colonization cases. In 47.45% (28/59) of CLABSIs cases The distribution of CLABSIs events among hospital and 34.7% (50/144) of colonization cases the duration of units was as follows: 25/59 (43%) in ICU; 20/59 (35%) catheterization was ≥15 days. in internal medicine department; 14/59 (19%) in other A higher incidence of CLABSIs was observed in units. The distribution of catheter colonizations among catheters of FEM site as compared to the other 2 sites, hospital units was 62/144 (37%) for ICU, 42/144 (29%) for although not in a statistically significant level. More spe - internal medicine department, 40/144 (12%) for others. cifically, the incidence of CLABSIs among the 3 sites The total patients’ demographic characteristics in cases was as follows: SC:5.1 infections per 1000 catheter days, of CLABSIs and tip colonization are presented in Table 1. IJ:3.73 infections per 1000 catheter days, and FEM:6.93 The 3 groups of patients with different catheter insertion infections per 1000 catheter days (p = 0.37; ANOVA). sites had equally distributed demographic characteristics Regarding catheter colonization, a higher incidence and severity of illness (as defined by APACHI score; data of infection was also observed in FEM catheters com- not shown). pared to the other sites that was established in a statisti- The median length of stay prior to central line inser - cally significant level. More specifically, the incidence of tion was 16 days (Interquartile range = 55) in CLABSIs by colonization was as follows: SC:13.39 per 1000 catheter MDROs and 25 days (Interquartile range = 57) in CLAB- days; IJ:7.34 per 1000 catheter days; and FEM:22.91 per SIs by other pathogens (p = 0.13). In tip colonizations, the 1000 catheter days (p = 0,009; ANOVA) (Table  2). Simi- median length of stay prior to central line insertion was larly, the incidence of CLABSIs and tips colonization 10 days (Interquartile range = 36.75) in MDROs cases and from MDROs was higher in FEM site as compared to 14 days (Interquartile range = 64.25) in cases where other the others. More specifically, the incidence of CLABSIs pathogens were involved (p = 0.40). The mean dura - by MDROs was as follows: SC: 3.83 infections per 1000 tion of catheterization until the onset of infection was catheter days; IJ:1.49 per 1000 catheter days; FEM:5.86 Table 1 Study populations’ demographic and clinical characteristics VARIABLE No of patients CLABSI (n = 59) N (%) Colonization (n = 144) N (%) Age, mean +/− SD, (years) 55.08 +/− 19.8 53.9 +/− 17.9 Gender (M/F) 41/18 100/44 Obesity 19 (32.2) 84 (58.3) Diabetes mellitus 9 (15.2) 67 (46.5) Pulmonary disease 16 (27.1) 48 (33.3) Hypertension 11 (18.6) 75 (52) Renal disease 17 (28.8) 15 (10.4) Oncologic disease 16 (27.1) 36 (25) Immune deficiency/suppression 17 (28.8) 33 (22.9) Admission category Medical 43 (72.8) 87 (60.4) Surgery 16 (27.1) 57 (39.6) Mechanical ventilation 37 (62.7) 105 (72.9) Unit of cath insertion (ICU/other) 38/21 97/48 Cardiovascular disease 17 (28.8) 49 (34) Neurological disease 38 (64.4) 29 (20.1) Gastroenterological disease 18 (30.5) 27 (18.7) Hospital death 19 (32.2) 42 (29.1) Sepsis 11 (18.6) 29 (20.1) APACHE score 12.8+/− 8.2 13.2 +/− 7.4 Length of catheter stay (mean +/− SD) 16.19+/−10.7 14.05+/− 9.7 No number of catheters P itiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 5 of 8 Table 2 CLABSI and  tip colonization rates among  the  3 Pseudomonas aeruginosa and Klebsiella pneumoniae and sites of catheterization two isolates of Proteus mirabilis. In CLABSIs the types of pathogens were as follows: In FEM: 10 (76.9%) Gram- SC IJ FEM P–value negatives, 2 (15.4%) Gram-positives and one (7.7%) yeast; TOTAL ISOLATES in IJ: 16 (53.3%) Gram-negatives, 10 (33.3%) Gram-pos- CLABSI (No) 16 30 13 X = 6.53 p = 0.03 itives and 4 (13.3%) yeasts; in SC; 12 (75%) Gram-nega- Per 1.000 catheter/ 5.1 3.73 6.93 ANOVA F = 1.06 p = 0.37 tives, 3 (18.7%) Gram-positives and one (6.2%) yeast. In days tips colonization the types of pathogens were as follows: Tip colonization (No) 42 59 43 X = 38.74, p = 0.000 In FEM: 32 (74.4%) Gram-negatives, 5 (11.6%) Gram- Per 1.000 catheter/ 13.39 7.34 22.91 ANOVA F = 6.23 p = 0.009 positives and 6 (13.9%) yeasts; in IJ: 48 (81.3%) Gram- days negatives, 5 (8.4%) Gram-positives, 5 (8.4%) yeasts; in MDROs 2 SC: 31 (73.8%) Gram-negatives, 5 (11.9%) Gram-positives CLABSI (No) 12 12 11 X = 16.14, p = 0.000 and 6 (14.3%) yeasts (Table 4). Per 1000 catheter/ 3.83 1.49 5.86 ANOVA F = 3.66 p = 0.04 days Tip colonization (No) 28 36 24 X = 24.59, p = 0.000 Discussion Per 1000 catheter/ 8.93 4.48 12.79 ANOVA F = 3.05 p = 0.06 The present study has shown that CLABSIs and catheter days tip colonization rates are differing among the three com - p≤ 0.05 significant monly used CVC insertion sites. Indeed, a significantly increased rate of colonization, as well as a trend towards increased rate of CLABSIs in the FEM site were observed per 1000 catheter days (p = 0.04; ANOVA) (Table 2). The in comparison to the other two sites. Notably, although incidence of colonization by MDROs among the three most CVCs were inserted via the IJ vein (66.8%), yet their sites was as follows: SC:8.93 per 1000 catheter days; contribution to CLABSIs was the lowest. IJ:4.48 per 1000 catheter days; FEM:12.79 per 1000 cath- In the literature conflicting data exist regarding the eter days (p = 0.06; ANOVA) (Table  2). No significant risk of acquiring infection for the three sites of catheteri- difference in the proportion of MDROs associated with zation, with studies supporting higher risk at the FEM colonization (88/144 = 61%) vs infection (35/59 = 59.3%) site and lower at the SC [10], while others reporting no was observed (p = 0.91, Pearson chi-square). difference [11, 12]. The latter was found even in studies The duration (in days) of catheterization until the conducted in immunocompetent patients when optimal onset of infection was not statistically different among insertion sites are selected, experienced operators insert the 3 insertion sites with regards to CLABSIs in total the catheters, strict sterile technique is present, and (p = 0.77, ANOVA) and CLABSIs from MDROs trained intensive care unit nursing staff perform catheter (p = 0.83, ANOVA). In tip colonization longer catheter care. Furthermore, in a multicenter study where patients duration was observed in SC insertion site as compared were catheterized through FEM or SC site, CVC place- to the other two (p = 0.002 ANOVA) (Table  3). Simi- ment in the FEM area was associated with a substantially larly, no differences in age were observed between the greater risk of CLABSI compared to the SC insertion [13]. 3 sites with regards to CLABSIs from MDROs (p = 0.14 In a recent survey, insertion into the FEM and IJ vein was ANOVA), while patients with SC catheters were signifi - independently associated with an increasing risk of sub- cantly younger than those with IJ or FEM catheters in sequent CLABSI [14], while in another, the SC site was tip colonizations and CLABSIs in total (p = 0.002 and associated with the lowest risk of infection when com- p = 0.001 respectively ANOVA) (Table  3). No difference pared to the other two sites [15]. Since it is well known in tip colonization rates of the 3 sites was noted between that the risk of catheter infections is in part related to the males and females, while CLABSIs in IJ site were more density of local skin flora [16], FEM site carries obvious frequent in females compared to males (p < 0,004 Pearson sources of contamination from groin secretions. There - chi-square) (Table 3). fore, many of the clinical practice guidelines recommend A total of 18 different microorganisms were respon - that the FEM site should be avoided due to the perceived sible for the 144 CVC tip colonization’s while in CLAB- higher risk of CLABSIs associated with this site [17]. SIs a total of 12 different microorganisms were isolated. However, the preferred site for placement of a CVC is Microorganisms involved in the 3 types of catheters’ complex and based on the skill and expertise of the oper- infection/colonization are presented in Table  4. There ator, the availability and expertise of ultrasound-guided was no significant difference in the type of pathogen iso - placement, the risk of bleeding and other complications lated between the site groups for both CLABSIs and tip (pneumothorax), as well as the urgency of placement. In colonizations. MDROs included Acinetobacter baumanii, emergent and high-risk situations, the FEM route is often Pitiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 6 of 8 Table 3 Duration of catheter stay, age of patients and gender proportions among the 3 sites of catheterization N Mean Std. Deviation 95% confidence interval P-value CLABSIs Duration Lower Bound Upper Bound FEM 13 15.23 16.13 5.48 24.98 0,77 IJ 30 15.73 8.31 12.63 18.84 SC 16 17.81 10.1 12.43 23.19 Age FEM 13 58.23 21.71 45.11 71.35 0.001 IJ 30 61.73 16.75 55.48 67.99 SC 16 40.06 16.24 31.41 48.72 TIP COLONIZATION Duration FEM 43 11.42 11.1 8.00 14.84 0.002 IJ 59 12.85 7.84 10.80 14,89 SC 42 18.43 9.56 15.45 21.41 Age FEM 43 56.74 19.70 50.68 62.81 0.002 IJ 59 57.61 16.45 53.32 61.9 SC 42 45.79 15.85 40.85 50.73 MDROs in CLABSI Duration FEM 11 14.4 15.43 3.36 25.44 0.83 IJ 12 13.67 7.59 8.84 18.49 SC 12 16.56 8.6 9.94 23.17 Age FEM 11 57.7 21.84 42.07 73.33 0.14 IJ 12 64.08 16.53 53.57 74.59 SC 12 47.44 16.4 34.84 60.05 Gender SC n (%) IJ n (%) FEM n (%) P-value CLABSI Male 11 (26.8) 15 (36.6) 15 (36.6) 0.004 Female 2 (11.1) 15 (83.3) 1 (5.6) Tip Colonization Male 31 (31.3) 36 (36.4) 32 (32.2) 0.23 Female 12 (26.7) 23 (51.1) 10 (22.2) n number; p≤ 0.05 significant chosen due to the ease and perceived lower insertion risk organisms of significantly greater virulence may be of this site [18]. responsible. In our study, Gram-negative pathogens and especially According to the international CLABSI pathogen dis- MDROs predominated in CLABSIs as well in catheter tribution patterns published in several previous  stud- colonization, followed by Gram-positive and yeast infec- ies, the microorganisms causing CRIs usually belong to tions, with MDR A. baumanii being the predominant the normal resident flora of the skin at the insertion site, pathogen (16/59, 27.1% and 44/144, 30.5%, respectively). mainly Gram-positives such as Staphylococcus aureus, The results are  also suggesting that the FEM site carries Staphylococcus epidermidis, Streptococcus spp., Enteroc- a greater risk of infection than either the IJ or SC sites coccus spp., Corynebacterium spp., and fungi such as for organisms other than coagulase-negative staphylo- Candida spp. [19–21]. However, recently published data cocci. This may have some  implications for treatment have revealed that CVC infections by Gram-negatives of suspected CLABSI arising from the FEM site where either predominated in terms of pathogen distribution P itiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 7 of 8 Table 4 Pathogen distribution among tip colonizations and CLABSIs CLABSIs n (%) TIP COLONIZATION n (%) SC IJ FEM SC IJ FEM Gram-negative bacteria MDR K. pneumoniae 5/31.2 2/6.6 6/46.1 9/21.4 10/16.9 8/18.6 MDR A. baumannii 2/12.5 10/33.3 4/30.7 13/30.9 19/32.2 12/27.9 MDR P. aeruginosa 3/18.7 – – 5/11.9 4/6.7 3/6.9 MDR P. mirabilis – – – – 1/1.6 1/2.3 Non-MDR K. pneumoniae – – – 1/2.3 1/1.6 1/2.3 Non-MDR P. aeruginosa – 1/3.3 – 1/2.3 5/8.4 1/2.3 E. coli – – – 1/2.3 4/6.7 4/9.3 Gram-positive bacteria Coagulase-negative staphylococci 1/6.2 8/26.6 1/7.6 2/4.7 2/3.3 4/9.3 Methicillin-resistant S. aureus (MRSA) 2/12.5 – 1/7.6 1/2.3 2/3.3 – Enterococcus spp. – 2/6.6 – 1/2.3 1/1.6 – Yeasts Candida spp. 1/6.2 4/13.3 1/7.6 6/14.2 5/8.4 6/13.9 Other bacteria 2/12.5 3/10 – 2/4.7 4/6.7 2/4.6 n number or showed increasing trends [22–24]. In our study the sites, we have made an attempt to search for potential pathogen distribution of catheter infections follows the reasons to justify the longer SC catheter duration com- recently reported Greek ICU profile of central line colo - pared to the other two sites, however, based on the exist- nization and infection pathogens, where the incidence of ing data, we have not reached any definite conclusion. A. baumanii is high, possibly due to the local predomi- nance of Gram-negative microorganisms [25]. The emer - gence of MDR bacteria has created a new burden on Conclusion medical care in Greek hospitals, particularly for patients The findings of the present study support that IJ and SC admitted to ICU [25]. This fact, might have  contrib - insertion sites are safer to use compared to the FEM site uted to the domination of these pathogens in the micro- as concerns  both CLABSIs and catheter colonizations. bial profile of catheter infection  in the current study. Moreover, a significant shift in the epidemiology of Indeed, in our institute, the rates of the 3 most commonly CRIs towards a predominance of Gram-negative patho- isolated MDR Gram-negatives (61% A. baumanii, 25% K. gens and especially MDROs was observed. Since  MDR pneumoniae, 14% P. aeruginosa) for the same time period Gram-negative infections are linked to  significant was 21.6% among hospitalized  patients for all clinical mortality  rates, empirical treatment should take  their specimens, 63.3% of which were isolated from ICU (data increasing prevalence into consideration. not shown). Moreover, 43% of CLABSIs by MDROs and 59% of colonizations by MDROs were recovered from Abbreviations ICU patients, whereas all patients from other units had a CLABSI: Catheter associated blood stream infection; CRI: Catheter-related history of prior admission to an ICU before the isolation infection; CVC: Central-venous catheters; FEM: Femoral; IJ: Internal jugular; MDRO: Multidrug-resistant organism; SC: Subclavian. of MDROs. In addition, it should be also noted that in a significant proportion  of CRIs (47.45% of CLABSIs and Acknowledgements 34.7% of colonization cases) the duration of catheteriza- Authors acknowledge the contribution of the hospital healthcare work- ers who participated in this study. We would also like to acknowledge the tion was ≥15 days. This is  a highly contributing factor significant contribution of Pavlos Mariatos, Director of Quality Management for catheter infection and colonization that should be Department. acknowledged. On the contrary, as concerns the length of Authors’ contributions hospital stay prior to central line insertion, no evidence VP, PK, GS, AT designed and set up methodology, PK, IB, EK, IS performed the from our analysis has proven  that it consists a causative study, VP, PK, IB, GS, AT analyzed the data, all authors contributed to read and agent for the colonization by MDROs. In terms of the approved the final manuscript. differences in catheterization duration among the three Funding No specific funding was received for this study. Pitiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 8 of 8 Availability of data and materials catheter-associated infection risk reduction in critically ill adults. Crit Care All data generated or analysed during this study are included in this published Med. 2012;40:1627–34. article. 12. Reyes JA, Habash ML, Taylor RP. FEM central venous catheters are not associated with higher rates of infection in the pediatric critical care Ethics approval and consent to participate population. Am J Infect Control. 2012;40(1):43–7. This study has been approved by the ethical committee of Metropolitan 13. Arvaniti K, Lathyris D, Blot S, Apostolidou-Kiouti F, Koulenti D, Haidich AB. Hospital review board. Cumulative evidence of randomized controlled and observational stud- ies on catheter-related infection risk of central venous catheter insertion Consent for publication site in ICU patients: a pairwise and network meta-analysis. Crit Care Med. Not applicable. 2017;45(4):e437–48. 14. Van der Kooi TI, Wille JC, van Benthem BH. Catheter application, insertion Competing interests vein and length of ICU stay prior to insertion affect the risk of catheter- The authors declare that they have no competing interests. related bloodstream infection. J Hosp Infect. 2012;80(3):238–44. 15. Parienti JJ, et al. Intravascular complications of central venous catheteriza- Author details tion by insertion site. N Engl J Med. 2015;373(13):1220–9. Department of Microbiology, Medical School, National and Kapodistrian Uni- 16. Wolf HH, Leithäuser M, Maschmeyer G, Salwender H, Klein U, Chaberny versity of Athens, 75 Mikras Asias Street, 11527 Athens, Greece. Department I, et al. Infectious diseases working party (AGIHO) of the German Society of Internal Medicine, Metropolitan Hospital, 9 Ethnarchou Makariou Street, of Hematology and Oncology (DGHO): central venous catheter-related 18547 Athens, Greece. infections in hematology and oncology: guidelines of the infectious diseases working party (AGIHO) of the German Society of Hematology Received: 8 April 2020 Accepted: 18 November 2020 and Oncology (DGHO). Ann Hematol. 2008;87:863–76. 17. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. 2011 https ://www.cdc.gov/ infec tionc ontro l/guide lines /BSI/index .html. 18. Health Protection Surveillance Center. Prevention of intravascular catheter-related Infection in Ireland. Available at: http://www.hpsc.ie/ References hpsc/A-Z/Micro biolo gyAnt imicr obial Resis tance /Infec tionC ontro landH AI/ 1. Al-Rawajfah OM, Hewitt JB, Stetzer F, Cheema J. Length of stay and Guide lines /File,4115,en.pdf. charges associated with health care-acquired bloodstream infections. Am 19. The Joint Commission. Preventing central line–associated bloodstream J Infect Control. 2012;40:227–32. infections: a global challenge, a global perspective. Oak Brook: Joint 2. Hollenbeak CS. The cost of catheter-related bloodstream infections: Commission Resources; 2012. implications for the value of prevention. J Infus Nurs. 2011;34(5):309–13. 20. See I, Freifeld AG, Magill SS. Causative organisms and associated 3. O’Grady NP, Alexander M, Dellinger EP, Burns LA, Garland J, Heard SO, antimicrobial resistance in healthcare-associated central line-associated et al. Guidelines for the prevention of intravascular catheter-related infec- bloodstream infections from oncology settings, 2009–2012. Clin Infect tions. Atlanta: Centers for Disease Control and Prevention; 2011. Dis. 2016;62(10):1203–9. 4. Lutwick L, Al-Maani AS, Mehtar S, Memish Z, Rosenthal VD, Dramowski 21. Wright MO, Decker SG, Allen-Bridson K, Hebden JN, Leaptrot D. A, Lui G, Osman T, Bulabula A, Bearman G. Managing and preventing Healthcare-associated infections studies project: an American Journal of vascular catheter infections: a position paper of the international society Infection Control and National Healthcare Safety Network data quality for infectious diseases. Int J Infect Dis. 2019;84:22–9. collaboration: location mapping. Am J Infect Control. 2018;46(5):577–8. 5. Marik PE, Flemmer M, Harrison W. The risk of catheter-related blood- 22. Marcos M, Soriano A, Iñurrieta A, Martínez JA, Romero A, Cobos N, et al. stream infection with FEM venous catheters as compared to SC and IJ Changing epidemiology of central venous catheter-related bloodstream venous catheters: a systematic review of the literature and meta-analysis. infections: increasing prevalence of gram-negative pathogens. J Antimi- Crit Care Med. 2012;40(8):2479–85. crob Chemother. 2011;66:2119–25. 6. Lorente L, Jimenez A, Iribarren JL, Jimenez JJ, Martin MM, Mora ML. 23. Weiner LM, Webb AK, Limbago B, Dudeck MA, Patel J, Kallen AJ, Edwards The micro-organism responsible for central venous catheter related JR, Sievert DM. Antimicrobial-resistant pathogens associated with health- bloodstream infection depends on catheter site. Intensive Care Med. care-associated infections: summary of data reported to the National 2006;32:1449–50. Healthcare Safety Network at the Centers for Disease Control and Preven- 7. Ling ML, Apisarnthanarak A, Jaggi N, Harrington G, Morikane K, Thu LTA, tion, 2011-2014. Infect Control Hosp Epidemiol. 2016;37(11):1288–301. et al. APSIC guide for prevention of central line associated bloodstream 24. Lin KY, Cheng A, Chang YC, Hung MC, Wang JT, Sheng WH, et al. Central infections (CLABSI). Antimicrob Resist Infect Control. 2016;5:16. line-associated bloodstream infections among critically-ill patients in the 8. Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for era of bundle care. J Microbiol Immunol Infect. 2017;50:339–48. identifying intravenous-catheter-related infection. New Engl J Med. 25. Arvaniti K, Lathyris D, Clouva-Molyvdas P, Haidich AB, Mouloudi E, Syn- 1977;296:1305–9. nefaki E, et al. Comparison of Oligon catheters and chlorhexidine-impreg- 9. Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, exten- nated sponges with standard multilumen central venous catheters for sively drug-resistant, and pandrug-resistant bacteria: an international prevention of associated colonization and infections in intensive care expert proposal for interim standard definitions for acquired resistance. unit patients: a multicenter, randomized, controlled study. Crit Care Med. Clin Microbiol Infect. 2012;18:268–81. 2012;40(2):420–9. 10. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, Pettis AM, Rupp E, Sandora T, Maragakis LL, Yokoe DS. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: Publisher’s Note 2014 update. Infect Control Hosp Epidemiol. 2014;35(2):89–107. Springer Nature remains neutral with regard to jurisdictional claims in pub- 11. Parienti JJ, du Cheyron D, Timsit JF, Traoré O, Kalfon P, Mimoz O, Mermel lished maps and institutional affiliations. LA. Meta-analysis of SC insertion and non tunneled central venous http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Antimicrobial Resistance & Infection Control Springer Journals

Central venous catheter-related bloodstream infection and colonization: the impact of insertion site and distribution of multidrug-resistant pathogens

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Abstract

Background: Placement of central-venous catheters (CVCs) is an essential practice in the management of hospital- ized patients, however, insertion at the commonly used sites has often the potential of inducing major complications. Neverthelss, the impact of specific site central line catheter insertion on catheter-associated bloodstream infections (CLABSIs) has not been clarified yet in the literature. Objective: The aim of the study was to compare CLABSIs and catheter colonization rates among the three catheter insertion sites: subclavian (SC), internal jugular (IJ ) and femoral (FEM) in hospitalized patients. Moreover, to analyze the distribution of pathogens and their antimicrobial resistance profiles at these three sites, concurrently. Methods: We performed a retrospective analysis of data collected prospectively from all catheterized patients at a tertiary care Greek hospital from May 2016 to May 2018. Data was collected on 1414 CVCs and 13,054 CVC-days. Results: Τhe incidence of CLABSIs among the three sites was as follows: SC:5.1/1000 catheter/days, IJ: 3.73/1000 catheter/days and FEM: 6.93/1000 catheter/days (p = 0.37). The incidence of colonization was as follows: SC:13.39/1000 catheter/days; IJ:7.34/ 1000 catheter/days; FEM:22.91/1000 catheter/days (p = 0.009). MDROs pre- dominated in both CLABSIs and tip colonizations (59.3 and 61%, respectively) with Acinetobacter baumanii being the predominant pathogen (16/59, 27.1% and 44/144, 30.5%, respectively). The incidence of CLABSIs due to multidrug- resistant organisms (MDROs) was as follows: SC:3.83/1000 catheter days; IJ:1.49/1000 catheter days; FEM:5.86/1000 catheter days (p = 0.04). The incidence of tip colonization by MDROs among the 3 sites was as follows: SC:8.93/1000 catheter/days; IJ:4.48/1000 catheter/days; FEM:12.79/1000 catheter/days (p = 0.06). There was no significant difference in the type of pathogen isolated among site groups for both CLABSIs and tip colonizations. Conclusions: FEM site of catheter insertion was associated with a higher rate of bloodstream infection and catheters’ colonization compared to IJ and SC sites. Furthermore, this survey highlights the changing trend of the distribution of frequent pathogens and resistance patterns towards MDR Gram-negative pathogens, underscoring the need for consistent monitoring of antimicrobial resistance patterns of these specific infections. *Correspondence: atsakris@med.uoa.gr Department of Microbiology, Medical School, National and Kapodistrian University of Athens, 75 Mikras Asias Street, 11527 Athens, Greece Full list of author information is available at the end of the article © The Author(s) 2020. 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The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Pitiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 2 of 8 Keywords: Catheterization, Central venous catheter, Sepsis, Colonization, Bloodstream infection, Insertion site, Catheter Introduction Wayne, USA), are mainly used in our hospital. They are Bloodstream infections (BSI) are a significant cause of preferred exclusively for critically ill patients of ICU due morbidity and increased mortality in healthcare facilities; to their three infusion channels that facilitate the deliv- they are also attributed to an increased length of stay and ery of several parenteral medications and fluids simul - escalating costs [1].Central-line catheter use is a major taneously, but also in the others than ICU units. Double ® ® risk factor for bloodstream infections [2] with more than lumen catheters (Arrow /Teleflex , Wayne, USA), are 250,000 cases of hospital-acquired central line associated also used but in a smaller percentage, particularly in bloodstream infections (CLABSIs) within the United patients that do not require complex therapeutic inter- States annually [3]. Several factors, such as those related ventions. Catheters were inserted at optimal sites. The to the patient (i.e. immunodeficiency, renal replacement choice of the site of insertion was left to the discretion therapy), central-venous catheter (CVC) use (prolonged of the physician caring for the patient. The operators catheterization, type of catheter material, and anatomical were proficient in accessing all three sites. Maximal ster - site of catheter insertion), and healthcare practice (poor ile barrier precautions (large sterile drape; surgical hand barrier methods during catheter insertion and handling) antisepsis; and mask, cap, sterile gloves, and gown) were have been shown to increase the risk of CVC infection used at catheter insertion according to CDC recom- [4]. Regarding the anatomical site of insertion, the actual mendations. Catheters were immediately removed if no risk of infection at the three most commonly used inser- longer needed, or if a catheter-related infection (CRI) tion sites: subclavian (SC), internal jugular (IJ) and femo- was suspected. ral (FEM), remains controversial. Indeed, although earlier studies supported that FEM site access was associated Catheter care with a higher risk of infections, previous studies reported Standardized CVC care was achieved by a highly trained no significant differences in the rate of CLABSIs between nursing staff proficient in all aspects of CVC care. All these three sites, provided that all precaution measures insertion sites were maximally visualized for potential are constantly implemented throughout the hospital dressing contamination. Every couple of days or earlier settings [5]. Furthermore, while it has been suggested if clinically required, the nursing staff changed the dress - that anatomical insertion site may influence the type of ing, cleaned the skin site and the catheter hub with iodine bacteria isolated from catheter tip culture as a cause of solution, and changed the intravenous accessory tubing. CLABSI [6], no studies have compared the three sites in Furthermore, the nursing staff independently enforced terms of the pathogen distribution and resistance profiles sterile insertion technique. of microorganisms isolated. The objective of the present study was to compare Data collection CLABSIs and catheter tip colonization rates among the After insertion, catheters were checked using a check-box three insertion sites in central line catheterized patients form containing the patient’s diagnosis, operator’s name, as well as to analyze and compare distribution of patho- site chosen,date placed and removed, date of intensive gens and resistance profiles among the three groups. care units (ICU) discharge or death, mechanical ventila- tion, arterial catheters, parenteral nutrition, vasopressor Methods support, and daily clinical assessment (e.g., induration, We performed a retrospective analysis of data collected discharge, erythema, and tenderness) of possible catheter prospectively from consecutive admissions to Metropoli- infection. The operator inserting the catheter entered the tan Hospital, a tertiary care hospital in Athens, covering initial data; nurse personnel entered data the following a 24-month period from May 2016 to May 2018. This days while the infection control nurse monitored data observational study was approved by the institutional collection 3–4 times per week. review board. We retrospectively collected study data from three dif- ferent sources where information was completed: 1) ICU database (for demographic and clinical data related to the Selection of insertion sites patient’s admission and clinical course); 2) and 3) Clinical Triple lumen, non-antibiotic impregnated catheters Laboratory and hospital infection control team database ® ® (Arrow model,total provided by Arrow /Teleflex , (for blood culture and antibiotic susceptibility results). P itiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 3 of 8 Indications for catheter removal Catheter/days was defined as the number of CVCs CVCs were removed when a) there was a suspicion of presents among all units’ patients at 08:00 h each morn- infection, b) when the catheter was no longer required, ing. When more than one concurrent CVC was present and c) after 15 days of insertion. Fifteen days’ duration in the patient, they were counted as one CVC. is our institutional policy to avoid catheter infection Primary bloodstream infection was confirmed if either from excess catheter duration [7]; the duration is based criterion 1 or criterion 2 were satisfied: on the incidence of CVC infection from the institu- tion’s infection control program. Occasionally, CVCs 1 Patient had a recognized pathogen cultured from one remained more than 15 days if the risk of obtaining new or more blood cultures venous access was higher than leaving the current CVC 2 If the organism cultured was considered a common in place. skin contaminant (Diphtheroids, Bacillus species, coagulase-negative Staphylococcus or Micrococcus) and patient had at least one of the following signs or Culture techniques symptoms: fever (38 °C) or hypotension and positive All catheters were examined for the presence of patho- laboratory results were not related to an infection at gens either as a routine after removal or after suspicion another site, and at least one of the following: of infection. After disinfecting skin around the CVC entry site, the proximal 4–5 cm part of the tip was cut • Organism cultured from two or more blood cul- off using sterile scissors. The specimen was placed in tures drawn on separate occasions. a sterile container and transported to the microbiol- • Organism cultured from at least one blood cul- ogy laboratory within 15 min at room temperature. The ture from a patient with an intravascular line, and intradermal and intravascular portion of the catheter the physician instituted appropriate antimicrobial was analyzed by the semiquantitative culture technique therapy. described by Maki et  al. [8]. According to Maki’s tech- nique, catheter-tip culture is considered positive in the The clinical status of the patients was assessed daily presence of ≥15 colony-forming units (CFU) growth of by on-site attendings. The insertion sites were exam - any organism. Blood cultures were incubated in Becton ined routinely as part of the clinical assessment. Poten- Dickinson Bactec (BD Bio-sciences, USA) in aerobic tial CVC infection was considered any time an infection and anaerobic broth media. Identification of isolates occurred. and antimicrobial resistance patterns were determined by the VITEK 2Automated Compact System (BioMé- Statistical analysis rieux Co., France). E-test (BioMérieux Co., France) was Characteristics of patients and catheters were described performed as an additional test, in order to confirm as count (percent) or mean value (+/− standard devia- the resistance phenotypes reported by the VITEK Sys- tion) for qualitative and quantitative variables, respec- tem, according to the standard laboratory procedures. tively, and were compared between the three catheters Multidrug-resistant organisms (MDROs) were defined groups using Chi-square or T-test, as appropriate. Non- as species of microorganisms that exhibit antimicrobial normally distributed quantitative variables were resistance to at least one antimicrobial drug in three or expressed as median (interquartile range). The one-way more antimicrobial categories. This definition concerns ANOVA test was used to determine the existence of both gram-positive and gram-negative bacteria [9]. statistical significant difference in CLABSIs, coloni - zation rates, catheter duration at the three insertion Evaluation of CVC infection sites. A p-value of ≤0,05 was considered as statistically The definitions of catheter infection and colonization significant. are based on the Centers for Disease Control blood- stream infection guidelines and the semiquantitative Results culture technique by Maki et al. [8]. A total of 13,054 catheter days and 1414 catheters were Catheter associated BSI (CLABSI) was defined as a analyzed. Of them, 249 (3136 catheter days) were of SC laboratory confirmed BSI (a positive blood culture with site, 945 (8041 catheter days) of IJ site and 220 (1877 no other apparent source of infection) occurring in the catheter days) of FEM site. The mean duration of cath - presence of a CVC or within 48 h of CVC removal. eterization was 12.59 ± 8.32 [95% CI 11.6 to13.6] days for Catheter colonization: The presence of ≥ 15 CFU of SC sites, 8.51 ± 6.45 (95% CI 7.59 to 8.41) days for IJ sites a single organism per catheter if not accompanied by a and 8.53 ± 8.13(95% CI 6.93 to 9.07) days for FEM sites laboratory confirmed BSI of the patient. (p = 0.03, ANOVA). The overall incidence of CLABSIs Pitiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 4 of 8 was 5.32/1000 catheter days, and the overall catheter col- 16.1 ± 10.7 days in CLABSIs cases and 14. ± 9.7 days in onization rate was 12.48/1000 catheter days. colonization cases. In 47.45% (28/59) of CLABSIs cases The distribution of CLABSIs events among hospital and 34.7% (50/144) of colonization cases the duration of units was as follows: 25/59 (43%) in ICU; 20/59 (35%) catheterization was ≥15 days. in internal medicine department; 14/59 (19%) in other A higher incidence of CLABSIs was observed in units. The distribution of catheter colonizations among catheters of FEM site as compared to the other 2 sites, hospital units was 62/144 (37%) for ICU, 42/144 (29%) for although not in a statistically significant level. More spe - internal medicine department, 40/144 (12%) for others. cifically, the incidence of CLABSIs among the 3 sites The total patients’ demographic characteristics in cases was as follows: SC:5.1 infections per 1000 catheter days, of CLABSIs and tip colonization are presented in Table 1. IJ:3.73 infections per 1000 catheter days, and FEM:6.93 The 3 groups of patients with different catheter insertion infections per 1000 catheter days (p = 0.37; ANOVA). sites had equally distributed demographic characteristics Regarding catheter colonization, a higher incidence and severity of illness (as defined by APACHI score; data of infection was also observed in FEM catheters com- not shown). pared to the other sites that was established in a statisti- The median length of stay prior to central line inser - cally significant level. More specifically, the incidence of tion was 16 days (Interquartile range = 55) in CLABSIs by colonization was as follows: SC:13.39 per 1000 catheter MDROs and 25 days (Interquartile range = 57) in CLAB- days; IJ:7.34 per 1000 catheter days; and FEM:22.91 per SIs by other pathogens (p = 0.13). In tip colonizations, the 1000 catheter days (p = 0,009; ANOVA) (Table  2). Simi- median length of stay prior to central line insertion was larly, the incidence of CLABSIs and tips colonization 10 days (Interquartile range = 36.75) in MDROs cases and from MDROs was higher in FEM site as compared to 14 days (Interquartile range = 64.25) in cases where other the others. More specifically, the incidence of CLABSIs pathogens were involved (p = 0.40). The mean dura - by MDROs was as follows: SC: 3.83 infections per 1000 tion of catheterization until the onset of infection was catheter days; IJ:1.49 per 1000 catheter days; FEM:5.86 Table 1 Study populations’ demographic and clinical characteristics VARIABLE No of patients CLABSI (n = 59) N (%) Colonization (n = 144) N (%) Age, mean +/− SD, (years) 55.08 +/− 19.8 53.9 +/− 17.9 Gender (M/F) 41/18 100/44 Obesity 19 (32.2) 84 (58.3) Diabetes mellitus 9 (15.2) 67 (46.5) Pulmonary disease 16 (27.1) 48 (33.3) Hypertension 11 (18.6) 75 (52) Renal disease 17 (28.8) 15 (10.4) Oncologic disease 16 (27.1) 36 (25) Immune deficiency/suppression 17 (28.8) 33 (22.9) Admission category Medical 43 (72.8) 87 (60.4) Surgery 16 (27.1) 57 (39.6) Mechanical ventilation 37 (62.7) 105 (72.9) Unit of cath insertion (ICU/other) 38/21 97/48 Cardiovascular disease 17 (28.8) 49 (34) Neurological disease 38 (64.4) 29 (20.1) Gastroenterological disease 18 (30.5) 27 (18.7) Hospital death 19 (32.2) 42 (29.1) Sepsis 11 (18.6) 29 (20.1) APACHE score 12.8+/− 8.2 13.2 +/− 7.4 Length of catheter stay (mean +/− SD) 16.19+/−10.7 14.05+/− 9.7 No number of catheters P itiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 5 of 8 Table 2 CLABSI and  tip colonization rates among  the  3 Pseudomonas aeruginosa and Klebsiella pneumoniae and sites of catheterization two isolates of Proteus mirabilis. In CLABSIs the types of pathogens were as follows: In FEM: 10 (76.9%) Gram- SC IJ FEM P–value negatives, 2 (15.4%) Gram-positives and one (7.7%) yeast; TOTAL ISOLATES in IJ: 16 (53.3%) Gram-negatives, 10 (33.3%) Gram-pos- CLABSI (No) 16 30 13 X = 6.53 p = 0.03 itives and 4 (13.3%) yeasts; in SC; 12 (75%) Gram-nega- Per 1.000 catheter/ 5.1 3.73 6.93 ANOVA F = 1.06 p = 0.37 tives, 3 (18.7%) Gram-positives and one (6.2%) yeast. In days tips colonization the types of pathogens were as follows: Tip colonization (No) 42 59 43 X = 38.74, p = 0.000 In FEM: 32 (74.4%) Gram-negatives, 5 (11.6%) Gram- Per 1.000 catheter/ 13.39 7.34 22.91 ANOVA F = 6.23 p = 0.009 positives and 6 (13.9%) yeasts; in IJ: 48 (81.3%) Gram- days negatives, 5 (8.4%) Gram-positives, 5 (8.4%) yeasts; in MDROs 2 SC: 31 (73.8%) Gram-negatives, 5 (11.9%) Gram-positives CLABSI (No) 12 12 11 X = 16.14, p = 0.000 and 6 (14.3%) yeasts (Table 4). Per 1000 catheter/ 3.83 1.49 5.86 ANOVA F = 3.66 p = 0.04 days Tip colonization (No) 28 36 24 X = 24.59, p = 0.000 Discussion Per 1000 catheter/ 8.93 4.48 12.79 ANOVA F = 3.05 p = 0.06 The present study has shown that CLABSIs and catheter days tip colonization rates are differing among the three com - p≤ 0.05 significant monly used CVC insertion sites. Indeed, a significantly increased rate of colonization, as well as a trend towards increased rate of CLABSIs in the FEM site were observed per 1000 catheter days (p = 0.04; ANOVA) (Table 2). The in comparison to the other two sites. Notably, although incidence of colonization by MDROs among the three most CVCs were inserted via the IJ vein (66.8%), yet their sites was as follows: SC:8.93 per 1000 catheter days; contribution to CLABSIs was the lowest. IJ:4.48 per 1000 catheter days; FEM:12.79 per 1000 cath- In the literature conflicting data exist regarding the eter days (p = 0.06; ANOVA) (Table  2). No significant risk of acquiring infection for the three sites of catheteri- difference in the proportion of MDROs associated with zation, with studies supporting higher risk at the FEM colonization (88/144 = 61%) vs infection (35/59 = 59.3%) site and lower at the SC [10], while others reporting no was observed (p = 0.91, Pearson chi-square). difference [11, 12]. The latter was found even in studies The duration (in days) of catheterization until the conducted in immunocompetent patients when optimal onset of infection was not statistically different among insertion sites are selected, experienced operators insert the 3 insertion sites with regards to CLABSIs in total the catheters, strict sterile technique is present, and (p = 0.77, ANOVA) and CLABSIs from MDROs trained intensive care unit nursing staff perform catheter (p = 0.83, ANOVA). In tip colonization longer catheter care. Furthermore, in a multicenter study where patients duration was observed in SC insertion site as compared were catheterized through FEM or SC site, CVC place- to the other two (p = 0.002 ANOVA) (Table  3). Simi- ment in the FEM area was associated with a substantially larly, no differences in age were observed between the greater risk of CLABSI compared to the SC insertion [13]. 3 sites with regards to CLABSIs from MDROs (p = 0.14 In a recent survey, insertion into the FEM and IJ vein was ANOVA), while patients with SC catheters were signifi - independently associated with an increasing risk of sub- cantly younger than those with IJ or FEM catheters in sequent CLABSI [14], while in another, the SC site was tip colonizations and CLABSIs in total (p = 0.002 and associated with the lowest risk of infection when com- p = 0.001 respectively ANOVA) (Table  3). No difference pared to the other two sites [15]. Since it is well known in tip colonization rates of the 3 sites was noted between that the risk of catheter infections is in part related to the males and females, while CLABSIs in IJ site were more density of local skin flora [16], FEM site carries obvious frequent in females compared to males (p < 0,004 Pearson sources of contamination from groin secretions. There - chi-square) (Table 3). fore, many of the clinical practice guidelines recommend A total of 18 different microorganisms were respon - that the FEM site should be avoided due to the perceived sible for the 144 CVC tip colonization’s while in CLAB- higher risk of CLABSIs associated with this site [17]. SIs a total of 12 different microorganisms were isolated. However, the preferred site for placement of a CVC is Microorganisms involved in the 3 types of catheters’ complex and based on the skill and expertise of the oper- infection/colonization are presented in Table  4. There ator, the availability and expertise of ultrasound-guided was no significant difference in the type of pathogen iso - placement, the risk of bleeding and other complications lated between the site groups for both CLABSIs and tip (pneumothorax), as well as the urgency of placement. In colonizations. MDROs included Acinetobacter baumanii, emergent and high-risk situations, the FEM route is often Pitiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 6 of 8 Table 3 Duration of catheter stay, age of patients and gender proportions among the 3 sites of catheterization N Mean Std. Deviation 95% confidence interval P-value CLABSIs Duration Lower Bound Upper Bound FEM 13 15.23 16.13 5.48 24.98 0,77 IJ 30 15.73 8.31 12.63 18.84 SC 16 17.81 10.1 12.43 23.19 Age FEM 13 58.23 21.71 45.11 71.35 0.001 IJ 30 61.73 16.75 55.48 67.99 SC 16 40.06 16.24 31.41 48.72 TIP COLONIZATION Duration FEM 43 11.42 11.1 8.00 14.84 0.002 IJ 59 12.85 7.84 10.80 14,89 SC 42 18.43 9.56 15.45 21.41 Age FEM 43 56.74 19.70 50.68 62.81 0.002 IJ 59 57.61 16.45 53.32 61.9 SC 42 45.79 15.85 40.85 50.73 MDROs in CLABSI Duration FEM 11 14.4 15.43 3.36 25.44 0.83 IJ 12 13.67 7.59 8.84 18.49 SC 12 16.56 8.6 9.94 23.17 Age FEM 11 57.7 21.84 42.07 73.33 0.14 IJ 12 64.08 16.53 53.57 74.59 SC 12 47.44 16.4 34.84 60.05 Gender SC n (%) IJ n (%) FEM n (%) P-value CLABSI Male 11 (26.8) 15 (36.6) 15 (36.6) 0.004 Female 2 (11.1) 15 (83.3) 1 (5.6) Tip Colonization Male 31 (31.3) 36 (36.4) 32 (32.2) 0.23 Female 12 (26.7) 23 (51.1) 10 (22.2) n number; p≤ 0.05 significant chosen due to the ease and perceived lower insertion risk organisms of significantly greater virulence may be of this site [18]. responsible. In our study, Gram-negative pathogens and especially According to the international CLABSI pathogen dis- MDROs predominated in CLABSIs as well in catheter tribution patterns published in several previous  stud- colonization, followed by Gram-positive and yeast infec- ies, the microorganisms causing CRIs usually belong to tions, with MDR A. baumanii being the predominant the normal resident flora of the skin at the insertion site, pathogen (16/59, 27.1% and 44/144, 30.5%, respectively). mainly Gram-positives such as Staphylococcus aureus, The results are  also suggesting that the FEM site carries Staphylococcus epidermidis, Streptococcus spp., Enteroc- a greater risk of infection than either the IJ or SC sites coccus spp., Corynebacterium spp., and fungi such as for organisms other than coagulase-negative staphylo- Candida spp. [19–21]. However, recently published data cocci. This may have some  implications for treatment have revealed that CVC infections by Gram-negatives of suspected CLABSI arising from the FEM site where either predominated in terms of pathogen distribution P itiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 7 of 8 Table 4 Pathogen distribution among tip colonizations and CLABSIs CLABSIs n (%) TIP COLONIZATION n (%) SC IJ FEM SC IJ FEM Gram-negative bacteria MDR K. pneumoniae 5/31.2 2/6.6 6/46.1 9/21.4 10/16.9 8/18.6 MDR A. baumannii 2/12.5 10/33.3 4/30.7 13/30.9 19/32.2 12/27.9 MDR P. aeruginosa 3/18.7 – – 5/11.9 4/6.7 3/6.9 MDR P. mirabilis – – – – 1/1.6 1/2.3 Non-MDR K. pneumoniae – – – 1/2.3 1/1.6 1/2.3 Non-MDR P. aeruginosa – 1/3.3 – 1/2.3 5/8.4 1/2.3 E. coli – – – 1/2.3 4/6.7 4/9.3 Gram-positive bacteria Coagulase-negative staphylococci 1/6.2 8/26.6 1/7.6 2/4.7 2/3.3 4/9.3 Methicillin-resistant S. aureus (MRSA) 2/12.5 – 1/7.6 1/2.3 2/3.3 – Enterococcus spp. – 2/6.6 – 1/2.3 1/1.6 – Yeasts Candida spp. 1/6.2 4/13.3 1/7.6 6/14.2 5/8.4 6/13.9 Other bacteria 2/12.5 3/10 – 2/4.7 4/6.7 2/4.6 n number or showed increasing trends [22–24]. In our study the sites, we have made an attempt to search for potential pathogen distribution of catheter infections follows the reasons to justify the longer SC catheter duration com- recently reported Greek ICU profile of central line colo - pared to the other two sites, however, based on the exist- nization and infection pathogens, where the incidence of ing data, we have not reached any definite conclusion. A. baumanii is high, possibly due to the local predomi- nance of Gram-negative microorganisms [25]. The emer - gence of MDR bacteria has created a new burden on Conclusion medical care in Greek hospitals, particularly for patients The findings of the present study support that IJ and SC admitted to ICU [25]. This fact, might have  contrib - insertion sites are safer to use compared to the FEM site uted to the domination of these pathogens in the micro- as concerns  both CLABSIs and catheter colonizations. bial profile of catheter infection  in the current study. Moreover, a significant shift in the epidemiology of Indeed, in our institute, the rates of the 3 most commonly CRIs towards a predominance of Gram-negative patho- isolated MDR Gram-negatives (61% A. baumanii, 25% K. gens and especially MDROs was observed. Since  MDR pneumoniae, 14% P. aeruginosa) for the same time period Gram-negative infections are linked to  significant was 21.6% among hospitalized  patients for all clinical mortality  rates, empirical treatment should take  their specimens, 63.3% of which were isolated from ICU (data increasing prevalence into consideration. not shown). Moreover, 43% of CLABSIs by MDROs and 59% of colonizations by MDROs were recovered from Abbreviations ICU patients, whereas all patients from other units had a CLABSI: Catheter associated blood stream infection; CRI: Catheter-related history of prior admission to an ICU before the isolation infection; CVC: Central-venous catheters; FEM: Femoral; IJ: Internal jugular; MDRO: Multidrug-resistant organism; SC: Subclavian. of MDROs. In addition, it should be also noted that in a significant proportion  of CRIs (47.45% of CLABSIs and Acknowledgements 34.7% of colonization cases) the duration of catheteriza- Authors acknowledge the contribution of the hospital healthcare work- ers who participated in this study. We would also like to acknowledge the tion was ≥15 days. This is  a highly contributing factor significant contribution of Pavlos Mariatos, Director of Quality Management for catheter infection and colonization that should be Department. acknowledged. On the contrary, as concerns the length of Authors’ contributions hospital stay prior to central line insertion, no evidence VP, PK, GS, AT designed and set up methodology, PK, IB, EK, IS performed the from our analysis has proven  that it consists a causative study, VP, PK, IB, GS, AT analyzed the data, all authors contributed to read and agent for the colonization by MDROs. In terms of the approved the final manuscript. differences in catheterization duration among the three Funding No specific funding was received for this study. Pitiriga et al. Antimicrob Resist Infect Control (2020) 9:189 Page 8 of 8 Availability of data and materials catheter-associated infection risk reduction in critically ill adults. Crit Care All data generated or analysed during this study are included in this published Med. 2012;40:1627–34. article. 12. Reyes JA, Habash ML, Taylor RP. FEM central venous catheters are not associated with higher rates of infection in the pediatric critical care Ethics approval and consent to participate population. Am J Infect Control. 2012;40(1):43–7. This study has been approved by the ethical committee of Metropolitan 13. Arvaniti K, Lathyris D, Blot S, Apostolidou-Kiouti F, Koulenti D, Haidich AB. Hospital review board. Cumulative evidence of randomized controlled and observational stud- ies on catheter-related infection risk of central venous catheter insertion Consent for publication site in ICU patients: a pairwise and network meta-analysis. Crit Care Med. Not applicable. 2017;45(4):e437–48. 14. Van der Kooi TI, Wille JC, van Benthem BH. Catheter application, insertion Competing interests vein and length of ICU stay prior to insertion affect the risk of catheter- The authors declare that they have no competing interests. related bloodstream infection. J Hosp Infect. 2012;80(3):238–44. 15. Parienti JJ, et al. Intravascular complications of central venous catheteriza- Author details tion by insertion site. N Engl J Med. 2015;373(13):1220–9. Department of Microbiology, Medical School, National and Kapodistrian Uni- 16. Wolf HH, Leithäuser M, Maschmeyer G, Salwender H, Klein U, Chaberny versity of Athens, 75 Mikras Asias Street, 11527 Athens, Greece. Department I, et al. Infectious diseases working party (AGIHO) of the German Society of Internal Medicine, Metropolitan Hospital, 9 Ethnarchou Makariou Street, of Hematology and Oncology (DGHO): central venous catheter-related 18547 Athens, Greece. infections in hematology and oncology: guidelines of the infectious diseases working party (AGIHO) of the German Society of Hematology Received: 8 April 2020 Accepted: 18 November 2020 and Oncology (DGHO). Ann Hematol. 2008;87:863–76. 17. Centers for Disease Control and Prevention. Guidelines for the prevention of intravascular catheter-related infections. 2011 https ://www.cdc.gov/ infec tionc ontro l/guide lines /BSI/index .html. 18. Health Protection Surveillance Center. Prevention of intravascular catheter-related Infection in Ireland. Available at: http://www.hpsc.ie/ References hpsc/A-Z/Micro biolo gyAnt imicr obial Resis tance /Infec tionC ontro landH AI/ 1. Al-Rawajfah OM, Hewitt JB, Stetzer F, Cheema J. Length of stay and Guide lines /File,4115,en.pdf. charges associated with health care-acquired bloodstream infections. Am 19. The Joint Commission. Preventing central line–associated bloodstream J Infect Control. 2012;40:227–32. infections: a global challenge, a global perspective. Oak Brook: Joint 2. Hollenbeak CS. The cost of catheter-related bloodstream infections: Commission Resources; 2012. implications for the value of prevention. J Infus Nurs. 2011;34(5):309–13. 20. See I, Freifeld AG, Magill SS. Causative organisms and associated 3. O’Grady NP, Alexander M, Dellinger EP, Burns LA, Garland J, Heard SO, antimicrobial resistance in healthcare-associated central line-associated et al. Guidelines for the prevention of intravascular catheter-related infec- bloodstream infections from oncology settings, 2009–2012. Clin Infect tions. Atlanta: Centers for Disease Control and Prevention; 2011. Dis. 2016;62(10):1203–9. 4. Lutwick L, Al-Maani AS, Mehtar S, Memish Z, Rosenthal VD, Dramowski 21. Wright MO, Decker SG, Allen-Bridson K, Hebden JN, Leaptrot D. A, Lui G, Osman T, Bulabula A, Bearman G. Managing and preventing Healthcare-associated infections studies project: an American Journal of vascular catheter infections: a position paper of the international society Infection Control and National Healthcare Safety Network data quality for infectious diseases. Int J Infect Dis. 2019;84:22–9. collaboration: location mapping. Am J Infect Control. 2018;46(5):577–8. 5. Marik PE, Flemmer M, Harrison W. The risk of catheter-related blood- 22. Marcos M, Soriano A, Iñurrieta A, Martínez JA, Romero A, Cobos N, et al. stream infection with FEM venous catheters as compared to SC and IJ Changing epidemiology of central venous catheter-related bloodstream venous catheters: a systematic review of the literature and meta-analysis. infections: increasing prevalence of gram-negative pathogens. J Antimi- Crit Care Med. 2012;40(8):2479–85. crob Chemother. 2011;66:2119–25. 6. Lorente L, Jimenez A, Iribarren JL, Jimenez JJ, Martin MM, Mora ML. 23. Weiner LM, Webb AK, Limbago B, Dudeck MA, Patel J, Kallen AJ, Edwards The micro-organism responsible for central venous catheter related JR, Sievert DM. Antimicrobial-resistant pathogens associated with health- bloodstream infection depends on catheter site. Intensive Care Med. care-associated infections: summary of data reported to the National 2006;32:1449–50. Healthcare Safety Network at the Centers for Disease Control and Preven- 7. Ling ML, Apisarnthanarak A, Jaggi N, Harrington G, Morikane K, Thu LTA, tion, 2011-2014. Infect Control Hosp Epidemiol. 2016;37(11):1288–301. et al. APSIC guide for prevention of central line associated bloodstream 24. Lin KY, Cheng A, Chang YC, Hung MC, Wang JT, Sheng WH, et al. Central infections (CLABSI). Antimicrob Resist Infect Control. 2016;5:16. line-associated bloodstream infections among critically-ill patients in the 8. Maki DG, Weise CE, Sarafin HW. A semiquantitative culture method for era of bundle care. J Microbiol Immunol Infect. 2017;50:339–48. identifying intravenous-catheter-related infection. New Engl J Med. 25. Arvaniti K, Lathyris D, Clouva-Molyvdas P, Haidich AB, Mouloudi E, Syn- 1977;296:1305–9. nefaki E, et al. Comparison of Oligon catheters and chlorhexidine-impreg- 9. Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, exten- nated sponges with standard multilumen central venous catheters for sively drug-resistant, and pandrug-resistant bacteria: an international prevention of associated colonization and infections in intensive care expert proposal for interim standard definitions for acquired resistance. unit patients: a multicenter, randomized, controlled study. Crit Care Med. Clin Microbiol Infect. 2012;18:268–81. 2012;40(2):420–9. 10. Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O’Grady NP, Pettis AM, Rupp E, Sandora T, Maragakis LL, Yokoe DS. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: Publisher’s Note 2014 update. Infect Control Hosp Epidemiol. 2014;35(2):89–107. Springer Nature remains neutral with regard to jurisdictional claims in pub- 11. Parienti JJ, du Cheyron D, Timsit JF, Traoré O, Kalfon P, Mimoz O, Mermel lished maps and institutional affiliations. LA. 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