Infectious disease/CDC update
Vital Signs: Central Line–Associated Blood Stream Infections—United States, 2001, 2008, and 2009

https://doi.org/10.1016/j.annemergmed.2011.07.035Get rights and content

Background

Health care–associated infections (HAIs) affect 5% of patients hospitalized in the United States each year. Central line–associated bloodstream infections (CLABSIs) are important and deadly HAIs, with reported mortality of 12% to 25%. This article provides national estimates of the number of CLABSIs among patients in ICUs, inpatient wards, and outpatient hemodialysis facilities in 2008 and 2009 and compares ICU estimates with 2001 data.

Methods

To estimate the total number of CLABSIs among patients aged 1 year or older in the United States, Centers for Disease Control and Prevention (CDC) multiplied central line use and CLABSI rates by estimates of the total number of patient-days in each of 3 settings: ICUs, inpatient wards, and outpatient hemodialysis facilities. CDC identified total inpatient-days from the Healthcare Cost and Utilization Project's National Inpatient Sample and from the Hospital Cost Report Information System. Central line use and CLABSI rates were obtained from the National Nosocomial Infections Surveillance System for 2001 estimates (ICUs only) and from the National Healthcare Safety Network for 2009 estimates (ICUs and inpatient wards). CDC estimated the total number of outpatient hemodialysis patient-days in 2008 by using the single-day number of maintenance hemodialysis patients from the US Renal Data System. Outpatient hemodialysis central line use was obtained from the Fistula First Breakthrough Initiative, and hemodialysis CLABSI rates were estimated from the National Healthcare Safety Network. Annual pathogen-specific CLABSI rates were calculated for 2001 to 2009.

Results

In 2001, an estimated 43,000 CLABSIs occurred among patients hospitalized in ICUs in the United States. In 2009, the estimated number of ICU CLABSIs had decreased to 18,000. Reductions in CLABSIs caused by Staphylococcus aureus were more marked than reductions in infections caused by Gram-negative rods, Candida spp, and Enterococcus spp. In 2009, an estimated 23,000 CLABSIs occurred among patients in inpatient wards, and in 2008, an estimated 37,000 CLABSIs occurred among patients receiving outpatient hemodialysis.

Conclusion

In 2009 alone, an estimated 25,000 fewer CLABSIs occurred in US ICUs than in 2001, a 58% reduction. This represents up to 6,000 lives saved and $414 million in potential excess health care costs in 2009 and approximately $1.8 billion in cumulative excess health care costs since 2001. A substantial number of CLABSIs continue to occur, especially in outpatient hemodialysis centers and inpatient wards.

Implications for Public Health Practice

Major reductions have occurred in the burden of CLABSIs in ICUs. State and federal efforts coordinated and supported by CDC, the Agency for Healthcare Research and Quality, and the Centers for Medicare & Medicaid Services and implemented by numerous health care providers likely have helped drive these reductions. The substantial number of infections occurring in non-ICU settings, especially in outpatient hemodialysis centers, and the smaller decreases in non–S aureus CLABSIs reveal important areas for expanded prevention efforts. Continued success in CLABSI prevention will require increased adherence to current CLABSI prevention recommendations, development and implementation of additional prevention strategies, and the ongoing collection and analysis of data, including specific microbiologic information. To prevent CLABSIs in hemodialysis patients, efforts to reduce central line use for hemodialysis and improve the maintenance of central lines should be expanded. The model of federal, state, facility, and health care provider collaboration that has proven so successful in CLABSI prevention should be applied to other HAIs and other health care–associated conditions.

Introduction

Health care–associated infections (HAIs) account for a substantial portion of health care–acquired conditions1 that harm patients receiving medical care. Nearly 1 in every 20 hospitalized patients in the United States each year acquires an HAI. Central line–associated bloodstream infections (CLABSIs) are one of the most deadly types of HAIs, with a mortality rate of 12% to 25%.2 The Centers for Disease Control and Prevention (CDC) defines a CLABSI as recovery of a pathogen from a blood culture (a single blood culture for organisms not commonly present on the skin and 2 or more blood cultures for organisms commonly present on the skin) in a patient who had a central line at infection or within the 48-hour period before development of infection. The infection cannot be related to any other infection the patient might have and must not have been present or incubating when the patient was admitted to the facility.

In recent years, large-scale regional and statewide projects, such as the Pittsburgh Regional Healthcare Initiative and the Michigan Keystone Project, have demonstrated roughly 70% reductions in CLABSI rates in ICUs by increasing adherence to recommended best practices for the insertion of central lines.3, 4 Decreases in CLABSIs have been attributed to various factors, including increased financial and leadership support for CLABSI prevention, improved education and engagement of clinicians in prevention efforts, packaging of prevention recommendations into practice bundles, increased data monitoring and feedback on progress, improvement of the safety culture in health care, and local and statewide collaborative prevention efforts.

In 2009, the US Department of Health and Human Services set a national goal for a 50% reduction in CLABSIs by 2013.5 CDC monitors progress toward this goal through the National Healthcare Safety Network. This article describes progress in CLABSI reductions in ICUs and estimates the numbers of CLABSIs occurring in non-ICU settings. CDC estimated the number of CLABSIs among hospitalized patients aged 1 year or older in 2009 and among patients receiving outpatient hemodialysis in 2008. CDC also compared the number of CLABSIs in ICUs and the pathogens causing inpatient CLABSIs in 2001 and 2009.

Section snippets

Materials and Methods

For each setting (ICU, inpatient ward, and hemodialysis facility) and period, CDC multiplied patient-day estimates by central line use ratios to estimate the total number of central line–days nationally and then applied CLABSI rates to estimate the total number of infections. CDC estimated the total number of inpatient-days in US hospitals by averaging estimates from the Healthcare Cost and Utilization Project's National Inpatient Sample6 and the Hospital Cost Report Information System.7

Results

For the 2009 calculations, an estimated 168 million inpatient-days occurred in nonfederal acute care hospitals in the United States. After adding approximately 4.9% to account for patient-days in federal hospitals, CDC allocated 12.5% of days to ICUs and 87.5% to inpatient wards, yielding 22.1 million ICU-days and 154.3 million inpatient ward–days.

In 2001, the pooled mean central line use ratio in ICUs was 0.53 central line–days per patient-day, which yielded 11.7 million central line–days. The

Conclusions and Comment

In 2009, an estimated 25,000 fewer CLABSIs occurred among patients in ICUs in the United States than in 2001 (a 58% reduction). The cumulative number of CLABSIs prevented since 2001 is substantially higher because reductions have been occurring annually for the past decade.11 Given the reported mortality from CLABSIs, these reductions represent an estimated 3,000 to 6,000 lives saved and estimated excess health care costs of $414 million12 in ICUs in 2009 alone. Assuming that each CLABSI

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Editor's note: This article is part of a regular series on emerging infection from the Centers for Disease Control and Prevention (CDC) and the EMERGEncy ID NET, an emergency department–based and CDC-collaborative surveillance network. Important infectious disease public health information with relevance to emergency physicians is reported. The goal of this series is to advance knowledge about communicable diseases in emergency medicine and foster cooperation between the front line of clinical medicine and public health agencies.

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