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Central line-associated bloodstream infections (CLABSIs) or catheter-associated urinary tract infections (CAUTIs) have been increasing since the beginning of the COVID-19 pandemic. What is the IP's role in preventing them and the mortalities that sometimes accompany them?
Health care-acquired infections (HAIs) linked to indwelling catheters (either central line-associated bloodstream infection [CLABSI] or catheter-associated urinary tract infection [CAUTI]) have been the focus of preventive measures for decades. These types of infections are often associated with intensive care units but are also found in other areas of health care facilities. By establishing standardized, evidence-based procedures and products implemented by infection preventionists (IPs), rates of CLABSI and CAUTI were estimated to have been reduced by 58% from 2008 to 2018.1 Current evidence regarding the incidence of CLABSI or CAUTI suggests that although progress has been made in reducing these infections, more work is needed to complete the job. Then the COVID-19 pandemic happened.
The pandemic has had impacts throughout health care, possibly increasing the rates of CLABSIs and CAUTIs in hospitals. Significantly increased rates of hospitalization due to infections caused by the SARS-CoV-2 virus stressed resources in most forms of caregiving. Data from the CDC’s National Healthcare Safety Network (NHSN) summarizing the number of HAIs that occurred during 2021, compared with HAI rates before the COVID-19 pandemic (2019 data), indicated that a trend of increasing infections that started during 2020 had continued during 2021.2 As a result, infections related to care requiring indwelling catheters, from CLABSI and CAUTI, increased from 2020 to 2021. Data from the NHSN report for acute care hospitals at the national level over the period showed that significant increases in CLABSIs (7%) and CAUTIs (5%) occurred.3
Interestingly, the CDC report in 2021 indicated that there was also a 14% increase in hospital-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia over this period. Bacteremia may be linked to central lines and, if caused by MRSA, can be very difficult to treat. These bloodstream infections often have a more pronounced impact on older patients, resulting in a high mortality rate (eg, 26%).4 Because older patients tended to be more susceptible to the SARS-CoV-2 virus, the pandemic may have contributed to the increased rates of CLABSI and of bacteremia caused by MRSA.
A critical question regarding the recently increased rates of CLABSIs and CAUTIs is whether the standardized, evidence-based procedures (often at the direction of IPs) that had resulted in significant reductions in these types of infections before the pandemic took a back seat under the enormous pressure brought about by the pandemic. Detailed findings from
studies of evidence-based strategies to reduce HAIs in hospitals have suggested that between 65% to 70% of CLABSIs and CAUTIs are preventable. Using prevention bundles implemented by the facility’s IPs can provide a cost-effective mechanism to reduce CLABSIs and CAUTIs in adult and pediatric patients.5
To test the roles that IPs play in helping reduce rates of CLABSIs and CAUTIs, investigators conducted an evaluation in a large acute care hospital system of IPs’ roles as leaders in implementing evidence-based procedures. The research data indicated that in this hospital system, the roles of IPs needed to be better established across all facilities. The researchers found that IP directors led 9 programs and managers led 18.6 They determined that when the programs were led by IP directors rather than managers, standard infection rates linked to CLABSIs and CAUTIs were significantly reduced. The study authors suggested that this distinction between IP directors and managers was due to the direct access the IP directors had to senior leadership at the facilities. In another study conducted at an academic medical center where increases in CLABSI and CAUTI rates had been observed, the use of evidence-based maintenance bundles audited by the IP department resulted in a 4% and 19% reduction, respectively, in rates of CLABSIs and CAUTIs compared with a baseline period.7 It is unknown whether the links between IPs and senior administrators in hospitals under the added pressure of the pandemic had been compromised, but these may have contributed to the recent increases in rates of CLABSIs and CAUTIs.
Are there other measures physicians might take to help reduce the problem of CLABSIs or CAUTIs by changing how they conduct many procedures? Regarding the use of central lines, are they always needed for critical care patients? One study that focused entirely on CLABSIs, and how to decrease the impact of these infections in critical care medicine, considered the necessity of central lines in many cases. The researchers suggested that when using peripheral intravenous catheters rather than central lines, the lower risk of peripheral lines may reduce the number of CLABSIs in patients for whom a central line was not necessary.8 In the investigators’ study of 554 consults, 75 were for central venous catheters (CVCs), with 36 of these consults resulting in CVC insertion. Six of those CVC insertions were later deemed avoidable. Of those 6 avoidable insertions, 3 CLABSIs resulted in an estimated monetary loss of $132,000. Thus, there are potential economic costs related to determining whether CVC insertion is necessary or whether it might be replaced by a peripheral line. If IPs play a role in discussing the use of CVCs, they could act as an excellent sounding board regarding the potential use of peripheral lines over CVCs when appropriate.
As with the potential to shift from CVCs to peripheral lines described above, there are alternatives to indwelling urinary tract catheters, at least for men. For men, external collection devices (ECDs) for urine include condom catheters, reusable body-worn urinals, and an external continence device. For women, developing an external ECD has proved to be more problematic.9 A study of the use of ECDs compared with indwelling urinary tract catheters in reducing CAUTIs found that for the 75 men involved, those patients using ECDs had a significant reduction in urinary tract infections compared with those using the indwelling catheters.10 Thus, the focus in this potential measure to reduce CAUTIs for men can now include prevention bundles that encourage the use of ECDs. For facilities that do not currently use ECDs, nurses and other practitioners must be educated on their proper application. This educational approach could fall to IPs. Overall, reducing CAUTIs will require active involvement by IPs to help with education relative to prevention bundles that will focus on the proper use of indwelling catheters for women and men and may involve the proper use of ECDs for male patients.
The recent increase in CLABSIs and CAUTIs in acute care facilities may have been partly caused by constraints placed on health care facilities due to the COVID-19 pandemic. However, many measures that IPs can direct to present evidence-based prevention bundles to facility personnel more effectively should help reverse the trend in these infections as we move out of the shadow of the pandemic.