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Invited Commentary
Infectious Diseases
March 4, 2020

How Should Surveillance Systems Account for Concurrent Intravascular Catheters?

Author Affiliations
  • 1Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
  • 2Division of Infectious Diseases, Rhode Island Hospital, Providence
  • 3Department of Epidemiology and Infection Control, Rhode Island Hospital, Providence
JAMA Netw Open. 2020;3(3):e200400. doi:10.1001/jamanetworkopen.2020.0400

The risk of central venous catheter (CVC)-associated bloodstream infections has decreased dramatically.1 The same may not be true for infections associated with short-term peripheral venous catheters.2 The effects of future preventive efforts should be measured using data derived from evidence-based surveillance programs. Dube et al3 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 al3 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 CLABSI risk (Table).3-9 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 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.10 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.

Table.  Association of Concurrent Catheters With CLABSI Risk
Association of Concurrent Catheters With CLABSI Risk

The study by Dube et al3 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,5 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.

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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).

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
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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/cix562PubMedGoogle ScholarCrossref
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.2020.0396Google Scholar
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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:10.1086/657941PubMedGoogle ScholarCrossref
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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.2010.07.012PubMedGoogle ScholarCrossref
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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.2012.02.034PubMedGoogle ScholarCrossref
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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:10.1086/677634PubMedGoogle ScholarCrossref
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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.2014.7PubMedGoogle ScholarCrossref
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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.2019.180PubMedGoogle ScholarCrossref
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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.0000000000002399PubMedGoogle ScholarCrossref
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