Parenteral Nutrition Associated CLABSI in the Era of Bundles

Purpose:
To evaluate trends in central line-associated bloodstream infection (CLABSI) and fungemia in ICU and non-ICU patients receiving parenteral nutrition (PN) with a focus on identifying enhancements to current standards of care for CLABSI prevention.

Background/Significance:
Recently hospitals have achieved striking reductions in CLABSI using a bundle of evidence-based actions. However, PN remains an independent risk factor for CLABSI, particularly with respect to fungemia. CLABSI carries an attributable mortality of up to 30%, and can increase hospital costs by $29,156. Therefore, our initiative to reduce CLABSI strives to avoid inappropriate PN through documentation of PN indication and weekly interdisciplinary team review of all PN patients.

Methods:
Adult ICU and non-ICU cases of CLABSI in 2007 and 2009, as determined by our Infection Control Department, were retrospectively reviewed for PN administration via a central line during the septic episode. These were further analyzed for diagnosis of fungal vs. bacterial CLABSI. PN use for each year was determined by averaging the daily PN census. This project was institutional review board approved.

Results:
Review of 92,505 device days for ‘07 and ‘09 revealed an 80.2% decline in CLABSI rates (3.42 to 0.68/1000 catheter days)in non-ICU and a 54.4% drop in ICU patients (2.63 to 1.2). Total CLABSI episodes fell from 139 to 39, with episodes of CLABSI in PN recipients dropping from 46 to 8, an 82.6% decline. For ‘09, our results show a potential for saving 18-25 lives and $2,915,600 over ‘07. Fungemia in ‘07 accounted for 36 of 139 CLABSIs (26%) and 8 of 39 (21%) in ‘09. Episodes of PN-associated fungemia declined 84.6% from 26 to 4. Still, 50% of all fungemias occurred in the PN group. Non-PN fungemias decreased 60% from 10 to 4. Average PN use fell from 19.5 to 15 patients/day, a 23% reduction.

Conclusions and Implications for Practice:
PN is associated with a sizable proportion of CLABSI, but preventive strategies, such as adhering to the central line bundle and employing an interdisciplinary team approach to reduce PN use mitigates the risk. While total episodes of fungemia fell sharply, PN remains linked with half of the cases.