Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis
Central-line-associated bloodstream infections (CLABSIs) are a major problem in intensive care units (ICUs) worldwide. We aimed to quantify the effectiveness of central-line bundles (insertion or maintenance or both) to prevent these infections.
Methods
We searched Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library to identify studies reporting the implementation of central-line bundles in adult ICU, paediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 1990, and June 30, 2015. For the meta-analysis, crude estimates of infections were pooled by use of a DerSimonian and Laird random effect model. The primary outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Incidence risk ratios (IRRs) were obtained by use of random-effects models.
Findings
We initially identified 4337 records, and after excluding duplicates and those ineligible, 96 studies met the eligibility criteria, 79 of which contained sufficient information for a meta-analysis. Median CLABSIs incidence were 5·7 per 1000 catheter-days (range 1·2–46·3; IQR 3·1–9·5) on adult ICUs; 5·9 per 1000 catheter-days (range 2·6–31·1; 4·8–9·4) on PICUs; and 8·4 per 1000 catheter-days (range 2·6–24·1; 3·7–16·0) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 19·5 per 1000 catheter-days (median 2·6, IQR 1·2–4·4) in all types of ICUs. In our meta-analysis the incidence of infections decreased significantly from median 6·4 per 1000 catheter-days (IQR 3·8–10·9) to 2·5 per 1000 catheter-days (1·4–4·8) after implementation of bundles (IRR 0·44, 95% CI 0·39–0·50, p<0·0001; I2=89%).
Interpretation
Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs.
Funding
None.
Introduction
Health-care-associated infections are a major problem in intensive care units (ICUs) worldwide.1 They have been associated not only with impaired immunity of critically ill patients but also with the presence of central lines, urine catheters, and invasive ventilation.2, 3 The true number of health-care-associated bloodstream infections is not known, but 18 000 cases are estimated to have occurred in intensive care in 2009 in the USA, which were associated with a mortality as high as 25%.4 However, the International Nosocomial Infection Control Consortium (INICC) stated that the pooled incidence of central-line-associated bloodstream infections (CLABSIs) in INICC ICUs (ie, in Africa, Asia, Europe, and Latin America), of 4·9 infections per 1000 central-line-days, is nearly five times higher than that reported from comparable ICUs in the USA.5 Most hospital-acquired bloodstream infections are associated with the presence of a central-line.6, 7, 8 CLABSIs are the most common health-care-associated infections in paediatric intensive care units (PICUs), and subsequently in neonatal intensive care units (NICUs) and adult ICUs. Furthermore, CLABSIs are responsible for substantial mortality, morbidity, extended duration of stay in hospital, and additional costs to hospitals.9, 10, 11, 12, 13 Evidence suggests that CLABSI prevention is crucial for safe patient care for all age groups.
The Institute for Healthcare Improvement developed so-called bundles to improve patient care. A bundle is a set of evidence-based practices that have been proven to improve patient outcomes, provided they are completed collectively and reliably. In 2006, Pronovost and colleagues wrote a key paper14 in which they concluded that implementation of central-line insertion bundles significantly reduced CLABSI incidence in adult ICUs. Growing evidence suggests that addition of a maintenance bundle to a central-line insertion bundle might be even more effective in prevention of CLABSIs in children and infants.15, 16, 17, 18 A central-line insertion and maintenance bundle is defined as a combination of interventions, such as full barrier precaution during the insertion of a central line, cleaning of the skin with chlorhexidine, application of appropriate hand hygiene, and prompt removal when the central line is no longer needed.
Research in context
Evidence before this study
Health-care associated infections are a large problem in intensive care units (ICUs) worldwide. Risk factors for these infections are associated with both invasive procedures such as insertion and maintenance care of central lines in neonatal, paediatric, and adult ICU patients. Studies have previously investigated the effectiveness of central lines in adult ICUs, including a 2014 systematic review. We focused on effectiveness of the implementation of central-line bundles and the estimated cost savings on the entire lifespan of patients. We searched Embase, MEDLINE, Web-of-Science, Cochrane Library, and PubMed (with no language restriction) using a combination of search terms of “catheterization, central venous/adverse effects”, “infection control/methods”, “intensive care units”, and “quality control”. We included literature published between Jan 1, 1990, and June 30, 2015.
Added value of this study
Our study makes an important contribution to clinical practice and shows there is an overwhelming number of publications reporting implementation of central-line bundles are effective in ICU patients, including neonates and children. We show that implementation of central-line bundles are effective in low-income and middle-income countries as well as in high-income countries. Our findings show that central-line bundles are cost saving.
Implications of all the available evidence
Health-care professionals should make efforts to implement central-line bundles in low-income, middle-income, and high-income countries, and stop undertaking new effectiveness studies.
CLABSI prevention requires broad practice changes and implementation of multifaceted programmes to improve infection control.14, 19, 20 It also requires changes in the behaviour of health-care professionals through education, performance assessments, provision of feedback, use of teamwork, and improvements in the overall safety culture.21
A rigorous systematic review and meta-analysis of the effectiveness of central-line bundles has not yet been done in critically ill patients, of all ages, during their entire life span. Robust evidence of bundle effectiveness in individual studies is restricted on account of small sample sizes.15 Additionally, compliance with the application of bundles is not always consistently assessed. No clear evidence shows that central-line bundles are cost effective. Furthermore, it is unclear what implementation strategy would be best to increase bundle compliance. Our systematic review and meta-analysis aims to assess the effectiveness of the implementation of central-line bundles to prevent CLABSIs in adult, paediatric, and neonatal patients in ICUs.
Section snippets
Search strategy and selection criteria
We did this systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.22 The research protocol was registered in the PROSPERO international prospective register of systematic reviews (CRD42014007303).23
We systematically searched for articles published between Jan 1, 1990, and June 30, 2015, in the Embase, MEDLINE OvidSP, Web-of-Science, Cochrane Library, PubMed, and Google Scholar databases using the search terms
Results
We initially identified 4337 records. After removal of duplicates, the search strategy yielded 2715 unique publications, 191 of which were deemed relevant based on the title and abstract and were retrieved. Of these, and after full-text reading, 96 records were used in the systematic review (figure 1), which included 60 records in adult ICUs,32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70,
Discussion
The main finding of this systematic review and meta-analysis of 2370 ICUs, is a significant association between implementation of central-line insertion and maintenance bundles and reduction of the incidence of CLABSIs in all ICU settings. The risk reduction was more conspicuous in studies with a CLABSI incidence of five or higher per 1000 catheter-days at baseline than in studies with a CLASBSI incidence lower than five per 1000 catheter-days.
A high baseline incidence of CLABSIs was associated
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