Central Line–Associated Bloodstream Infections in Intensive Care Units Surveillance results: 2016-2017

In 2016–2017, incidence rates are 0.91 per 1,000 catheter days in coronary ICUs, 0.62 in teaching adult ICUs, 0.46 in non-teaching adult ICUs, 2.16 in pediatric ICUs and 2.78 in neonatal ICUs. The lowest pooled mean rate is thus found in adult non-teaching ICUs (Table 2). The CLABSI incidence rate is highest in neonatal and pediatric ICUs, and these rates are significantly higher than that of adult ICUs (p < 0.05). Even though the main case definition excludes infections with a mucosal barrier injury, Table 2 also presents rates including these cases, to allow comparisons with American incidence rates. In neonatal ICUs, rates tend to increase as birth weight decreases (Table 3).

Table 2 – CLABSI Incidence Rate and Catheter Utilization Ratio, by Type of Healthcare Facility and Type of ICU, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days [95% CI])

95% CI: 95% confidence interval.

Table 3 – CLABSI Incidence Rate in Neonatal ICUs, by Birth Weight Category, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days [95% CI])

In 2016–2017, compared to the previous four years (Figure 1), CLABSI incidence rates declined significantly in neonatal ICUs (p < 0.05), but remained stable (p > 0.05) in adult teaching ICUs, adult non-teaching ICUs, pediatric ICUs and coronary ICUs.

Figure 1 – Evolution of CLABSI Incidence Rates, by Type of Healthcare Facility and Type of ICU, in ICUs that previously participated in SPIN (N = 67), Québec, 2012–2016 and 2016–2017 (Incidence Rate per 1,000 Catheter days [95% CI])

Figure 2 – Evolution of Catheter Utilization Ratios, by Type of Healthcare Facility and Type of ICU, in ICUs that previously participated in SPIN (N = 67), Québec, 2012–2016 and 2016–2017

Patients who developed a CLABSI are aged between 0 and 94 years, with a median age of 66 years old in the adult ICUs, 0.5 years old in pediatric ICUs and of a little less than one month old in neonatal ICUs. In adult ICUs, the central lines most frequently associated with bloodstream infections are the 'other' central venous catheters (CVCs) that include central lines previously named 'regular' CVCs, followed by peripherally inserted central catheters (PICCs) (Figure 3). In neonatal ICUs, PICCs are the most frequently associated with CLABSI, followed by umbilical catheters.

Figure 3 – Type of Central Line Used in CLABSI Cases, by Type of Healthcare Facility and Type of ICU, Québec, 2016–2017 (N)

NB: More than one central line may be reported in any given case of CLABSI, which explains why the total number of central lines is higher than the total number of CLABSIs presented earlier in this paper.

In 2016–2017, 17 % of CLABSI cases died within 30 days after bacteremia onset (Table 4). Case fatality is 0 % in coronary ICUs (Table 4) but the number of cases is very small. The overall case fatality of 17 % is not a significant increase compared to the case fatality of 13 % observed in 2015–2016 (p > 0.05).

Figure 4 – 30-Day Case Fatality, by Type of Healthcare Facility and Type of ICU, Québec, 2016–2017 (%)

Table 4 – 30-Day Case Fatality, by Type of Healthcare Facility and Type of ICU, Québec, 2016–2017 (N, %)

Figure 5 shows that the microorganisms most frequently isolated in reported CLABSI cases are coagulase-negative staphylococci (CoNS, 31 %), followed by Enterococcus sp. (13 %) then S. aureus (13 %). However, CoNS and Candida sp. are present in almost two thirds of cases resulting in death (57 %).

Figure 5 – Categories of Isolated Microorganisms in All Cases (N = 158) and Cases of Mortality Within 30 Days (N = 26), Québec, 2016–2017 (%)

In 2016–2017, no S. aureus strains are resistant to oxacillin and one Enterococcus faecium resistant to vancomycin is reported (Table 5), for a global resistance proportion of 5 % among all E. faecium and E. faecalis. Two carbapenem-resistant enterobacteria are reported: one Klebsiella oxytoca and one Citrobacter freundii (Figure 6). Please note that the second graph in Figure 6 presents data that exclude Pseudomonas sp.

Table 5 – Percentage of Strains Tested and Percentage of Resistance to Antibiotics for Certain Isolated Microorganisms, Québec, 2016–2017 (N, %)

CSE 2: cefepime or ceftazidime;
CSE 4: cefepime, cefotaxime, ceftazidime or ceftriaxone;
Fluoroquinolones 2: ciprofloxacin or levofloxacin;
Fluoroquinolones 3: ciprofloxacin, levofloxacin or moxifloxacin;
Multiresistant 1: intermediate or resistant to an agent in three of the following five categories: cephalosporins 4, fluoroquinolones 3, aminoglycosides, carbapenems, piperacillin or piperacillin/tazobactam.
Multiresistant 2: intermediate or resistant to an agent in three of the following five categories: cephalosporins 2, fluoroquinolones 2, aminoglycosides, carbapenems, piperacillin or piperacillin/tazobactam.
Multiresistant 3: intermediate or resistant to an agent in three of the following six categories: cephalosporins 2, fluoroquinolones 2, aminoglycosides, carbapenems, piperacillin or piperacillin/tazobactam, ampicillin/sulbactam.

Figure 6 – Evolution of Antibiotic Resistance in Gram-Positive Bacteria, Gram-Negative Bacteria and Pseudomonas sp., Québec, 2012–2013 to 2016–2017 (%)

In 2016–2017, one coronary ICU (33 % of ICUs), one adult teaching ICU (4 % of ICUs) and three adult non-teaching ICUs (10 % of ICUs) remain below the 90th percentile of 2012–2013 to 2015–2016 rates for their ICU type (Figures 7, 8 and 9). No pediatric or neonatal ICU ranks above the 90th percentile in their respective units type (figures 10 and 11). Tables 6 and 7 present the numerical values that correspond to the rates displayed in Figures 7 through 11. Tables 8 and 9 show the catheter utilization rates for each ICU.

Figure 7 – CLABSI Incidence Rate per ICU (2016–2017) and Percentile Ranking (2012–2013 to 2015–2016), Coronary ICUs, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days)

Figure 8 – CLABSI Incidence Rate per ICU (2016–2017) and Percentile Ranking (2012–2013 to 2015–2016), Teaching Adult ICUs, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days)

Figure 9 – CLABSI Incidence Rate per ICU (2016–2017) and Percentile Ranking (2012–2013 to 2015–2016), Non-Teaching Adult ICUs, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days)

Figure 10 – CLABSI Incidence Rate (2015–2016) and Percentile Ranking (2012–2013 to 2015–2016) per ICU, Pediatric ICUs, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days)

Figure 11 – CLABSI Incidence Rate (2016–2017) and Percentile Ranking (2012–2013 to 2015–2016), per ICU, Neonatal ICUs, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days)

NB for Figures 7 to 11: In healthcare facilities with more than one type of ICU: S = surgical, M = medical, X = mixed and B = burn trauma.

Table 6 – CLABSI Incidence Rate per ICU, Distribution of CLABSI rates for 2012–2016, by ICU Types, for Teaching Healthcare Facilities, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days)

* In healthcare facilities with more than one type of adult ICU: S = surgical, M = medical, X = mixed and B = burn trauma.

Table 7 – CLABSI Incidence Rate per ICU, Distribution of CLABSI rates for 2012–2016, by ICU Types, for Non-teaching Healthcare Facilities, Québec, 2016–2017 (Incidence Rate per 1,000 Catheter days)

Table 8 – Catheter Utilization Ratio per ICU, Distribution of Ratios for 2012–2016, by ICU Types, for Teaching Healthcare Facilities, Québec, 2016–2017

*  In healthcare facilities with more than one type of adult ICU: S = surgical, M = medical, X = mixed and B = burn trauma.

Table 9 – Catheter Utilization Ratio per ICU, Breakdown for 2012–2016, by ICU Types, for Non-teaching Healthcare Facilities, Québec, 2016–2017

Comité de surveillance provinciale des infections nosocomiales (SPIN) – bactériémies sur cathéters centraux aux soins intensifs

Editorial Committee 

Élise Fortin, Direction des risques biologiques et de la santé au travail. Institut national de santé publique du Québec

Muleka Ngenda-Muadi, Direction des risques biologiques et de la santé au travail. Institut national de santé publique du Québec

Caroline Quach, Centre universitaire de santé McGill. Hôpital de Montréal pour enfants

Isabelle Rocher, Direction des risques biologiques et de la santé au travail. Institut national de santé publique du Québec

Claude Tremblay, Centre hospitalier universitaire de Québec de Québec – Université Laval

Mélissa Trudeau, Direction des risques biologiques et de la santé au travail. Institut national de santé publique du Québec

Jasmin Villeneuve, Direction des risques biologiques et de la santé au travail. Institut national de santé publique du Québec