Central Line-Associated Bloodstream Infections (CLABSI) in Oncology Patients: The Impact of Mucositis on CLABSI Rates

Background:  The National Healthcare Safety Network (NHSN) provides definitions about how to classify CLABSI as primary or secondary to another site of infection.  Anecdotal evidence suggests infection preventionists may differ in how they apply this definition to oncology patients who have CLABSI and concurrent mucositis.  It is unclear if longitudinal trends in a center’s CLABSI rate are influenced by whether mucositis-associated CLABSI are designated as primary or secondary infections. 

Objective: To determine whether longitudinal trends in CLABSI rates among pediatric oncology patients differed when mucositis-associated CLABSI were categorized as primary as compared to secondary CLABSI. 

Methods: In 2006, multiple interventions to reduce CLABSI were implemented on a 42-bed pediatric oncology unit at a tertiary care children’s hospital, including central line insertion, maintenance, and dressing change bundles.  At this time, we also instituted prompt bedside reviews for all CLABSI by a multidisciplinary team that included infection preventionists, oncology nurses and attending physicians. Data on mucositis was prospectively captured and documented on CLABSI worksheets. We reviewed data on all CLABSI captured on worksheets from 2006 through 2010. Every CLABSI was classified as either a mucositis-associated or non-mucositis-associated infection.  Statistical testing was performed to assess longitudinal trends (Stata 10.0 “nptrend”). 

	All CLABSI	CLABSI rate*	1° CLABSI	1° CLABSI rate*	1° CLABSI	1° CLABSI rates*
	1° & 2°		Excludes mucositis-assoc’d CLABSI		Strict adherence to definition
2006	n=64	6.7	n=42	4.4	n=61	6.4
2007	n=55	5.1	n=36	3.3	n=50	4.6
2008	n=57	5	n=41	3.6	n=53	4.6
2009	n=33	3.5	n=26	2.7	n=30	3.2
2010	n=23	2.9	n=13	1.6	n=18	2.3
p-values		0.046		0.072		0.051

*=per 1000 catheter days

Results: The rate of overall CLABSIs including 1°, 2°, and mucositis cases decreased from 6.7/1000 CL days in 2006 to 3.5/1000 CL days in 2009. Using a stricter interpretation of NHSN infection surveillance definitions, the rate of CLABSIs decreased from 6.4/1000 CL days to 3.2/1000 CL days. The table below shows raw data and rates of CLABSI over the time period.  Based on these data, there has been a trend toward an overall decline in CLABSI whether mucositis associated cases are included or excluded.

Conclusions: Reductions in the rate of CLABSI among pediatric oncology patients were observed, whether cases that occurred in patients with mucositis were included or excluded from the data. Meticulous attention to infection prevention activities related to line maintenance and insertion likely resulted in an overall CLABSI reduction. Additional efforts to define how CLABSI are classified in patients with mucositis is needed to optimize inter-institutional comparisons of CLABSI rates.