Do central line-associated bloodstream infection (CLABSI) rates differ based on whether they were placed in the ED versus the ICU?

A recent article published in Academic Emergency Medicine attempted to answer this very question. Central lines inserted in the emergency department are often cited as being “dirty” or not having the same sterile precautions that are used when central lines are placed elsewhere. This study was a prospective observation study which followed CLABSI rates of 994 ED central venous catheter insertions and compared them to CLABSI rates of ICU-inserted catheters. In total, the ED’s 4,504 central line days were compared to ICU’s 54,338 central line days. CLABSI rates for ED and ICUs were 2.0 CLABSIs/1,000 Line days versus 2.3 CLABSIs/1,000 Line days, respectively. Of note, during their 28-month study period a central line bundle was introduced which reduced ED CLABSI rates from 3.0/1,000 line days to 0.5/1,000 line days.

Risk factors for the development of CLABSIs were found to be number of line days (median 5 for those without CLABSIs vs 10 for those who did develop CLABSIs, p<0.005) and hospital length of stay (median 8 versus 13, p= 0.006).

Although this observational study did not control for certain variables which may increase CLABSI rates, it still has the effect of showing that ED CLABSI rates are at least comparable to ICU CLABSI rates.

Do central line infection rates differ based on insertion location?

This is a frequently asked question in the ED given spatial constraints and the inability to access certain parts of the body in critically ill patients. An important meta-analysis published in Critical Care Medicine in 2012 showed that there was no difference in infection rates between internal jugular, femoral, and subclavian sites (more on this in a bit).

The current official guidelines from the Infectious Disease Society of America (published 2009) states, “Avoid using the femoral vein for central venous access in adult patients [38, 50, 51, 54]. Category 1A”. In addition, the CDC Healthcare Infection Control Practices Advisory Committee in 2011 stated the exact same recommendation in their Guidelines for the Prevention of Intravascular Catheter-Related Infections. These guidelines have not been updated since the release of theCritical Care Medicine article published in 2012. To back up their 1A recommendations they cite 4 articles:

  1. The first cited trial published in 2008 (randomized controlled trial or RCT) states in their conclusion that “jugular venous catheterization access does not appear to reduce the risk of infection compared with femoral access, except among those with a high BMI” and also concluded that inserting a femoral line may be protective in patients with a lower BMI. This was based on rates of catheter colonization on removal. CLABSI rates did not differ based on BMI.
  2. The second cited RCT published in 2001 compared rates of infection between subclavian and femoral sites, stating that infection rates and thrombosis rates of the subclavian site were significantly less than femoral sites but did not assess IJ line infection rates.
  3. The third was a prospective observational study of 204 patients published in 1998 that did not show any statistical significance between IJ, subclavian, and femoral “clinical infection rates,” as the study may have been underpowered with 204 patients. An increase in colonization rates of femoral lines was statistically significant, however.
  4. The last cited study was a prospective observational study published in 2005 which followed 2,595 catheter insertions. They found a statistically significant difference in local infection rates and CLABSIs between femoral, internal jugular, and subclavian sites with femoral being least desirable, followed by internal jugular, followed by subclavian lines as most desirable.

In the more recent Critical Care Medicine article the meta-analysis included both RCTs (the 2 cited above) as well as 8 cohort studies (including the 2 observational studies listed above). The 2 oldest studies were released in 1998 (observational) and in 2001 (RCT). All other studies were released 2005 or later. As stated previously, there were no differences in systemic infection rates between the 3 sites. Additionally, they observed a significant reduction in infection rates over time which was likely explained by the introduction of the “bundle” which was able to streamline aseptic technique as well as the emergence of ultrasound guidance. There were also no significant differences between the 3 sites with regard to DVT rates.

It seems as though it is time for an update to the level 1A evidence stated in the current guidelines to one that is more evidence-based. The Critical Care Medicine article suggests that the best place to place a central line is dependent on the clinician’s most skilled region as infection rates did not differ. Now, it seems as though receiving a central line in the ED versus the ICU also may not have an effect on infection rate.

Maybe our femoral ED-placed lines aren’t so “dirty” after all.

Sources:

Theodoro D, Olsen MA, Warren DK, McMullen KM, Asaro P, Henderson A, Tozier M, Fraser V.Emergency Department Central Line-associated Bloodstream Infections (CLABSI) Incidence in the Era of Prevention Practices. Acad Emerg Med. 2015 Sep;22(9):1048-55. doi: 10.1111/acem.12744. PubMed PMID: 26336036.

Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug;40(8):2479-85. doi: 10.1097/CCM.0b013e318255d9bc. Review. PubMed PMID: 22809915.

Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:1–45

O’Grady NP, Alexander M, Burns LA, et al.Healthcare Infection Control Practices Advisory Committee (HICPAC) (Appendix 1). Summary of recommendations: Guidelines for the Prevention of Intravascular Catheter-related Infections. Clin Infect Dis. 2011;52:1087–1099

Parienti JJ, Thirion M, Mégarbane B, Souweine B, Ouchikhe A, Polito A, Forel JM, Marqué S, Misset B, Airapetian N, Daurel C, Mira JP, Ramakers M, du Cheyron D, Le Coutour X, Daubin C, Charbonneau P; Members of the Cathedia Study Group. Femoral vs jugular venous catheterization and risk of nosocomial events in adults requiring acute renal replacement therapy: a randomized controlled trial. JAMA. 2008 May 28;299(20):2413-22. doi: 10.1001/jama.299.20.2413. PubMed PMID: 18505951.

Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, Rigaud JP, Casciani D, Misset B, Bosquet C, Outin H, Brun-Buisson C, Nitenberg G; French Catheter Study Group in Intensive Care.Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001 Aug 8;286(6):700-7. PubMed PMID: 11495620.

Goetz AM, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998 Nov;19(11):842-5. PubMed PMID: 9831940

Lorente L, Henry C, Martín MM, Jiménez A, Mora ML. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters.Critical Care. 2005;9(6):R631-R635. doi:10.1186/cc3824.