Chaberny, I. F., Ruseva, E., Sohr, D., Buchholz, S., Ganser, A., Mattner, F., & Gastmeier, P. (2009). Surveillance with successful reduction of central line-associated bloodstream infections among neutropenic patients with hematologic or oncologic malignancies. Annals of Hematology, 88, 907–912.

The purpose of the study was to introduce prospective surveillance for nosocomial infections to improve prevention measures and reduce central line-associated blood stream infections (CLABSIs) in patients with hematologic malignancies.

Surveillance was performed for 18 months, after which the incidence rates for CLABSIs were calculated. Ward staff were then presented with the data and trained on measures to reduce CLABSIs according to national and international guidelines. During this time, they also implemented the use of chlorhexidine silver sufadiazine-coated catheters. Surveillance was then conducted for an additional 18 months.

• In total, 268 patients (57% male, 43% female) were included.
• All patients were 18 years or older.
• Patients were undergoing hematopoietic stem cell transplantation (HSCT).
• Patients were studied during neutropenic periods (defined as an absolute white blood count <1x10⁹ cells/L for at least two days).

• Twenty-bed HSCT unit
• The unit had 17 adult beds and 3 pediatric beds, although only adults were included in this study.
• Data from approximately 24 participating national and international centers for bone marrow transplantation from Germany, Switzerland, and Austria were used as a comparator for CLABSI incidence rates.

Active treatment

This was a prospective surveillance (pre/post design) study.

• Incidences (episodes per 100 patients) and incident densities (CLABSIs per 1,000 neutropenic days) were calculated.    
• Incidence densities were compared using the exponential maximum likelihood estimation test.
• Categorical variables were compared using chi-square or Fisher exact test, as appropriate.
• Risk factors were identified using a multivariate analysis with sequential backward stepwise elimination.
   

During the first study period (prior to intervention), CLABSIs occurred at a rate of 24.3 per 1,000 neutropenic days. This rate was notably higher than the median of the comparator group (17.7 per 1,000 neutropenic days) during the same study period. Following intervention, the CLABSI incidence rate dropped to 16.2 per 1,000 neutropenic days, which was below the median of the comparator group (17.7 per 1,000 neutropenic days). The reduction was significant (odds ratio = 0.58; 95% confidence interal [0.34-0.99]).

Strict adherence to hand hygiene and other preventive guidelines when handling central lines in neutropenic patients can have a positive impact on lowering the incidence of CLABSIs.

• The intervention involved educating clinical staff regarding improved preventive measures in handling central lines. The study did not monitor compliance with the new practices, which were multifaceted.  
• The outcome measure of 1,000 neutropenic days did not account for catheter dwell time as the usual CLABSI rate of patient catheter days. In addition to staff training, they also implemented the use of an antimicrobial-impregnated catheter, so it was difficult to determine which of these interventions was truly responsible for the change in results.
   

As part of the intervention, staff education included demonstrating that CLABSI incidence rates at the facility were higher than at comparable centers. This approach provides motivation for changes in nursing practice.