604 - Why Not a CLABSI? Varied Adjudication of Blood Stream Infections Among Infants with Central Lines in Level 4 Neonatal ICUs

Publication Number: 604.7027

Michael A. Padula, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Isabella Zaniletti, IZ Statistics LLC, Tampa, FL, United States; Susana Chavez-Bueno, Children's Mercy Kansas City and University of Missouri Kansas City School of Medicine, Kansas City, MO, United States; Carl H. Coghill, UAB, Birmingham, AL, United States; Theresa Grover, University of Colorado School of Medicine, Aurora, CO, United States; Mary Catherine C. Harris, Children's Hospital of Philadelphia, Gladwyne, PA, United States; Kyong-soon Lee, The Hospital for Sick Children, Toronto, ON, Canada; Alexandra K. Medoro, Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, United States; Karna Murthy, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Jessica Roberts, Children's Healthcare of Atlanta, Atlanta, GA, United States; Jennifer Rumpel, Arkansas Children's Hospital, Little Rock, AR, United States; Lakshmi Srinivasan, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States

Background: Blood stream infections (BSI) remain among the most impactful causes of morbidity and mortality for infants receiving intensive care. When BSI occur with an indwelling central line, cases are adjudicated as Central Line Associated Bloodstream Infections (CLABSI) at each center per specific National Healthcare Safety Network (NHSN) criteria. While CLABSI is widely used as quality metric, little has been reported regarding the proportion of eligible cases determined to be non-CLABSI among different Level 4 Neonatal Intensive Care Units (NICUs).

Objective: We aimed to determine (a) the inter-center variation of CLABSI assignment among Level 4 NICUs for infants with Lab-confirmed Blood Stream Infections (LCBI) and an indwelling central line and (b) the proportion and types of secondary BSI (i.e., other categorical NHSN infections) among the non-CLABSI cohort.

Design/Methods: Retrospective cohort analysis of all BSI with a central line present during admission among 45 Children’s Hospitals Neonatal Consortium (CHNC) NICUs from 2010-2023. LCBI were defined per NHSN guidelines. BSI present on admission, single-isolate commensals, and repeat infections within 14 days were excluded. Infections qualifying for analysis included (1) CLABSI cases, reflecting hospital designation and NHSN reporting, (2) secondary BSIs, captured explicitly (documented in the CHNC) or implicitly (other categorical bacterial or fungal infections within the infection window period (+/- 3 days) or repeat infection timeframe (14 days prior)), and (3) unassigned LCBI.

Results: Of 15,130 BSI in 12,130 infants, subsets were excluded for the following reasons: present on admission (4,110), single-isolate commensals (2,230), and repeat infections (136). In the remaining 8,623 LCBI, 75% (6,508) had a central line at the time of infection. Among these eligible infections, only 2,580 (39.8%) were deemed CLABSI with a range of 13.9-66.2% among centers with 30+ cases. Secondary BSI were assigned in 1,078 (16.6%; range 2.4- 75.0%), leaving 2,850 (43.8%; range 15.6-84.1%) as unassigned. (Fig. 1) Adjusted odds of non-CLABSI designation ranged from 0.28-3.53 (12.6-fold) among centers. (Fig. 2) Most common primary infections types included respiratory (37.9% [16.2-52%], median [IQR]), gastrointestinal (31.6% [9.1-44.6%]), and skin/soft tissue (14.8% [6.4-29.6%]).

Conclusion(s): Among these Level 4 NICUs, less than 40% of eligible LCBI with a central line were deemed CLABSI. Marked variation exists among centers for both CLABSI and secondary BSI assignment, with odds of a non-CLABSI varying 12-fold. Further study of sources of this variation is warranted.

Figure 1. Inter-center Variation in Adjudication of CLABSI Among Infants with Lab-Confirmed BSI and an Indwelling Central Line
Lab-confirmed Blood Stream Infections (LCBI) adjudicated as CLABSI (Determined), Secondary BSI (Assigned), or Unassigned, by center.

Figure 2. Adjusted Odds of a Non-CLABSI for an Eligible Lab-Confirmed Blood Stream Infection (LCBI), By Center
Odds of a Lab-confirmed Blood Stream Infection in the presence of a central catheter as being adjudicated as a non-CLABSI, by center, adjusted by year. (Center odds ratio range: 0.28-3.53. Median percentage non-determined CLABSI=63.7%)

Figure 1. Inter-center Variation in Adjudication of CLABSI Among Infants with Lab-Confirmed BSI and an Indwelling Central Line
Lab-confirmed Blood Stream Infections (LCBI) adjudicated as CLABSI (Determined), Secondary BSI (Assigned), or Unassigned, by center.

Figure 2. Adjusted Odds of a Non-CLABSI for an Eligible Lab-Confirmed Blood Stream Infection (LCBI), By Center
Odds of a Lab-confirmed Blood Stream Infection in the presence of a central catheter as being adjudicated as a non-CLABSI, by center, adjusted by year. (Center odds ratio range: 0.28-3.53. Median percentage non-determined CLABSI=63.7%)