The Second Central Line Increases Central-Line–Associated Bloodstream Infection Risk by 80%: Implications for Inpatient Quality Reporting Programs
Authors: Dube William , Jacob Jesse , Zheng Ziduo , Huang Yijian , Robichaux Chad , Steinberg James , Fridkin Scott 
Published: November 2020

Background: The NHSN methods for central-line–associated bloodstream infection (CLABSI) surveillance do not account for additive CLABSI risk of concurrent central lines. Past studies were small and modestly risk adjusted but quantified the risk to be ~2-fold. If the attributable risk is this high, facilities that serve high-acuity patients with medically indicated concurrent central-line use may disproportionally incur CMS payment penalties for having high CLABSI rates. We aimed to build evidence through analysis using improved risk adjustment of a multihospital CLABSI experience to influence NHSN CLABSI protocols to account for risks attributed to concurrent central lines. Methods: In a retrospective cohort of adult patients at 4 hospitals (range, 110–733 beds) from 2012 to 2017, we linked central-line data to patient encounter data (age, comorbidities, total parenteral nutrition, chemotherapy, CLABSI). Analysis was limited to patients with >2 central-line days, with either a single central line or concurrence of no more than 2 central lines where insertion and removal dates overlapped by >1 day. Propensity-score matching for likelihood of concurrence and conditional logistic regression modeling estimated the risk of CLABSI attributed to concurrence of >1 day. To evaluate in Cox proportional hazards regression of time to CLABSIs, we also analyzed patients as unique central-line episodes: low risk (ie, ports, dialysis central lines, or PICC) or high risk (ie, temporary or nontunneled) and single versus concurrent. Results: In total, 64,575 central lines were used in 50,254 encounters. Among these patients, 517 developed a CLABSI; 438 (85%) with a single central line and 74 (15%) with concurrence. Moreover, 4,657 (9%) patients had concurrence (range, 6%–14% by hospital); of these, 74 (2%) had CLABSI, compared to 71 of 7,864 propensity-matched controls (1%). Concurrence patients had a median of 17 NHSN central-line days and 21 total central-line days. In multivariate modeling, patients with more concurrence (>2 of 3 of concurrent central-line days) had an higher risk for CLABSI (adjusted risk ratio, 1.62; 95% CI, 1.1–2.3) compared to controls. In survival analysis, 14,610 concurrent central-line episodes were compared to 31,126 single low-risk central-line episodes; adjusting for comorbidity, total parenteral nutrition, and chemotherapy, the daily excess risk of CLABSI attributable to the concurrent central line was ~80% (hazard ratio 1.78 for 2 high-risk or 2 low-risk central lines; hazard ratio 1.80 for a mix of high- and low-risk central lines) (Fig. 1). Notably, the hazard ratio attributed to a single high-risk line compared to a low-risk line was 1.44 (95% CI, 1.13–1.84). Conclusions: Since a concurrent central line nearly doubles the risk for CLABSI compared to a single low-risk line, the CDC should modify NHSN methodology to better account for this risk.

Funding: None

Disclosures: Scott Fridkin reports that his spouse receives consulting fees from the vaccine industry.