Risk factors for central venous catheter-related infections in a neonatal population - systematic review<sup>,</sup>

Rosado, Viviane; Camargos, Paulo A.M.; Anchieta, Lêni M.; Bouzada, Maria C.F.; Oliveira, Gabriela M. de; Clemente, Wanessa T.; Romanelli, Roberta M. de C.

doi:10.1016/j.jped.2017.03.012

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Review article • J. Pediatr. (Rio J.) 94 (1) • Jan-Feb 2018 • https://doi.org/10.1016/j.jped.2017.03.012 copy

Risk factors for central venous catheter-related infections in a neonatal population - systematic review^☆ ☆ Please cite this article as: Rosado V, Camargos PA, Anchieta LM, Bouzada MC, Oliveira GM, Clemente WT, et al. Risk factors for central venous catheter-related infections in a neonatal population - systematic review. J Pediatr (Rio J). 2018;94:3-14. ^,^☆☆ ☆☆ Study carried out at Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

This was a systematic review of the incidence density and risk factors for central venous catheter-related infections in a neonatal population.

Data source:

The MEDLINE, Embase, Cochrane, BDENF, SciELO, and LILACS databases were used without date or language restriction. Studies that analyzed risk factors for bloodstream infections in newborns were identified.

Data synthesis:

A total of 134 articles were found that met the eligibility criteria. Of these articles, 14 were selected that addressed risk factors for central venous catheter-related infection in neonates. Catheter-related bloodstream infections remain an important complication, as shown by the incidence rates reported in the studies included in this review. The observed risk factors indicate that low birth weight, prematurity, and longer catheter permanence are related to a higher incidence of bloodstream infections. It has been observed that low rates of catheter-related infections, i.e., close to zero, are already a reality in health institutions in developed countries, since they use infection surveillance and control programs.

Conclusion:

Catheter-related bloodstream infections still show high incidence density rates in developing countries. The authors emphasize the need for further longitudinal studies and the need for better strategies to prevent risk factors, aiming at the reduction of catheter-related infections.

KEYWORDS
Catheter-related infections; Central venous catheterization; Risk factors

ID	Author	Methodological limitations	Inconsistency	Indirect evidence	Inaccuracy	Publication bias	Consequence
E1	Hruszkewycz et al.	Moderate	Elevated	Low	Elevated	Low	+1
E2	Sengupta A et al.	Moderate	Low	Low	Low	Low	-2
E3	Jen-Fu Hsu et al.	Moderate	Moderate	Low	Moderate	Low	-1
E4	Ohki Y et al.	Moderate	Low	Low	Low	Low	-2
E5	Milstone AM et al.	Moderate	Low	Low	Low	Low	-2
E6	Greenberg RG et al.	Moderate	Moderate	Low	Moderate	Low	-1
E7	Yumani DF et al.	Moderate	Low	Low	Low	Low	-2
E8	Duarte ED et al.	Moderate	Low	Low	Low	Moderate	-1
E9	Barbosa MH et al.	Moderate	Elevated	Low	Elevated	Moderate	+1
E10	Shalabi M et al.	Moderate	Moderate	Low	Moderate	Low	-1
E11	Bellemin, K et al.	Moderate	Low	Low	Low	Low	-2
E12	Costa P et al.	Moderate	Low	Low	Low	Moderate	-1
E13	Geffers C et al.	Moderate	Low	Low	Low	Low	-2
E14	Padula et al.	Moderate	Moderate	Low	Moderate	Low	-1

ID	Author/country	Design characteristics	Study population/time of follow-up		Objective	Results
S1	Hruszkewycz et al./USA	Case-control	263 neonates	1989	To assess the incidence and spectrum of complications associated with central venous catheter (CVC) placement in severely ill neonates.	Five infants (29%) developed six episodes of bloodstream infection. Infants with CVC-related infection had lower gestational age (24 weeks vs. 32 weeks, p = 0.04) and lower birth weight (580 g vs. 1285 g, p = 0.02). The overall bloodstream infection rate was one episode per 100 days of catheter use.
S2	Sengupta A, Lehmann C, Diener-West M, Perl TM, Milstone AM/USA	Retrospective cohort	683 neonates	2006-2008	To determine risk factors for CVC-BSI during PICC use in high-risk newborns.	The duration of catheter use is a risk factor for CVC-BSI (IRR: 1.33 [95% CI: 1.12-1.57]). There was a significant daily increase in the risk of CVC-BSI after 35 days.
S3	Jen-Fu Hsu, Ming-Horng Tsai, Hsuan-Rong Huang, Reyin Lien, Shih-Ming Chu, Chung-Bin Huang Risk/Taiwan	Retrospective cohort	275 neonates	2005-2006	To verify the risk of infection and other complications associated with PICC in very low-birth weight neonates.	Significant risk factors for CVC-BSI: femoral catheters (increased risk of CVC-BSI compared to non-femoral catheters: (OR 1.76, 95% CI: 1.01-3.07, p = 0.045) and longer time of PICC use: (RR 4.66, 95% CI: 1.93-11.28; p < 0.001)).
S4	Ohki Y, Maruyama K, Harigaya A, Kohno M, Arakawa H/Japan	Multicenter prospective cohort	946 neonates/19 NICUs	2005-2007	To investigate the incidence and risk factors for PICC-related complications using a multicenter survey.	Multiple logistic regression analysis showed that longer catheter use (OR, 1.35, 95% CI: 1.14-1.60, p = 0.0005) independently contributed to overall complications.
S5	Milstone AM, Reich NG, Advani S, et al./USA	Multicenter retrospective cohort	3967 neonates/nine NICUs	2005-2009	To determine the association of risk of CVC-associated bloodstream infections during the time of permanence of peripherally-inserted central catheters (PICCs) in high-risk newborns.	PICCs with a time of use of 8-13 days, from 14 to 22 days, and those ≥23 days each had an increased risk of infection compared to PICCs that remained ≤7 days (p < 0.05). There was an increased risk of CVC-BSI in neonates with PICCs (adjusted incidence rate ratio of 2.04, 1.12-3.71).
S6	Greenberg RG et al./USA³⁴34 Greenberg RG, Cochran KM, Smith PB, Edson BS, Schulman J, Lee HC, et al. Effect of catheter dwell time on risk of central line-associated bloodstream infection in infants. Pediatrics. 2015;136:1080-6.	Multicenter retrospective cohort	13,327 neonates/141 NICUs	2011-2013	To test the hypothesis that a longer CVC time of use is associated with a higher incidence of CVC-BSI.	Mean gestational age was 29 weeks (interquartile range: 26-33). The incidence of CVC-BSI was 0.93 per 1000 CVC-day. The longer time of device use was not associated with an increased risk of BSI for PICC. For long-term catheters, the incidence of infection was significantly higher at week seven (HR 4.0; 95% CI: 1.1-15, p < 0.004) and week nine (HR 4.7; 1.1-20 p < 0.003) compared to week one.
S7	Yumani DF, van den Dungen FA, van Weissenbruch MM/The Netherlands³⁵35 Yumani DF, van den Dungen FA, van Weissenbruch MM. Incidence and risk factors for catheter-associated bloodstream infections in neonatal intensive care. Acta Paediatr. 2013;102:e293-8.	Retrospective cohort	196 neonates	2007	To determine the incidence and potential risk factors for catheter-associated bloodstream infections in newborns.	18.1 infections/1000 CVC-day (95% CI: 13.7-23.8) according to the adjusted criteria used by the CDC before 2008. Umbilical catheters had a higher infection rate than non-umbilical central catheters (rate ratio = 2.4; 95% CI: 1.2-4, <0.0009), and if it remained for more than five days, the infection rate increased (p < 0.05).
S8	Duarte ED, Pimenta AM, Silva BCNe, Paula CMd./Brazil³⁶36 Duarte ED, Pimenta AM, Silva BC, Paula CM. Fatores associados à infecção pelo uso do cateter central de inserção periférica em unidade de terapia intensiva neonatal. Rev Esc Enferm USP. 2013;47:547-54.	Prospective cohort	233 newborns	2010	To analyze the factors related to infection associated with the use of peripherally-inserted central catheters in neonates admitted at an intensive care unit.	Factors associated with removal due to infection suspicion after multivariate adjustment were: weight < 2500 g at the insertion (RR 1.99; 95% CI: 1.06-3.73, p = 0.031), repair (RR 2.3; 95% CI: 1.08-4.89, p = 0.030); and time of catheter use (RR 1.04; 95% CI: 1.02-1.06, p < 0.0000).
S9	Barbosa MH et al./Brazil³⁷37 Barbosa M, Figueiredo V, Wernet M, Pires P. Infecção de corrente sanguínea relacionada ao uso de cateteres venosos centrais em recém-nascidos. Nursing. 2009;11:82-6.	Retrospective cohort	18 neonates	2005	To analyze the risk factors associated with the occurrence of central venous catheter-associated bloodstream infections in newborns admitted at a neonatal intensive care unit (NICU).	Low birth weight, prematurity, and the use of TPN may have influenced the occurrence of infection.
S10	Shalabi M et al./Canada	Prospective cohort	7919/29 NICU	2010-2013	To compare CVC-BSI rates in preterm infants born at <30 weeks gestation who received a PICC vs. umbilical venous catheter immediately after birth as primary venous access.	There was no significant difference in infants with CVC-BSI/1000 CVC-day between the evaluated groups, although lower rates of late sepsis in the group of infants who received only one umbilical catheter were observed. There was an increase in episodes of late sepsis/1000 CVC-day in the PICC group compared to neonates who had an umbilical catheter and PICC (RR 1.73; 95% CI: 1.15-2.60, p < 0.001).
S11	Bellemin K et al./France	Retrospective cohort	1111/three NICUs	2007-2011	To evaluate incidence and risk factors for CVC-BSI.	The incidence density was 16/1000 CVC-day (95% CI: 14.0-18.2): 6.5 (95% CI: 4.3-9.3) for umbilical CVC and 20.2 (95% CI: 5-23.1) for other CVCs. The median time to CVC-BSI was eight days. In the multivariate analysis, birth weight ≤ 750 g (HR 6.3, 95% CI: 1.0-38.1) and intravenous lipid emulsion (HR 2.3, 95% CI: 1.3-3.9) were significantly associated with CVC-BSI for umbilical CVC. Similar results were observed for other CVCs.
S12	Costa P et al./Brazil	Prospective cohort	383	2010-2012	Identify the risk factors for PICC-associated bloodstream infection in neonates.	In the bivariate analysis, lower mean weight and corrected gestational age, and longer catheter use were associated with the occurrence of CVC-BSI. In the multivariate analysis, corrected gestational age (RR 1.12; 95% CI: 1.061-1.186, p < 0.002), transient metabolic disorder (RR 3.02; 95% CI: 1.72-5.05, p < 0.000), apnea (RR 2.38; 95% CI: 1.10-4.56, p < 0.016), and two-way and polyurethane catheters (RR 3.70; 95% CI: 2.0-6.9, p < 0.0000) were associated with CVC-BSI.
S13	Geffers C, Gastmeier A, Schwab F, Groneberg K, Ruden H, Gastmeier P/Germany⁴¹41 Geffers C, Gastmeier A, Schwab F, Groneberg K, Ruden H, Gastmeier P. Use of central venous catheter and peripheral venous catheter as risk factors for nosocomial bloodstream infection in very-low-birth-weight infants. Infect Control Hosp Epidemiol. 2010;31:395-401.	Multicenter prospective cohort	2126 neonates/22 NICUs	2010	To describe the association between CVC and peripherally-inserted central catheter use and the risk of laboratory-confirmed BSI for newborns with birth weight <1500 g.	The incidence density for BSI was 3.3/1000 patient-days. The use of a central venous catheter (HR 6.2; 95% CI: 3.83-9.97, p < 0.001) was one of the independent significant factors for BSI.
S14	Padula et al./USA⁴²42 Padula MA, Dewan ML, Shah SS, Padula AM, Srinivasan L, McGowan KL, et al. Risk factors associated with laboratory-confirmed bloodstream infections in a tertiary neonatal intensive care unit. Pediatr Infect Dis J. 2014;33:1027-32.	Prospective cohort	409 neonates	2006-2009	To determine the clinical signs and risk factors associated with laboratory-confirmed BSI in patients assessed for late sepsis in a tertiary NICU.	Use of enteral contrast within the previous 48 h was the most significant risk factor for laboratory-confirmed BSI [OR: 9.58 (95% CI: 2.03-45.19)], followed by the presence of a central venous catheter.

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[1] * Corresponding author. E-mail:vivrosado@gmail.com (V. Rosado).