Research Article| Volume 123, P27-33, May 2022

Download started.


Central-line-associated bloodstream infections, multi-drug-resistant bacteraemias and infection control interventions: a 6-year time-series analysis in a tertiary care hospital in Greece

Published:February 08, 2022DOI:



      Central-line-associated bloodstream infections (CLABSIs) are serious healthcare-associated infections with substantial morbidity and hospital costs.


      To investigate the association between the incidence of CLABSIs, the implementation of specific infection control measures, and the incidence of multi-drug-resistant (MDR) bacteraemias in a tertiary care hospital in Greece from 2013 to 2018.


      Analysis was applied for the following indices, calculated monthly: CLABSI rate; use of hand hygiene disinfectants; isolation rate of patients with MDR bacteria; and incidence of bacteraemias [total Gram-negative carbapenem-resistant Acinetobacter baumanii, carbapenem-resistant Pseudomonas aeruginosa and carbapenem-resistant Klebsiella pneumoniae; and Gram-positive meticillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci].


      The total number of bacteraemias from carbapenem-resistant Gram-negative pathogens was significantly correlated with an increased CLABSI rate for all (total) hospital departments [incidence rate ratio (IRR) 1.17, 95% confidence interval (CI) 1.05–1.31, P=0.006] and the adult intensive care unit (ICU) (IRR 1.37, 95% CI 1.07–1.75, P=0.013). In the adult ICU, every increase in the incidence of each resistant Gram-negative pathogen was significantly correlated with a decreased CLABSI rate (carbapenem-resistant A. baumanii: IRR 0.59, 95% CI 0.39–0.90, P=0.015; carbapenem-resistant K. pneumoniae: IRR 0.48, 95% CI 0.25–0.94, P=0.031; carbapenem-resistant P. aeruginosa: IRR 0.54, 95% CI 0.33–0.89, P=0.015). The use of hand disinfectants was correlated with a decreased CLABSI rate 1–3 months before the application of this intervention for all (total) hospital departments (IRR 0.80, 95% CI 0.69–0.93, P=0.005), and for scrub disinfectants in the current month for the adult ICU (IRR 0.34, 95% CI 0.11–1.03, P=0.057). Isolation of patients with MDR pathogens was not associated with the incidence of CLABSIs.


      Hand hygiene was associated with a significant reduction in the incidence of CLABSIs at the study hospital. Time-series analysis is an important tool to evaluate infection control interventions.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hospital Infection
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Centers for Disease Control and Prevention
        National and state healthcare-associated infections progress report.
        CDC, Atlanta, GA2018 (Available at:) ([last accessed January 2022])
        • Centers for Disease Control and Prevention
        Vital signs: central line-associated bloodstream infection – United States, 2001, 2008, and 2009.
        MMWR Morb Mortal Wkly Rep. 2011; 60: 243-248
        • Magill S.S.
        • O'Leary E.
        • Janelle S.J.
        • Thompson D.L.
        • Dumyati G.
        • Nadle J.
        • et al.
        Emerging Infections Program Hospital Prevalence Survey Team. Changes in prevalence of health care associated infection in U.S. hospitals.
        N Engl J Med. 2018; 379: 1732-1744
        • European Centre for Disease Prevention and Control
        Point prevalence survey of healthcare associated infections and antimicrobial use in European acute care hospitals.
        ECDC, Stockholm2019 (Available at:) ([last accessed January 2022])
        • Suetens C.
        • Latour K.
        • Kärki T.
        • Ricchizzi E.
        • Kinross P.
        • Moro M.L.
        • et al.
        Healthcare-Associated Infections Prevalence Study Group. Prevalence of healthcare-associated infections estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017.
        Euro Surveill. 2018; 23: 1800516
        • Zilberberg M.D.
        • Shorr A.F.
        Economic aspects of preventing health care-associated infections in the intensive care unit.
        Crit Care Clin. 2012; 28: 89-97
        • Halton K.A.
        • Cook D.
        • Paterson D.L.
        • Safdar N.
        • Graves N.
        Cost-effectiveness of a central venous catheter care bundle.
        PLoS One. 2010; 5e12815
        • Nuckols T.K.
        • Keeler E.
        • Morton S.C.
        • Anderson L.
        • Doyle B.
        • Booth M.
        • et al.
        Economic evaluation of quality improvement interventions for bloodstream infections related to central catheters: a systematic review.
        JAMA Intern Med. 2016; 176: 1843-1854
        • Park J.Y.
        • Kwon K.T.
        • Lee W.K.
        • Kim H.I.
        • Kim M.J.
        • Song D.Y.
        • et al.
        The impact of infection control cost reimbursement policy on central line-associated bloodstream infections.
        Am J Infect Control. 2020; 48: 560-565
        • O'Grady N.P.
        • Alexander M.
        • Burns L.A.
        • Dellinger E.P.
        • Garland J.
        • Heard S.O.
        • et al.
        Healthcare Infection Control Practices Advisory Committee. Guidelines for the prevention of intravascular catheter-related infections.
        Clin Infect Dis. 2011; 52: e162-e193
        • Rupp S.M.
        • Apfelbaum J.L.
        • Blitt C.
        • Caplan R.A.
        • Connis R.T.
        • Domino K.B.
        • et al.
        Practice guidelines for central venous access: a report by the American Society of Anesthesiologists Task Force on Central Venous Access.
        Anesthesiology. 2012; 116: 539-573
        • Schiffer C.A.
        • Mangu P.B.
        • Wade J.C.
        Camp-Sorrell D, Cope DG, El-Rayes BF, et al. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline.
        J Clin Oncol. 2013; 31: 1357-1370
        • Ling M.L.
        • Apisarnthanarak A.
        • Jaggi N.
        • Harrington G.
        • Morikane K.
        • Thu le T.A.
        • et al.
        APSIC guide for prevention of central line associated bloodstream infections (CLABSI).
        Antimicrob Resist Infect Control. 2016; 5: 16
        • Weiner-Lastinger L.M.
        • Abner S.
        • Edwards J.R.
        • Kallen A.J.
        • Karlsson M.
        • Magill S.S.
        • et al.
        Antimicrobial-resistant pathogens associated with adult healthcare-associated infections: summary of data reported to the National Healthcare Safety Network, 2015–2017.
        Infect Control Hosp Epidemiol. 2020; 41: 1-18
        • Schuts E.C.
        • Hulscher M.E.J.L.
        • Mouton J.W.
        • Verduin C.M.
        • Stuart J.W.T.C.
        • Overdiek H.W.P.M.
        • et al.
        Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis.
        Lancet Infect Dis. 2016; 16: 847-856
        • Baur D.
        • Gladstone B.P.
        • Burkert F.
        • Carrara E.
        • Foschi F.
        • Döbele S.
        • et al.
        Effect of antibiotic stewardship on the incidence of infection and colonisation with antibiotic-resistant bacteria and Clostridium difficile infection: a systematic review and meta-analysis.
        Lancet Infect Dis. 2017; 17: 990-1001
        • Chandramohan S.
        • Navalkele B.
        • Mushtaq A.
        • Krishna A.
        • Kacir J.
        • Chopra T.
        Impact of a multidisciplinary infection prevention initiative on central line and urinary catheter utilization in a long-term acute care hospital.
        Open Forum Infect Dis. 2018; 5: ofy156
        • Hansen S.
        • Schwab F.
        • Schneider S.
        • Sohr D.
        • Gastmeier P.
        • Geffers C.
        Time-series analysis to observe the impact of a centrally organized educational intervention on the prevention of central-line-associated bloodstream infections in 32 German intensive care units.
        J Hosp Infect. 2014; 87: 220-226
        • Flett K.B.
        • Ozonoff A.
        • Graham D.A.
        • Sandora T.J.
        • Priebe G.P.
        Impact of mandatory public reporting of central line-associated bloodstream infections on blood culture and antibiotic utilization in pediatric and neonatal intensive care units.
        Infect Control Hosp Epidemiol. 2015; 36: 878-885
        • Dandoy C.E.
        • Hausfeld J.
        • Flesch L.
        • Hawkins D.
        • Demmel K.
        • Best D.
        • et al.
        Rapid cycle development of a multifactorial intervention achieved sustained reductions in central line-associated bloodstream infections in haematology oncology units at a children's hospital: a time series analysis.
        BMJ Qual Saf. 2016; 25: 633-643
        • Hsu H.E.
        • Mathew R.
        • Wang R.
        • Broadwell C.
        • Horan K.
        • Jin R.
        • et al.
        Health care-associated infections among critically ill children in the US, 2013–2018.
        JAMA Pediatr. 2020; 174: 1176-1183
        • Wright M.O.
        • Decker S.G.
        • Allen-Bridson K.
        • Hebden J.N.
        • Leaptrot D.
        Healthcare-associated infections studies project: an American Journal of Infection Control and National Healthcare Safety Network data quality collaboration: location mapping.
        Am J Infect Control. 2018; 46: 577-578
        • Mermel L.A.
        • Allon M.
        • Bouza E.
        • Craven D.E.
        • Flynn P.
        • O'Grady N.P.
        • 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
        • National Healthcare Safety Network
        Bloodstream infection event (central line-associated bloodstream infection and non-central line associated bloodstream infection).
        Centers for Disease Control and Prevention, Atlanta, GA2022 (Available at:) ([last accessed January 2022])
      1. Centers for Disease Control and Prevention. Central line-associated bloodstream infections. Atlanta, GA: CDC. Available at: [last accessed January 2022].

        • Yokoe D.S.
        • Anderson D.J.
        • Berenholtz S.M.
        • Calfee D.P.
        • Dubberke E.R.
        • Ellingson K.D.
        • et al.
        A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates.
        Infect Control Hosp Epidemiol. 2014; 35: 967-977
        • Klevens R.M.
        • Edwards J.R.
        • Richards Jr., C.L.
        • Horan T.C.
        • Gaynes R.P.
        • Pollock D.A.
        • et al.
        Estimating health care-associated infections and deaths in US hospitals: 2002.
        Public Health Rep. 2007; 122: 160-166
        • Dicks K.V.
        • Lofgren E.
        • Lewis S.S.
        • Moehring R.W.
        • Sexton D.J.
        • Anderson D.J.
        A multicenter pragmatic interrupted time series analysis of chlorhexidine gluconate bathing in community hospital intensive care units.
        Infect Control Hosp Epidemiol. 2016; 37: 791-797
        • Taylor J.E.
        • McDonald S.J.
        • Earnest A.
        • Buttery J.
        • Fusinato B.
        • Hovenden S.
        • et al.
        A quality improvement initiative to reduce central line infection in neonates using checklists.
        Eur J Pediatr. 2017; 176: 639-646
        • Gohil S.K.
        • Yim J.
        • Quan K.
        • Espinoza M.
        • Thompson D.J.
        • Kong A.P.
        • et al.
        Impact of a central-line insertion site assessment (CLISA) score on localized insertion site infection to prevent central-line-associated bloodstream infection (CLABSI).
        Infect Control Hosp Epidemiol. 2020; 41: 59-66
        • Monegro A.F.
        • Muppidi V.
        • Regunath H.
        Hospital acquired infections.
        Stat Pearls, Treasure Island, FL2022
        • Maltezou H.C.
        • Kontopidou F.
        • Dedoukou X.
        • Katerelos P.
        • Gourgoulis G.M.
        • Tsonou P.
        • et al.
        Working Group for the National Action Plan to Combat Infections due to Carbapenem-Resistant, Gram-Negative Pathogens in Acute-Care Hospitals in Greece. Action plan to combat infections due to carbapenem-resistant, Gram-negative pathogens in acute-care hospitals in Greece.
        J Glob Antimicrob Resist. 2014; 2: 11-16
        • Haessler S.
        • Martin E.M.
        • Scales M.E.
        • Kang L.
        • Doll M.
        • Stevens M.P.
        • et al.
        Stopping the routine use of contact precautions for management of MRSA and VRE at three academic medical centers: an interrupted time series analysis.
        Am J Infect Control. 2020; 48: 1466-1473
        • Perneger T.V.
        What's wrong with Bonferroni adjustments.
        BMJ. 1998; 316: 1236-1238