Don't Jump to Conclusions, a Central Line-associated Bloodstream Infection Pseudo-Outbreak Investigation

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      Central-line associated bloodstream infections (CLABSI) are serious infections that have significant morbidity and mortality. Our institution tracks CLABSIs in all settings. Between February 2021 to March 2021, surveillance by our Infection Prevention and Control Department identified five Portacath (PAC) CLABSIs with methicillin susceptible Staphylococcus aureus (MSSA) in pediatric oncology patients. This was a significant increase from our baseline of 3 MSSA PAC CLABSI in the 12 months prior, initiating an outbreak investigation.


      A line list was created and identified two epidemiologic links: all PAC were placed in interventional radiology (IR), and primary points of access were ambulatory oncology clinics. There was no common product used. Four of the five infections had identical antimicrobial susceptibility profiles. Pulsed-field Gel Electrophoresis (PFGE) was performed to discriminate between isolates.  Observations in IR for line placement were performed with attention to skin preparation. Ambulatory oncology observations were performed to review skin preparation for PAC access and hand hygiene practices. We confirmed with the PAC manufacturer there were no recalls of the PAC lot numbers.


      All 5 isolates were unrelated by PFGE and, therefore excluded a true outbreak.  Observations in IR revealed variabilities in skin preparation and recommendations were made to standardize practices to align with those in our operating rooms. Although no variations in practice were noted in ambulatory oncology this was used as an opportunity to re-educate staff on the attention to detail for PAC access.


      Outbreak identification by traditional epidemiologic methods are complemented with technology such as PFGE to identify conclusive links between patients and can demonstrate when an apparent outbreak is not due to a single pathogen. Obtaining PFGE data supported broad-based interventions including observations of practice at the time of line insertion and access, as well as reeducation to providers performing these roles, to reduce CLABSI in our institution.
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