Date of Award

5-8-2022

Degree Type

Thesis

Degree Name

MS in Epidemiology & Biostatistics

First Advisor

Dr. Fatima Mir

Second Advisor

Dr. Faisal Mahmood

Third Advisor

Mr. Syed IqbalAzam

Department

Community Health Sciences

Abstract

Background: Hospital Acquired Infections (HAIs); are infections in patients during the process of hospital stay which was not present at the time of admission. They are the most common adverse effect of health care delivery and cause of prolonged hospital stay, high costs and are a significant cause of morbidity and mortality. Central line-associated bloodstream infections (CLABSI) are a common cause of HAIs. No systematic reliable estimates of HAI are available from Pakistan. Several modifiable and non-modifiable risk factors have been identified but their significance varies depending upon the population being studied and local environment.The current study aims to identify local predictors of CLABSI to make appropriate recommendations to decrease the rate of infection based on modifiable predictors
Methods: We conducted a cohort study from 1st January 2019 to 31st June 2020 at Dr.Ziauddin University Hospital, Karahi Pakistan.The cohort represented all adult patients who were admitted to the ICU and had a central line placed. They wereenrolled through consecutive sampling and followed up till discharge or till removal of central line or development of CLABSI whichever came first. Two hundred seventeen patients were enrolled in the study.Data was collected using a structured questionnaire for demographic and clinical variables atadmission which included age, sex,comorbidities like Diabetes Mellitus (DM), heart disease (CHD),chronic kidney disease (CKD) &chronic liver disease (CLD). Additional variables ascertained were number of days from hospital admission to central line placement, total number of central line days, site of central line placement, prior antibiotic use and days of total parenteral nutrition days through line.The event of interest was the development of CLABSI after insertion of central line and time to the development of CLABSI. Patients with central line, who were discharged without CLABSI or LAMA were considered censored.Cross tabulations between CLABSI status and categorical demographic & clinical variables were done. Mean time to CLABSI with 95% confidence interval were also computed using Kaplan Meier method. Variables were also tested for proportional hazard assumption. The choice of appropriate Parametric regression technique for survival data was made. Finally, Parametric regression technique with Weibull distribution was applied to identify significant risk factorsat the univariate and multivariable levels. The results are reported as crude and adjusted hazard ratios with 95% confidence intervals. Plausbile binary interactions were also assessed with a p-value< 0.1. Multicollinearity were also assessed after univariate analysis for the variables which were eligible for multivariable analysis i.e. either had p-value>< 0.25 or biologically plausible as candidate for interaction.The study was approved by the Aga Khan and Ziauddin Universities EthicalReview Committees. Results A total of 217 adult ICU patientswho had central line placed either on or several days after admission were enrolled from Ziauddin University hospital. The CLABSI incidence was found to be 34% (76/217). The highest number of infections were noted between days 4-9 peaking at day 5 and day 6. Age (P=0.033), Femoral Site of central line compared to Internal Jugular (P=0.039), cardiac disease (HTN,IHD,CCF) (P=0.001) and chronic kidney disease (P=0.009) were found to be significant risk factors at univariate level. Cardiac Disease (aHR=1.87; 95% CI:1.17,2.98; P=0.008), Femoral site central line site in comaprison to Internal Jugular (aHR=1.63;95% CI:1.00,2.66; P=0.049) and Age (aHR 1.026, 95% CI: 1.00,1.044;P= 0.003) were found to be significant risk factors at multivariable level. No multicollinearity and significant interactions were observed. Conclusion Thepredictive factors for CLABSI in our study are the placement of the central line in the Femoral vein compared toIternal Jugular vein placement, presence of cardiac disease (mostly Hypertension and IHD) and Age. Studies are needed to ascertain other important factors like number of personnel handling the line, infection control practices and baseline risk of infections in the hospital setting. Mitigation strategies could target placement of central line in the Internal Jugular vein rather than femoral vein, control of cardiac risk factors and aggressive infection control measure along with early removal of central lines if clinically relevant or resiteearly if prolonged access is deemed necessary. Also high vigilance for infection in patients with heart and kidney disease>< 0.1. Multicollinearity were also assessed after univariate analysis for the variables which were eligible for multivariable analysis i.e. either had p-value< 0.25 or biologically plausible as candidate for interaction.The study was approved by the Aga Khan and Ziauddin Universities EthicalReview Committees. >< 0.25 or biologically plausible as candidate for interaction.The study was approved by the Aga Khan and Ziauddin Universities EthicalReview Committees.
Results: A total of 217 adult ICU patientswho had central line placed either on or several days after admission were enrolled from Ziauddin University hospital. The CLABSI incidence was found to be 34% (76/217). The highest number of infections were noted between days 4-9 peaking at day 5 and day 6. Age (P=0.033), Femoral Site of central line compared to Internal Jugular (P=0.039), cardiac disease (HTN,IHD,CCF) (P=0.001) and chronic kidney disease (P=0.009) were found to be significant risk factors at univariate level. Cardiac Disease (aHR=1.87; 95% CI:1.17,2.98; P=0.008), Femoral site central line site in comaprison to Internal Jugular (aHR=1.63;95% CI:1.00,2.66; P=0.049) and Age (aHR 1.026, 95% CI: 1.00,1.044;P= 0.003) were found to be significant risk factors at multivariable level. No multicollinearity and significant interactions were observed.
Conclusion: Thepredictive factors for CLABSI in our study are the placement of the central line in the Femoral vein compared toIternal Jugular vein placement, presence of cardiac disease (mostly Hypertension and IHD) and Age. Studies are needed to ascertain other important factors like number of personnel handling the line, infection control practices and baseline risk of infections in the hospital setting. Mitigation strategies could target placement of central line in the Internal Jugular vein rather than femoral vein, control of cardiac risk factors and aggressive infection control measure along with early removal of central lines if clinically relevant or resiteearly if prolonged access is deemed necessary. Also high vigilance for infection in patients with heart and kidney disease.

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