Prescription Precision: An Exploration into Antimicrobial Management of Central-Line Associated Bloodstream Infections at UC San Diego Health
Abstract
Background
Central-line associated bloodstream infections (CLABSIs) are a major source of preventable morbidity and mortality in hospitalized patients. Antimicrobial stewardship (AMS) practices are key in preventing antimicrobial resistance in healthcare-associated infections such as CLABSIs. According to the CDC and IDSA guidelines, this includes initiation of empiric antimicrobial therapy, followed by de-escalation of antimicrobials once microbiological data is available. Suboptimal AMS practices result in disrupted microbiome and selection of resistant organisms and are associated with increased morbidity and mortality, cost of care, and duration of hospitalization. This study aims to characterize patterns associated with CLABSIs in patients hospitalized at UC San Diego Health and to analyze AMS practices in the management of CLABSIs, including empiric choices, de-escalation, and the consultation with the infectious diseases team.
Methods
Electronic medical records were reviewed to identify hospitalized patients with a CLABSI (N=39) between July 1, 2022 and June 30, 2023 at Jacobs Medical Center (JMC) and Hillcrest Medical Center (HMC). Patients who met the NHSN surveillance case definition of CLABSI (defined as a positive blood culture in patients with a central line at the time of infection, or within 48 hours before the development of an infection, without an alternate source of bacteremia) were included in the analysis. Central line-associated mucosal barrier infections were excluded per NHSN definitions. Chart review was conducted to analyze pathogens involved, de-escalation patterns, and the Infectious Diseases team's contribution in each case. After completion of chart review, two infectious disease physicians reviewed the cases to assess the appropriateness of treatment, including empiric therapy, and appropriate and timely responses to antimicrobial de-escalation.
Results
24 patients at JMC and 15 patients at HMC met the case definition of CLABSI. At JMC, the most frequent organisms were vancomycin-resistant enterococcus (12.5%), methicillin- sensitive Staphylococcus aureus (12.5%), and Pseudomonas aeruginosa (12.5%). At HMC, the most frequent organisms were polymicrobial (20%), enterococcus (13.3%), and vancomycin-resistant enterococcus (13.3%). Of note, at HMC, three cases had Candida fungemia, with two of them having Candida as the only organism. 82% of cases across both sites included an ID consultation, and all cases exhibited appropriate antimicrobial treatment and stewardship practices.
Conclusions
At both hospitals, appropriate antimicrobial management and stewardship was uniformly followed, reflecting a strong commitment at UCSD Health to optimizing antibiotic use and minimizing selection of resistance. The infectious disease team was involved in the care of the majority of the CLABSI cases. Lastly, there were slight variations in the most common causative organisms between JMC and HMC, a difference that is likely attributable to the difference in patient populations and the presence of more complex services at JMC. These results suggest that UCSD policies and training surrounding CLABSI management are appropriate and being implemented by healthcare teams. Examining other healthcare associated infections, such as catheter-associated urinary tract infections or ventilator- associated pneumonias, is an important next step to gain insight into infection trends and stewardship practices at UCSD Health.