The Risk Factors And Prevention Of Catheter-related Bloodstream Infections In PICC For Premature Infants

Objective:As peripheral catheterization is widely used in neonatal treatment now,patients often undergo PICC catheterization.The newborns,especially the premature infants,are most of time in critical conditions with low resistance and complications.It is high likely to cause Catheter-related Blood Stream Infection(CRBSI)as a result of the invasive operations during PICC,which reduces the quality of life of the patients,prolongs the hospitalization and increases the cost,some may even lead to the death of the newborns.1.To understand the incidence,risk factors and related expenses during hospitalization of CRBSI in premature infants.2.To understand the distribution of pathogenic microorganisms in CRBSI of premature infants.3.To explore the feasibility of the action research theory in preventing the incidence of CRBSI in NICU premature infants,and to establish a suitable scheme for NICU patients.Methods:1.Retrospective case-control study: we collected the data of 69 premature infants with CRBSI in NICU hospitalized from January 2017 to January 2019 in three hospitals of shanxi Province.Criteria: newborns with gestational age less than 37 weeks;operated PICC when first hospitalized in NICU after observation and nursing;CRBSI occurred at least 48 hours after or extubation within 48 hours the catheterization is operated.Exclusion criteria: PICC existed before the hospitalization;skin infected at the site of catheterization before PICC.PICC duration less than 48h;treatment withdrawn and patient dischargedunder the parents' request;patients with incomplete information.The exclusion criteria for CRBSI is: infants younger than 48 h old who do not meet the diagnostic criteria for nosocomial infection.Base on the number of CRBSI cases,which is 69,we collected 207 cases of NICU preterm infants without CRBSI at a ratio of 1: 3,which makes a total of 276 cases.The collected clinical data mainly included: gender,gestational age,age in days,hospital admission number,major disease diagnosis,birth weight,catheterization duration,duration of PICC catheter indwelling,PICC indwelling vessels,times for first catheterization,5-minute Apgar score,whether the mother delivered vaginally or not,with or without pregnancy complications,etc.The general epidemiological characteristics of premature infants with CRBSI were analyzed,and the clinical characteristics of infants without CRBSI were compared.The risk factors related to CRBSI were analyzed by binary Logistic regression.The hospital expenses of 72 premature infant patients without CRBSI were compared with those of those with CRBSI.2.Detection of pathogenic microorganisms: blood culture was carried out by double-sided and double-bottle method,and blood samples were cultured by HP/PYP blood culture bottles.The identification of bacterial species was carried out by the automatic microbiological analyzer of the French company merieux.The contaminated samples were excluded by the doctors of the NICU and the infectious-medicine department together to determine whether the blood samples were the pathogenic microorganisms causing CRBSI.3.Non-randomized controlled experimental study: two spiral-loop program implementation was carried out based on the theory of action research.The theory of action research includes four main components: plan--action--observation--reflection.After the first round of reflection,the plan--action again--observation--reflection was modified according to the results of reflection.Such a spiral of perfecting the process until the research results.After consulting literatures and referring to the latest and effective methods of PICC nursing of premature infants home and abroad while considering the characteristics of NICU premature infant nursing,a nursing team was established and theprevention program of CRBSI for premature infants was preliminarily formulated.Each cycle was completed in a spiral process according to the following aspects: plan,action,observation and reflection.And the nursing team was fully involved in the planning,implementing,observation and improvement of the program.Through the combination of observation method and questionnaire survey,data were collected to confirm the feasibility and effectiveness of the spiral cycle program which uses action research method.Results:1.baseline investigation: from January 2017 to January 2019,there were 1,950 premature infants in the NICU of the three hospitals,including 1,054 male infants and 896 female infants.A total of 69 premature infants(41 males and 28 females)developed CRBSI.37 of them with an age ?1 day and 32 with an age > 1 day;23 with a weight <1500g,46 with a weight?1500g;36 of them with a gestational age < 27 weeks,24 with a gestational age between 27 and 32 weeks,and 9 with a gestational age between 32 and 37 weeks.The case –time rate of CRBSI was 3.53%(69/1950)and the incidence of CRBSI was 6.86/‰(69/10051).univariate analysis results show: that the risk factors for CRBSI in NICU premature infants were: gestational age(P < 0.001),weight(P < 0.001),ways of delivery(P < 0.001),the regular usage of antibiotic(P < 0.001),5 minutes Apgar score(P < 0.001),duration of catheter indwelling(P < 0.001),PICC puncture times(P < 0.001),catheter puncturing operation time(P < 0.001),catheter obstruction(P = 0.002),catheter displacement(P <0.001).while the following factors are not relevant to the occurrence of CRBSI: the gender(P = 0.470),age in days(P = 0.780),ethnicity(P = 1.000),place of residence(P = 0.263),major diagnosis of the newborn's diseases(P = 0.449),maternal diseases during pregnancy(P = 0.521),medical insurance type(P = 0.797),puncturing(P = 0.122),dressing change time(P = 0.161),seasons(P = 0.132),therefore they are not statistically significant.The results of multivariate analysis: Combing the variables of statistically significance in the results of univariate analysis with the multivariate analysis,the results of binaryLogistic regression analysis showed that: low gestational age was a risk factor for CRBSI in premature infants.The risk of infection in Infants with gestational age of 27-32 weeks was 1.636 times lower than that in infants with gestational age of less than 27 weeks(P =0.012,OR = 2.636,95%CI = 1.240~5.605).Comparing with patients with a weight less than 1500 g,patients who weigh more had a 3.062 times lower infection rate(P=0.054,OR= 4.062,95%CI = 0.974~16.936).Comparing with cesarean delivery,the risk of infection was reduced by 8.043 times(P < 0.001,OR = 9.043,95%CI = 2.697~30.328).Duration of catheter indwelling was a risk factor,and the risk of CRBSI infection was 3.186 times higher in premature infants with PICC indwelling of(7-14 days)than those with(7 days)(P < 0.001,OR = 4.186,95%CI = 2.304~7.606).The more punctures in catheter operation,the higher the risk of CRBSI,the risk of infection increases by 2.033 times with each one more puncture(P=0.002,OR=3.033,95%CI=1.507~6.102).Patients with a blocked catheter had a 4.958 fold increased risk of infection compared to those without a blocked catheter(P = 0.099,OR = 5.958,95%CI = 0.714~49.704).Patients with catheter displacement had a 4.401-fold increased risk of infection comparing to those without catheter displacement,(P = 0.006,OR = 5.401,95%CI = 1.633~17.866).The longer the nursing staff spend in catheterization,the greater the risk of CRBSI is.The risk of CRBSI in premature infants increased by 6.257 times when the catheter placement is done in30-60 minutes,comparing to that is completed within 30 minutes(P < 0.001,OR = 7.257,95%CI = 3.349~15.728).The results of economic analysis showed that the average gestational age of CRBSI preterm infants and non-CRBSI preterm infants was 28-31 weeks.Generally,the hospitalization duration of CRBSI infants was 56-71 days,averagely 62 days.infants without CRBSI were hospitalized 33 to 54 days,with an average of 44 days.The total hospitalization cost for CRBSI infants was 173,627.00 yuan,while the total hospitalization cost for non-CRBSI patients was 112,892.32 yuan.The hospitalization cost of CRBSI infants was higher than that of non-CRBSI infants at all gestational ages.The hospitalization cost of CRBSI children with a weight < 1000 g was 56,627 yuan higher than those weigh more than 1000 g.Among the non-CRBSI infants,the ones with a body mass< 1000 g spend 7675.5 more than those with a weight > 1000 g.2.Monitoring results of pathogenic microorganisms: a total of 69 cases of pathogenic bacteria were detected,among which 38 cases were gram-positive(55.05%)and 15 cases were coagulase-negative staphylococcus(21.73%).The most common pathogen was klebsiella pneumoniae in 6 cases(8.70%).There were 6 cases(8.70%)of fungi,and 6 cases were all near-smooth candida.3.After two rounds of spiral cycle based on the action research theory,the incidence of CRBSI in premature infants decreased significantly.The CRBSI infection rate was1.87‰ during March-May 2019,and 2.82‰ after the first spiral cycle,with no statistical significance between the two.(P > 0.05,c2 = 0.148);The infection rate after the second round dropped sharply to 0.34‰.The infection rate comparison between the two rounds was statistically significant(P < 0.05,c2 = 5.729).After two rounds of observation and supervision,the scores of the nursing team in the second round of PICC-related technical operation was significantly higher than that in the first round and they had statistical significance.Conclusion:1.The main risk factors for premature infants with CRBSI: gestational age,weight,ways of maternal delivery,catheter indwelling time,puncture times,catheter displacement,duration of indwelling and Catheter jam.2.The duration of hospitalization and hospitalization cost of premature infants with CRBSI were higher than those without CRBSI,and the lighter the body weighs,the higher the hospitalization cost is.3.The most common pathogenic microorganism in premature infants CRBSI is coagulase negative staphylococcus.4.The application of action research method has reduced the incidence of CRBSI in premature infants and improved the nursing staff's performance in PICC operation,which is worth trying in the field of NICU.