In this retrospective cohort study, we found that only 3.7% of patients who received a central line catheter insertion in ED developed CRBSI, and the occurrence of CRBSI was an independent risk factor for in-hospital mortality. These findings suggest that CRBSI is a relatively common and serious complication in patients who have to undergo central line insertion in ED.
Despite the increasing awareness about CRBSI-associated mortality, morbidity, and excess medical burden, the incidence of this nosocomial infection is increasing, ranging from 3–20% depending on the study population8–10. A recent population-based study reported that CRBSI occurred in 19.2% of patients with suspected systemic inflammatory response syndrome11. However, there is only limited data exploring the incidence of CRBSI in patients who undergo catheter insertion in the ED. Although we could not collect detailed clinical data, such as the severity of the acute illness, specific diagnosis, and indications of central line catheterization, the incidence of CRBSI was quite similar to that reported by previous research12,13. Additionally, the risk factors for occurring CRBSI, including age, TPN, hemodialysis, and repeated trials, have also been cited in the literature14,15. Notably, repeated trials for insertion were the most potent predictor for mortality (adjusted OR: 3.11, 95% CI: 1.28–7.53). This finding underscores the importance of efforts to place the catheter in a single trial, such as ultrasound-guided access, for reducing the incidence of CRBSI16.
Saliba et al.6 found that Staphylococcus species were the most common causative microorganism for CRBSI, which was also observed in our study – notably Staphylococcus epidermidis was more common than Staphylococcus aureus. Furthermore, in cases where longer maintenance of catheterization (usually > 10 days) is required, endoluminal spread from the catheter hub is a known pathway for infection17. Colonization by cutaneous pathogens along the external skin of the catheter was found to be the main cause of bacteremia in our study. Therefore, sterilization efforts for strengthening the infection bundle, including hand hygiene, aseptic skin preparation, and avoidance of inappropriate insertion sites, must be enforced to reduce CRBSI after catheterization in ED18,19.
Owing to the extensive research and implementation of aggressive monitoring and management strategies in patients with suspected CRBSI, CRBSI-associated mortality has decreased considerably over recent years20,21. Nevertheless, the correlation between the occurrence of CRBSI and greater mortality is inconsistent. Similar to previous studies, we also found that the development of CRBSI was an independent risk factor for in-hospital mortality22,23. On the other hand, other retrospective cohort studies revealed that CRBSI was not an attributable factor in increasing ICU mortality11,24. There are multiple plausible explanations for this. First, the characteristics of the study populations are quite different from each other since age, underlying illnesses, and severity of active disease could have affected the mortality. Second, the management of patients with suspected CRBSI, including the timing of catheter removal and selection of empirical antibiotics, was not identical. Accordingly, future research must utilize a randomized controlled study design to provide high-level evidence about the association between mortality and CRBSI.
There were some limitations to our study. This was a single-centered retrospective study design which limits the generalizability of our results. The severity of disease, the patient's clinical profile in the ED, and the expertise of professionals dispensing these interventions would differ in each hospital. Moreover, we could not exclude several hidden confounding factors, such as sterile technique during insertion and manage, and include information about additional treatment outside ED. Despite the limitations, the strength of our study is its relatively large sample size of patients and the inclusion of various factors in the multivariate analysis of CRBSI and in-hospital mortality.
In conclusion, we found that CRBSI after central line insertion in the ED is a fairly common complication and is associated with poor outcomes such as in-hospital mortality. Management and prevention measures to reduce the occurrence of CRBSI are warranted to improve both clinical and patient outcomes.