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Central Line–Associated Bloodstream Infections in Neonates with Gastrointestinal Conditions: Developing a Candidate Definition for Mucosal Barrier Injury Bloodstream Infections

  • Susan E. Coffin (a1) (a2), Sarah B. Klieger (a1), Christopher Duggan (a3) (a4), W. Charles Huskins (a5), Aaron M. Milstone (a6), Gail Potter-Bynoe (a7), Bram Raphael (a3) (a4), Thomas J. Sandora (a4) (a7) (a8), Xiaoyan Song (a9), Danielle M. Zerr (a10) and Pediatric Prevention EpiCenter Consortium (a4) (a7) (a8) (a11)...



To develop a candidate definition for central line–associated bloodstream infection (CLABSI) in neonates with presumed mucosal barrier injury due to gastrointestinal (MBI-GI) conditions and to evaluate epidemiology and microbiology of MBI-GI CLABSI in infants


Multicenter retrospective cohort study.


Neonatal intensive care units from 14 US children’s hospitals and pediatric facilities.


A multidisciplinary focus group developed a candidate MBI-GI CLABSI definition based on presence of an MBI-GI condition, parenteral nutrition (PN) exposure, and an eligible enteric organism. CLABSI surveillance data from participating hospitals were supplemented by chart review to identify MBI-GI conditions and PN exposure.


During 2009–2012, 410 CLABSIs occurred in 376 infants. MBI-GI conditions and PN exposure occurred in 149 (40%) and 324 (86%) of these 376 neonates, respectively. The distribution of pathogens was similar among neonates with versus without MBI-GI conditions and PN exposure. Fifty-nine (16%) of the 376 initial CLABSI episodes met the candidate MBI-GI CLABSI definition. Subsequent versus initial CLABSIs were more likely to be caused by an enteric organism (22 of 34 [65%] vs 151 of 376 [40%]; P = .009) and to meet the candidate MBI-GI CLABSI definition (19 of 34 [56%] vs 59 of 376 [16%]; P < .01).


While MBI-GI conditions and PN exposure were common, only 16% of initial CLABSIs met the candidate definition of MBI-GI CLABSI. The high proportion of MBI-GI CLABSIs among subsequent infections suggests that infants with MBI-GI CLABSI should be a population targeted for further surveillance and interventional research.

Infect Control Hosp Epidemiol 2014;35(11):1391–1399


Corresponding author

Division of Infectious Diseases, Children’s Hospital of Philadelphia, 3535 Market Street, Suite 1579, Philadelphia, PA 19104 (


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1. Dudeck, MA, Horan, T, Peterson, KD, et al. National Healthcare Safety Network report, data summary for 2011, device-associated module. Am J Infect Control 2013;41(4):286300. doi:10.1016/j.ajic.2013.01.002.
2. Miller, MR, Griswold, M, Harris, JM, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 2010;125(2):206213. doi:10.1542/peds.2009–1382.
3. Wheeler, DS, Giaccone, MJ, Hutchinson, N, et al. A hospital-wide quality-improvement collaborative to reduce catheter-associated bloodstream infections. Pediatrics 2011;128(4):e995–e1007. doi:10.1542/peds.2010–2601.
4. Bizzarro, MJ, Sabo, B, Noonan, M, Bonfiglio, MP, Northrup, V, Diefenbach, K. A quality improvement initiative to reduce central line–associated bloodstream infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2010;31(3):241248. doi:10.1086/650448.
5. Schulman, J, Stricof, R, Stevens, TP, et al. Statewide NICU central-line-associated bloodstream infection rates decline after bundles and checklists. Pediatrics 2011;127(3):436444. doi:10.1542/peds.2010–2873.
6. Steinberg, JP, Robichaux, C, Tejedor, SC, Reyes, MD, Jacob, JT. Distribution of pathogens in central line–associated bloodstream infections among patients with and without neutropenia following chemotherapy: evidence for a proposed modification to the current surveillance definition. Infect Control Hosp Epidemiol 2013;34(2):171175. doi:10.1086/669082.
7. Fraser, TG, Gordon, SM. CLABSI rates in immunocompromised patients: a valuable patient centered outcome? Clin Infect Dis 2011;52(12):14461450. doi:10.1093/cid/cir200.
8. Beekmann, SE, Diekema, DJ, Huskins, WC, et al. Diagnosing and reporting of central line–associated bloodstream infections. Infect Control Hosp Epidemiol 2012;33(9):875882. doi:10.1086/667379.
9. Sexton, DJ, Chen, LF, Anderson, DJ. Current definitions of central line–associated bloodstream infection: is the emperor wearing clothes? Infect Control Hosp Epidemiol 2010;31(12):12861289. doi:10.1086/657583.
10. Lukenbill, J, Rybicki, L, Sekeres, MA, et al. Defining incidence, risk factors, and impact on survival of central line-associated blood stream infections following hematopoietic cell transplantation in acute myeloid leukemia and myelodysplastic syndrome. Biol Blood Marrow Transplant 2013;19(5):720724. doi:10.1016/j.bbmt.2013.01.022.
11. DiGiorgio, MJ, Fatica, C, Oden, M, et al. Development of a modified surveillance definition of central line–associated bloodstream infections for patients with hematologic malignancies. Infect Control Hosp Epidemiol 2012;33(9):865868. doi:10.1086/667380.
12. See, I, Iwamoto, M, Allen-Bridson, KT, Horan, T, Magill, SS, Thompson, ND. Mucosal barrier injury laboratory-confirmed bloodstream infection: results from a field test of a new National Healthcare Safety Network definition. Infect Control Hosp Epidemiol 2013;34(8):769776. doi:10.1086/671281.
13. Cole, CR, Frem, JC, Schmotzer, B, et al. The rate of bloodstream infection is high in infants with short bowel syndrome. J Pediatr 2010;156:941947.
14. Centers for Disease Control and Prevention (CDC). 17 CDC NHSN surveillance definitions. Atlanta: CDC, 2012.
15. Squires, RH, Duggan, C, Teitelbaum, DH, et al. Natural history of pediatric intestinal failure: initial report from the pediatric intestinal failure consortium. J Pediatr 2012;161(4):723728.e2. doi:10.1016/j.jpeds.2012.03.062.
16. Graham, PL III, Begg, MD, Larson, E, Della-Latta, P, Allen, A, Saiman, L. Risk factors for late onset gram-negative sepsis in low birth weight infants hospitalized in the neonatal intensive care unit. Pediatr Infect Dis J 2006;25(2):113117. doi:10.1097/01.inf.0000199310.52875.10.
17. Niedner, MF, Huskins, WC, Colantuoni, E, et al. Epidemiology of central line–associated bloodstream infections in the pediatric intensive care unit. Infect Control Hosp Epidemiol 2011;32(12):12001208. doi:10.1086/662621.
18. Blanchard, AC, Fortin, E, Rocher, I, et al. Central line–associated bloodstream infection in neonatal intensive care units. Infect Control Hosp Epidemiol 2013;34(11):11671173. doi:10.1086/673464.
19. Advani, S, Reich, NG, Sengupta, A, Gosey, L, Milstone, AM. Central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: extending risk analyses outside the intensive care unit. Clin Infect Dis 2013;52(9):11081115. doi:10.1093/cid/cir145.
20. Hocevar, SN, Edwards, JR, Horan, TC, Morrell, GOC, Iwamoto, M, Lessa, FC. Device-associated infections among neonatal intensive care unit patients: incidence and associated pathogens reported to the National Healthcare Safety Network, 2006–2008. Infect Control Hosp Epidemiol 2012;33(12):12001206. doi:10.1086/668425.
21. MacFie, J, Reddy, BS, Gatt, M, Jain, PK, Sowdi, R, Mitchell, CJ. Bacterial translocation studied in 927 patients over 13 years. Br J Surg 2005;93(1):8793. doi:10.1002/bjs.5184.
22. MacFie, J, O’Boyle, C, Mitchel, CJ, Buckley, PM, Johnstone, D, Sudworth, P. Gut origin of sepsis: a prospective study investigating associations between bacterial translocation, gastric microflora, and septic morbidity. Gut 1999;45:223228.
23. O’Boyle, C, MacFie, J, Mitchel, CJ, Johnstone, D, Sagar, PM, Sedman, AB. Microbiology of bacterial translocation in humans. Gut 1998;42:2935.
24. Taur, Y, Xavier, JB, Lipuma, L, et al. Intestinal domination and the risk of bacteremia in patients undergoing allogeneic hematopoietic stem cell transplantation. Clin Infect Dis 2012;55(7):905914. doi:10.1093/cid/cis580.
25. Milisavljevic, V, Garg, M, Vuletic, I, et al. Prospective assessment of the gastroesophageal microbiome in VLBW neonates. BMC Pediatr 2013;13(1):11. doi:10.1371/journal.pbio.0050177.
26. Cowan, ME, Frost, MR. A comparison between a detergent baby bath additive and baby soap on the skin flora of neonates. J Hosp Infect 1986;7:9195.
27. Polin, RA, Denson, S, Brady, MT; Committee on Fetus and Newborn; Committee on Infectious Diseases. Strategies for prevention of health care-associated infections in the NICU. Pediatrics 2012;129(4):e1085–e1093. doi:10.1542/peds.2012–0145.
28. Hull, MA, Jones, BA, Zurakowski, D, et al. Low serum citrulline concentration correlates with catheter-related bloodstream infections in children with intestinal failure. JPEN J Parenter Enteral Nutr 2011;35(2):181187. doi:10.1177/0148607110381406.
29. Ziegler, TR, Luo, M, Estívariz, CF, et al. Detectable serum flagellin and lipopolysaccharide and upregulated anti-flagellin and lipopolysaccharide immunoglobulins in human short bowel syndrome. Am J Physiol Regul Integr Comp Physiol 2008;294(2):R402R410. doi:10.1152/ajpregu.00650.2007.
30. Cole, CR, Hansen, NI, Higgins, R, et al. Bloodstream infections in very low birth weight infants with intestinal failure. J Pediatr 2012;160(1):5459.e2. doi:10.1016/j.jpeds.2011.06.034.
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Infection Control & Hospital Epidemiology
  • ISSN: 0899-823X
  • EISSN: 1559-6834
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