Skip to main content Accessibility help

Novel risk factors for central-line associated bloodstream infections in critically ill children

  • Charlotte Z. Woods-Hill (a1) (a2), Lakshmi Srinivasan (a3), Emily Schriver (a4) (a5), Tanya Haj-Hassan (a1), Orysia Bezpalko (a6) and Julia S. Sammons (a7) (a8)...



Central-line–associated bloodstream infections (CLABSI) cause morbidity and mortality in critically ill children. We examined novel and/or modifiable risk factors for CLABSI to identify new potential targets for infection prevention strategies.


This single-center retrospective matched case-control study of pediatric intensive care unit (PICU) patients was conducted in a 60-bed PICU from April 1, 2013, to December 31, 2017. Case patients were in the PICU, had a central venous catheter (CVC), and developed a CLABSI. Control patients were in the PICU for ≥2 days, had a CVC for ≥3 days, and did not develop a CLABSI. Cases and controls were matched 1:4 on age, number of complex chronic conditions, and hospital length of stay.


Overall, 72 CLABSIs were matched to 281 controls. Univariate analysis revealed 14 risk factors, and 4 remained significant in multivariable analysis: total number of central line accesses in the 3 days preceding CLABSI (80+ accesses: OR, 4.8; P = .01), acute behavioral health needs (OR, 3.2; P = .02), CVC duration >7 days (8–14 days: OR, 4.2; P = .01; 15–29 days: OR, 9.8; P < .01; 30–59 days: OR, 17.3; P < .01; 60–89 days: OR, 39.8; P < .01; 90+ days: OR, 4.9; P = .01), and hematologic/immunologic disease (OR, 1.5; P = .05).


Novel risk factors for CLABSI in PICU patients include acute behavioral health needs and >80 CVC accesses in the 3 days before CLABSI. Interventions focused on these factors may reduce CLABSIs in this high-risk population.


Corresponding author

Author for correspondence: Charlotte Z. Woods-Hill, Email:


Hide All

PREVIOUS PRESENTATION: Elements of this investigation were presented as an oral abstract the 2019 Society for Healthcare Epidemiology of America conference on April 24, 2019, in Boston, Massachusetts.



Hide All
1. Srinivasan, A, Wise, M, Bell, M, et al. Centers for Disease Control and Prevention (CDC). Vital signs: central-line–associated blood stream infections—United States, 2001, 2008, and 2009. Morb Mortal Wkly Rep 2011;60:243248.
2. Ziegler, MJ, Pellegrini, DC, Safdar, N. Attributable mortality of central-line associated bloodstream infection: systematic review and meta-analysis. Infection 2015;43:2936.
3. Goudie, A, Dynan, L, Brady, PW, Rettiganti, M. Attributable cost and length of stay for central line associated bloodstream infections. Pediatrics 2014;133(6):e15251532.
4. Elward, AM, Hollenbeak, CS, Warren, DK, Fraser, VJ. Attributable cost of nosocomial primary bloodstream infection in pediatric intensive care unit patients. Pediatrics 2005;115:868872.
5. Pittet, D, Tarara, D, Wenzel, RP. Nosocomial bloodstream infection in critically ill patients: excess length of stay, extra costs, and attributable mortality. JAMA 1994;271:15981601.
6. Simon, A, Ammann, RA, Bode, U, et al. Healthcare-associated infections in pediatric cancer patients: results of a prospective surveillance study from university hospitals in Germany and Switzerland. BMC Infect Dis 2008;8:70.
7. Miller, MR, Griswold, M, Harris, JM II, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 2010;125:206213.
8. Furuya, EY, et al. Central line–associated bloodstream infection reduction and bundle compliance in intensive care units: a national study. Infect Control Hosp Epidemiol 2016;37:805810.
9. Pronovost, P. Interventions to decrease catheter-related bloodstream infections in the ICU: the Keystone intensive care unit project. Am J Inf Control. 2008; 36:S171.e1–S171.e5.
10. Jeffries, HE, Mason, W, Brewer, M, et al. Prevention of central venous catheter-associated bloodstream infections in pediatric intensive care units: a performance improvement collaborative. Infect Control Hosp Epidemiol 2009;30:645651.
11. Edwards, JD, Herzig, CT, Liu, H, et al. Central line-associated blood stream infections in pediatric intensive care units: longitudinal trends and compliance with bundle strategies. Am J Infect Control. 2015;43:489493.
12. Ista, E, van der Hoven, B, Kornelisse, R, et al. Effectiveness of insertion and maintenance bundles to prevent central-line associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. Lancet Infect Dis 2016;16:724734.
13. Lyren, A, Brilli, RJ, Zieker, K, Marino, M, Muething, S, Sharek, PJ. Children’s hospitals’ solutions for patient safety collaborative impact on hospital-acquired harm. Pediatrics. 2017;140(3):e20163494. doi: 10.1542/peds.2016-3494
14. Wylie, M, Graham, D, Potter-Bynoe, G, et al. Risk factors for central line–associated bloodstream infection in pediatric intensive care units. Infect Control Hosp Epidemiol 2010;31:10491056.
15. Elward, A, Fraser, V. Risk factor for nosocomial primary bloodstream infection in pediatric intensive care unit patients: a 2-year prospective cohort study. Infect Control Hosp Epidemiol 2006;27:553560.
16. Doctor, A, Cholette, JM, Remy, KE, et al. Recommendations on RBC transfusion in general critically ill children based on hemoglobin and/or physiologic thresholds from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med 2018;19(9 suppl 1):S98S113.
17. Mehta, NM, Skillman, HE, Irving, SY, et al. Guidelines for the provision and assessment of nutrition support therapy in the pediatric critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. J Parenter Enteral Nutr 2017;41:706742.
18. Abman, SH, Hansmann, G, Archer, SL, et al. Pediatric pulmonary hypertension: guidelines from the American Heart Association and American Thoracic Society. Circulation 2015;132:20372099.
19. Bloodstream infection event (central-line associated bloodstream infection and non-central-line associated bloodstream infection. Centers for Disease Control and Prevention website. Published January 2019. Accessed October 15, 2019.
20. Feudtner, C, Christakis, DA, Connell, FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980–1997. Pediatrics 2000;106:205209.
21. Feudtner, C, Hays, RM, Haynes, G, Geyer, JR, Neff, JM, Koepsell, TD. Deaths attributed to pediatric complex chronic conditions: national trends and implications for supportive care services. Pediatrics 2001;107:E99.
22. Berry, JG, Hall, DE, Kuo, DZ, et al. Hospital utilization and characteristics of patients experiencing recurrent readmissions within children’s hospitals. JAMA 2011;305:682690.
23. Kronman, MP, Hersh, AL, Feng, R, Huang, YS, Lee, GE, Shah, SS. Ambulatory visit rates and antibiotic prescribing for children with pneumonia, 1994–2007. Pediatrics 2011;127:411418.
24. Feudtner, C, Feinstein, JA, Zhong, W, Hall, M, Dai, D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr 2014;14:199.
25. Miller, MR, Griswold, M, Harris, JM, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics 2010;125:206213.
26. Krishnaiah, A, Soothill, J, Wade, A, Mok, QQ, Ramnarayan, P. Central venous catheter-associated bloodstream infections in a pediatric intensive care unit: effect of the location of catheter insertion Pediatr Crit Care Med 2012;13(3):e176e180.
27. Brooks, E, Christy, NE, Mack, AH, McFadden, M. Patients with psychiatric disorders can also have CLABSIs: a response to “CLABSI or Munchausen’s or both.” Infect Control Hosp Epidemiol 2015;36:996997.
28. Egorova, NN, Pincus, HA, Shemesh, E, Kleinman, LC. Behavioral health diagnoses among children and adolescents hospitalized in the United States: observations and implications. Psychiatr Serv 2018;1;69:910918.
29. Bardach, NS, Coker, TR, Zima, BT, et al. Common and costly hospitalizations for pediatric mental health disorders. Pediatrics 2014;133:602609.
30. Divi, C, Koss, RG, Schmaltz, SP, Loeb, JM. Language proficiency and adverse events in US hospitals: a pilot study. Int J Qual Health C 2007;19:6067.
31. De Moissac, D, Bowen, S. Impact of language barriers on quality of care and patient safety for official language minority Francophones in Canada. J Patient Exp 2019;6:2432.
32. Mayr, FB, Yende, S, Linde-Zwirble, WT, et al. Infection rate and acute organ dysfunction risk as explanations for racial differences in severe sepsis. JAMA 2010;303:24952503.
33. Jones, JM, Fingar, KR, Miller, MA, et al. Racial disparities in sepsis-related in-hospital mortality: using a broad case capture method and multivariate controls for clinical and hospital variables, 2004–2013. Crit Care Med 2017;45:e1209e1217.
34. Mermel, LA. What is the predominant source of intravascular catheter infections? Clin Infect Dis 2011;52:211212.
35. Rupp, M, Yu, S, Huerta, T, et al. Adequate disinfection of a split-septum needleless intravascular connector with a 5-second alcohol scrub. Infect Control Hosp Epidemiol 2012;33:661665.
36. Wright, MO, Tropp, J, Schora, DM, et al. Continuous passive disinfection of catheter hubs prevents contamination and bloodstream infection. Am J Infect Control 2013;41:3338.
37. Caspari, L, Epstein, E, Blackman, A, Jin, L, Kaufman, DA. Human factors related to time-dependent infection control measures: “scrub the hub” for venous catheters and feeding tubes. Am J Infect Control 2017;1:648651.
38. Marschall, J, Mermel, LA, Fakih, M, et al. SHEA/IDSA practice recommendation: strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2014;35(suppl 2):S89S107.
39. Houbiers, JG, van de Velde, CJ, van de Watering, LM, et al. Transfusion of red cells is associated with increased incidence of bacterial infection after colorectal surgery: a prospective study. Transfusion 1997;37:126134.
40. Wolf, J, Curtis, N, Worth, LJ, et al. Central line-associated bloodstream infection in children: an update on treatment. Pediatr Infect Dis J 2013;32:905910.
41. Aledo, A, Heller, G, Ren, L, et al. Septicemia and septic shock in pediatric patients: 140 consecutive cases on a pediatric hematology–oncology service. J Pediatr Hematol Oncol 1998;20:215221.
42. Moskalewicz, RL, Isenalumhe, LL, Luu, C, et al. Bacteremia in nonneutropenic pediatric oncology patients with central venous catheters in the ED. Am J Emerg Med 2017;35:2024.
Type Description Title
Supplementary materials

Woods-Hill et al. supplementary material
Woods-Hill et al. supplementary material 1

 Word (14 KB)
14 KB
Supplementary materials

Woods-Hill et al. supplementary material
Woods-Hill et al. supplementary material 2

 Word (16 KB)
16 KB

Novel risk factors for central-line associated bloodstream infections in critically ill children

  • Charlotte Z. Woods-Hill (a1) (a2), Lakshmi Srinivasan (a3), Emily Schriver (a4) (a5), Tanya Haj-Hassan (a1), Orysia Bezpalko (a6) and Julia S. Sammons (a7) (a8)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed