The Importance of Patients and Caregivers Education to Prevent Central Line Associated Bloodstream Infections in Children with Malignancies: A Single Center Experience

Background

Long-term placement of central venous catheters (CVCs) is common in children with malignancies. The optimization of antiseptic protocols, together with proper manipulation by well-trained nursing staff, has lowered the incidence of central line associated bloodstream infections (CLABSI). Furthermore, actual chemotherapeutic protocols aim to avoid extensive inpatient hospitalizations.

However, self-management of CVCs is not simple: it requires adequate materials and an appropriate education of patients and caregivers. Therefore, the influence of social factors, such as language barriers, may be stronger than expected, especially in tertiary level institutions that act in multicultural settings.

Methods

We retrospectively analyzed patients who were admitted at our hematology-oncology service and who inserted any type of CVC between November 2012 and May 2018. Only patients with a complete and certified history of the CVC status from our experienced nurses were included.

Cultural and linguistic barriers (CLB) were defined as patients and families who did not speak Italian as mother tongue together with presence of important social or cultural issues that impaired proper CVC management. Furthermore, patients were stratified according to the presence of CLB (CLB+ versus CLB-). The diagnosis of CLABSI was made according to Center for Disease Prevention and Control Criteria (Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and non-central line-associated Bloodstream Infection). January 2018). A complete antibiogram was available in all cases of CLABSI.

Density of infection, defined as number of events/ 1000 CVC days, was calculated as CLABSIs x 1000 / number of central line days. The following risk factors were considered for CLABSI: presence of CLB, total days of CVC placement, total days with CVC spent as an outpatient (outpatient days), ratio between outpatient and inpatient days (O/I days), number of outpatient accesses, type of CVC, neutropenia, underlying disease, hematopoietic stem cell transplantation (HSCT) and type of HSCT. Chi-squared test was used to assess differences for categorical variables and Yates' correction was considered when appropriate. Pearson and Spearman rank correlation tests were applied.

Results and Discussion

Thirty-seven patients and 45 CVC were included in this study. We observed 8 cases of CLABSI out of 10209 days of catheterization thus the density of infection was 0.78/1000 catheters days.

Four patients had CLB and 3 of them developed CLABSI, accounting for 5 out of 8 CLABSI. A significant correlation was observed between the presence of CLB and CLABSI (chi-squared 7.07, p<0.01). Moreover, no difference was observed in O/I days among groups (CLB+ O/I days: 0.75, CLB- O/I days: 0.74, p>0.05). Neither the total days of CVC placement nor the total number of days spent with a CVC as an outpatient were correlated with a higher incidence of CLABSI (Pearson correlation respectively 0.03 and 0.04, p>0.05). Therefore, the outpatient management of CVC alone did not seem to be a risk factor for CLABSI.

Noticeable, 75% of patients who developed a CLABSI had a tunneled CVC implanted but a significant correlation between CVC type and CLABSI was not found. Tunneled CVCs were used in nearly 47% of our population; this could partially explain the higher incidence of infections in patients with this type of CVC. According to literature, the highest incidence was observed among neutropenic patients and who was affected by acute lymphoblastic leukemia, although the difference was not statistically relevant. No others significant correlations were observed.

Conclusion

Even though the number of patients is relative small and differences in the underlying disease may be a confounding element, we found a significant correlation between cultural and linguistic barriers and incidence of CLABSI. Current treatment protocols for many childhood cancers have significantly reduced morbidity and mortality in this group of patients. Thus, it has become particularly important to minimize the risks of complications, included CLABSI, related to therapy. Reducing cultural and language barriers by implementing cultural mediation seems to be a promising way to pursue this objective. At the same time, we trust the importance of CLB is worth deepening with further studies involving a greater number of patients.