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Impact of early infectious diseases consultation on the management of central line-associated bloodstream infection: a propensity score weighting retrospective cohort study

BMC Infectious Diseases volume 25, Article number: 526 (2025) Cite this article

Abstract

Background

Central line-associated bloodstream infection (CLABSI) is an important healthcare-associated infection, particularly in the intensive care unit (ICU). This study aimed to investigate the impact of early infectious disease consultation (IDC) on the quality of care metrics of CLABSI in patients admitted to the ICU.

Methods

Patients with CLABSI admitted to the ICU were included and divided into early IDC, and late or never IDC groups. The early IDC group indicated patients whose attending physician received IDC within 72 h of CLABSI onset. The main outcomes were the proportion of patients who received optimal targeted antibiotic treatment and catheter removal within 72 h of CLABSI onset. Propensity score analysis with the inverse probability of the treatment weighting method was used to compare the outcomes.

Results

Among the 197 enrolled patients, 52 (26.4%) underwent early IDC and 145 (63.6%) did not. The early IDC group showed considerably higher proportions of catheter removal (76.9% versus 44.8%; adjusted odds ratio (OR): 3.70, 95% confidence interval (CI): 1.72–7.98; P = 0.001) than the late or never IDC group. The proportions of patients receiving optimal targeted antibiotic treatment were significantly higher in the early IDC group than in the late or never IDC group (67.3% versus 46.9%, adjusted OR: adjusted OR: 2.40, 95% CI: 1.17–4.91, P = 0.016)).

Conclusions

Early IDC was associated with improvement of the quality of care for patients with CLABSI in the ICU. This findings support the implementation of early IDC should be considered as an integral part of care of CLABSI in ICU patients.

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Introduction

Central line-associated bloodstream infection (CLABSI) is responsible for substantial mortality, morbidity, extended admission duration, and additional costs to hospitals [1,2,3]. The multifaceted implementations of CLABSI bundles as evidence-based and concise interventions have reduced CLABSI rates [4, 5]. Among the implementations, daily catheter necessity assessment and prompt removal of unnecessary catheters is utmost recommended, but central venous catheters are inevitable medical devices for intensive care unit (ICU) patients who require a long-term infusion of intravenous fluids, antibiotics, critical care therapies, total parenteral nutrition, or hemodialysis. Therefore, despite effective interventions to reduce the incidence of CLABSI, central venous catheters continue to be a major cause of bloodstream infection (BSI) in ICU patients [6].

It is crucial to quickly identify patients suspected of having CLABSI and take two appropriate measures [7]. First, non-tunneled catheters causing CLABSI should be removed promptly to prevent CLABSI-related mortality, especially if the causative organisms are Staphylococcus aureus, Gram-negative bacilli, and Candida species [8, 9]. Second, empiric and tailored antibiotic therapy should be administered with a balance between the initiation of appropriate antibiotics and minimization of the overuse of broad-spectrum antibiotics. ICU patients, who have various risk factors for the acquisition of highly resistant organisms, are more likely to receive inappropriate or unnecessary broad-spectrum empirical antibiotic therapy in the early time of BSI [10].

Comprehensive infectious disease consultation (IDC) has been recognized to improve the care processes of patients with S.aureus bacteremia, Gram-negative bacteremia, and candidemia [11,12,13,14]. Furthermore, early IDC results in significantly greater adherence to quality care indicators and shorter hospital stays for patients with S.aureus bacteremia [15]. Early IDC may affect positively on decision-making regarding catheter removal and targeted antibiotic selection during the early phase of CLABSI. This study aimed to investigate the impact of early IDC on the quality of care metrics of CLABSI among patients admitted to the ICU.

Materials and methods

Study design and inclusion criteria

This retrospective cohort study was conducted between January 2018 and December 2022 at the two hospitals affiliated with Ewha Womans University (Mokdong Hospital and Seoul Hospital). In South Korea, the Korean National Healthcare-Associated Infections Surveillance System (KONIS) has conducted quarterly nationwide prospective surveillance of hospital-acquired infection including CLABSI in adult patients in ICUs. Mokdong and Seoul Hospitals have voluntarily participated in the KONIS since 2006 and 2019 respectively. All attending physicians regardless department have the opportunity for requesting formal IDC if they want. Patients were eligible for inclusion if they were older than 18 years and experienced episodes of CLABSI during ICU admission. Patients who were admitted to infectious disease department were excluded from the study. The included patients were divided into two groups: early IDC and late or never IDC, based on a previous literature [16]. The former indicated patients whose attending physician received a formal IDC within 72 h following the collection of the initial positive blood culture, while the latter indicated patients whose attending physician received it for more than 72 h or did not request IDC.

Definitions and covariates of interest

Central venous catheters included short- and long-term catheters. The short-term catheters were the non-tunneled catheters and dual-lumen hemodialysis catheters. Long-term catheters included cuffed and tunneled (Hickman, Perm, Chemo-Port), and peripherally inserted central catheters (PICC).

According to the National Health Safety Network case definition of BSI [17], laboratory-confirmed bloodstream infection (LCBI) was defined as a condition in which patients had a recognized pathogen culture from one or more blood culture samples (LCBI 1), or patients had common skin contaminants from two or more blood cultures at separate sites with clinical symptoms, including fever, chills, or hypotension (LCBI 2). CLABSI was defined as a primary LCBI without other sources of bacteremia in a patient who had a central catheter at least 48 h before infection.

We extracted clinical data from electronic medical records. The collected variables included demographics, Charlson Comorbidity Index score [18], length of hospital and ICU stay until CLABSI occurrence, the year of CLABSI diagnosis, catheter insertion site, receipt of anti-cancer chemotherapy within the past 6 months, receipt of systemic steroids or other immunomodulators (tacrolimus, cyclosporine, mycophenolate mofetil) within the past 2 weeks, receipt of total parenteral nutrition, and admission department (medical or surgical). The severity of BSI was assessed using the quick Pitt bacteremia score and the quick Sequential Organ Failure Assessment score [19]. Microbiologic data were also collected, including previous multidrug-resistant organism (MDRO) colonization within 3 months of CLABSI, and BioFire blood culture identification (BCID) utilization, which can determine pathogens and common resistance genes within 1–2 h [20]. MDROs include methicillin-resistant Staphylococcus species, vancomycin-resistant Enterococcus species, extended spectrum beta-lactamase producing Enterobacterales, and other pathogen resistant to at least one agent in at least three antibiotic categories based on automated antimicrobial susceptibility testing results (VITEK2, bioMerieux Inc., Marcy l’Etoile, France) [21].10

Outcomes

Two main outcomes were compared: First was the proportion of patients who underwent central catheter removal within 72 h of index blood culture collection. Second was the proportion of patients who received optimal targeted antibiotic treatment within 72 h of index blood culture collection. Optimal targeted antibiotic treatment was defined as administration of antibiotics to which the organisms were susceptible and considered as the most effective and narrowest spectrum treatment, indicated by pathogen identification and antimicrobial susceptibility resting results [22]. The determination of optimal targeted antibiotic treatment was made by three independent investigators (JHK, JB, and CJK), and any discrepancies resolved through consensus. Main outcomes were compared in a sensitivity analysis, excluding patients who died or were transferred to hospice care center within 72 h of index blood culture collection.

Secondary outcomes included the proportion of patients who received appropriate antibiotic treatment within 72 h of index blood culture collection, and 28-days all-cause mortality. Appropriate antibiotic treatment was defined as administration of antibiotics to which the organisms were susceptible and considered as the most effective treatment regardless spectrum [23].

Statistical analysis

Continuous data were expressed as medians with interquartile ranges, and categorical data were expressed as numbers with percentages. We compared the study groups using Wilcoxon rank-sum and chi-square tests, as appropriate. As group allocation was not randomized, we utilized the inverse probability of the treatment weighting (IPTW) method to minimize differences in baseline characteristics [24, 25]. A multivariable logistic regression modelling, including all baseline covariates, was used to produce a propensity score (Table S1). A calculated propensity score were used for performing the IPTW method. After the IPTW applying, the covariates between the groups were considered balanced if the standard difference was less than 10%.

In the crude and IPTW-applied datasets, a second multivariate logistic regression analysis for the outcomes was performed to calculate odds ratios (OR) with 95% confidence intervals (CI) respectively. This multivariate logistic regression analysis included age, sex, Charlson Comorbidity Index, and all other covariates showing P < 0.100 in univariate analysis. To assess homogeneity, we repeated these analyses for different subgroups: admission department (medical, surgical), Charlson comorbidity index score (≤ 2, > 2), center (Mokdong or Seoul Hospital), previous MDRO colonization (no, yes), MDRO infection (no, yes), quick Pitt bacteremia score (≤ 2, > 2), LCBI (1, 2), and Gram stain (positive organisms, other organisms). The interaction effect between the early IDC and the subgroup factors was tested in the main treatment model. A P-value < 0.05 indicates a significant interaction effect between the early IDC and the subgroup factor. All statistical analyses were performed using Stata, version 15.0 (StataCorp LP, College Station, TX, USA).

Result

Baseline characteristics

A total of 201 patients were screened for eligibility, and 197 met the inclusion criteria. Half of the attending physicians (96/197, 48.7%) requested IDC, and the median time from collecting the index culture to receiving a formal answer was 68 h (interquartile range, 40–99 h). Of the study population, 52 (26.4%) received a formal IDC within 72 h of collecting the index culture (early IDC group) and 145 (73.6%) did not (late or never IDC group). Catheter tip cultures were performed in 133 of 196 patients (67.9%). Among them, 28 patients (21.1%) had positive catheter tip cultures, while no specific organism was identified in the remaining 105 patients (78.9%). Of the 28 patients with positive cultures, 21 (75.0%) had organisms that were identical to those identified in their blood cultures.

Table 1 shows the baseline characteristics and group comparisons. Before adjustment, the early IDC group was younger (P = 0.015) and had more admitted to surgical department (P = 0.002). The late or never IDC group had a higher quick Pitt bacteremia scores (P = 0.026) than the early IDC group. The causative organisms generally did not differ between the two groups (P = 0.996) (Table S2). Among monomicrobial BSI, frequently identified organisms were coagulase-negative Staphylococci (n = 52), Enterococci (n = 33), Candida spp. (n = 24), and Acinetobacter spp. (n = 24). In the multivariable logistic regression model, age (adjusted OR 0.97, 95% CI 0.95–0.99, P = 0.027) and surgical department (adjusted OR 2.27, 95% CI 1.05–4.94, P = 0.038) were independently associated with the propensity of receiving early IDC (Table S1). After IPTW adjustment, the baseline variables of the two groups were generally balanced, with a standard difference of < 10% (Table 1).

Table 1 Baseline characteristics of the study population
Full size table

Outcomes

Catheter removal within 72 h of index blood culture was performed in 105 (53.2%) patients. The proportions of catheter removal did not differ significantly by pathogens (Gram-negative 53.7%; Gram-positive 57.0%; Candida 54.2%; polymicrobial 42.2%, P = 0.563). In the multivariate analyses, the early IDC group had significantly higher proportions of catheter removal than the late or never IDC group (76.9% versus 44.8%; adjusted OR: 3.70, 95% CI: 1.72–7.98; P = 0.001) (Table 2). Other covariates which were independently associated with catheter removal included female sex (adjusted OR: 2.70, 95% CI: 1.28–5.68; P = 0.009), previous MDRO colonization (adjusted OR: 0.46, 95% CI: 0.22–0.96; P = 0.038), and quick Pitt bacteremia score (adjusted OR: 0.53, 95% CI: 0.31–0.93; P = 0.026) (Table S3). The sensitivity analysis also showed significant association between early IDC and catheter removal (adjusted OR: 4.91, 95% CI: 1.85–13.02; P = 0.001).

Table 2 Outcome comparison between groups in the crude and IPTW-applying datasets
Full size table

At the same time, 103 (52.3%) patients received optimal targeted antibiotic treatment within 72 h of CLABSI. The proportions of optimal targeted treatment were tended to be higher in the Candida species than other pathogens (Gram negative 48.2%; Gram positive 55.8%; Candida 70.8%; polymicrobial 36.4%, P = 0.059). In the multivariable analyses, early IDC group was significantly associated with higher proportions of optimal targeted therapy in the late or never IDC group (67.3% versus 46.9%, adjusted OR: 2.40, 95% CI: 1.17–4.91, P = 0.016) (Table 2). Non-Gram-negative strains BSI was independently associated with reduced proportion of optimal targeted antibiotic treatment (adjusted OR: 0.69, 95% CI: 0.48–0.99; P = 0.049) (Table S4). The sensitivity analysis yielded similar results (adjusted OR: 2.87, 95% CI: 1.31–6.34; P = 0.009).

As secondary outcomes, the proportion of receiving appropriate antibiotic treatment was significantly higher in the early IDC group (78.9% versus 57.8%; adjusted OR 2.77, 95% CI: 1.20–6.38, P = 0.017), while 28-days all-cause mortality did not significantly differ (34.6% versus 42.1%; adjusted OR 1.52, 95% CI: 0.66–3.51, P = 0.326).

Subgroup analysis

In both aspects of catheter removal and optimal targeted antibiotic treatment, proportions tended to be higher in the early IDC group than in the late or never IDC group across the subgroups (Fig. 1). With the respect to the proportion of catheter removal, the regression models identified a significant interaction between the early IDC and the previous MDRO colonization, which means the effect of early IDC may be reduced in patients with prior MDRO colonization compared to those without (P = 0.034, Fig. 1). With the respect to the proportion of patients receiving optimal targeted treatment, the effect of the early IDC was not significantly altered by the subgroup factors (P = 0.119–0.976), except for quick Pitt bacteremia score (P = 0.001, Fig. 1).

Fig. 1
figure 1

The probability of outcomes as per stratified subgroup analysis. (A) catheter removal, (B) optimal targeted antibiotics treatment. BSI, bloodstream infection. MDRO, multidrug resistant organisms

Full size image

Discussion

In this retrospective cohort study, early IDC was associated with significantly improved quality of care metrics among ICU patients diagnosed with CLABSI in both earlier optimal targeted antibiotic treatment and catheter removal. These findings were in keeping with the results of previous studies that patients with complex infections have beneficial improvements in other care metrics when managed with the assistance of an IDC [13, 15, 26]. To our knowledge, the present study is the first comparative study to evaluate the effect of the timing of early IDC on the management of CLABSI in ICU patients during the early period of BSI.

Although long-term catheter salvage could be considered for less virulent organisms such as coagulase-negative Staphylococcus sppor for cases with limited vascular access, removal of non-tunneled catheters remains the preferred intervention for source control, particularly in CLABSI caused by multidrug-resistant Gram-negative bacilli, S.aureus, or Candida spp [27]. Catheter removal would be associated with faster defervescence and shown to be a prognostic factor of mortality [28]. Even BSIs were identified by attending physicians, the central venous catheter was not always recognized as the primary infectious source. This would be because catheter-related bacteremia often lacks obvious local signs such as exit-site inflammation. Furthermore, in the complex ICU setting, BSIs may appear to have originated from various sources, such as ventilator-associated pneumonia, or urinary tract infections making it even more challenging to identify the central venous catheter as the primary source [6]. A comprehensive approach by infectious disease specialists may enhance the early diagnosis of CLABSI as a portal of entry.

In the multivariate analysis, female sex was independently associated with a higher likelihood of catheter removal within 72 h of the index blood culture. Previous studies have suggested that female patients have a lower risk of developing sepsis or septic shock compared to male patients [29, 30]. Since catheter removal and reinsertion are often limited in patients with severe illness due to clinical instability, this factor may have contributed to the observed sex difference in the likelihood of early catheter removal. In addition, female patients may be less likely to be colonized with MDRO [31]. In our study, prior MDRO colonization was independently associated with a lower likelihood of early catheter removal. Furthermore, subgroup analysis revealed that the beneficial effect of early IDC on catheter removal may be attenuated in patients with MDRO colonization. Together, these results imply that a lower prevalence of MDRO colonization among female patients may facilitate early catheter removal and partially account for the observed sex difference.

In settings with a high prevalence of antimicrobial-resistant bacteria, many clinicians prefer to initiate empirical broad-spectrum antibiotics to ensure coverage of as many resistant pathogens as possible when managing BSI. They are concerned that a delay in effective treatment could leave their patients at risk of severe, potentially life-threatening complications [32]. Nevertheless, inappropriate and ineffective antibiotic prescriptions are still common. Gram staining, MALDI-TOF, and rapid genotypic methods, such as the BCID panel, provide presumptive information about causative organisms at an earlier stage of BSI. However, limitations in clinicians’ ability to interpret microbiological test results may pose a barrier to selecting appropriate and optimal antibiotic treatments [22, 33]. Especially, the interpretation of the genotypic method results may be difficult because of the complexity of resistance gene mechanisms and the absence of resistance genes might not always insure safe phenotypic susceptibility results [34]. Consequently, optimal and appropriate antibiotics might have been administered in many patients of the early IDC group.

In our study, early IDC did not reduce the all-cause mortality rate in patients with CLABSI, although our study was not designed to evaluate differences in mortality rates. Similar to our findings, a recent retrospective study on S.aureus bacteremia reported no difference in mortality; however, adherence to the care process was improved [15]. Several factors may explain this finding. First, the severity of the underlying disease requiring ICU admission as well as CLABSI may have contributed to mortality. Second, CLABSI-related mortality greatly depends on the virulence of the causative organism. Nearly one-third of CLABSI in the study was based on the definition of LCBI 2, which represents less virulent pathogens such as coagulase-negative Staphylococcus spp. Third, since a prospective sample size calculation was not feasible in this study, the absence of a significant association between early IDC and mortality should be interpreted with caution, as it may due to small sample size rather than a true lack of effect.

This study had certain limitations. The primary limitation was its retrospective design, which might have introduced some degree of subjectivity in outcome determination and restricted a more comprehensive understanding of the factors influencing the timing of IDC requests. Moreover, since only patients in the early IDC group had the opportunity to receive a catheter removal recommendation from infectious disease specialists within 72 h, this factor might have introduced bias. Consequently, this research does not confirm a causal relationship between the intervention and the associated outcomes. Second, the study sample size was small, and there was a substantial imbalance in the number of patients between the two groups, which might have affected the comparability of the findings. Although many potential confounders were accounted for in the multivariate analysis, the study results should be interpreted with caution. Third, this was a dual-center study, which could reduce the applicability of the findings to other hospital settings. However, the homogeneity shown in the subgroup analysis suggested that early IDC would have a positive effect on timely interventions of CLABSI management in different local epidemiology and hospitals.

In conclusion, among ICU patients with CLABSI, early IDC was associated with an improved quality of care, in terms of early catheter removal and optimal targeted antibiotic treatment. This findings support the implementation of early IDC should be an integral part of care of CLABSI in ICU patients.

Data availability

The datasets used and/or analyzed during this study are available from the corresponding author on reasonable request.

Abbreviations

BCID:

BioFire blood culture identification

BSI:

bloodstream infection

CLABSI:

central line-associated bloodstream infection

CI:

confidence intervals

ICU:

intensive care unit

IDC:

infectious diseases consultations

IPTW:

inverse probability of treatment weighting

KONIS:

Korean National Healthcare-Associated Infections Surveillance System

LCBI:

laboratory-confirmed bloodstream infection

MDRO:

multidrug-resistant organism

PICC:

peripherally inserted central catheters

OR:

odds ratios

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Acknowledgements

Not applicable.

Funding

This work was supported by a National Research Foundation of Korea (NRF) grant funded by the Korean Government Ministry of Science and ICT (2022R1A2C1092235).

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Authors and Affiliations

  1. Division of Infectious Diseases, Department of Internal Medicine, Ewha Womans University College of Medicine, Mokdong Hospital, Seoul, Republic of Korea

    Jeong-Han Kim, Jiyeon Bae & Hee Jung Choi

  2. Division of Infectious Diseases, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul Hospital, Seoul, Republic of Korea

    Ji Yun Bae, Kang-Il Jun & Chung-Jong Kim

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  1. Jeong-Han Kim
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  2. Jiyeon Bae
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  3. Ji Yun Bae
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  4. Kang-Il Jun
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  5. Chung-Jong Kim
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  6. Hee Jung Choi
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Contributions

Conceptualization and methodology: JHK, CJK, HJC. Data curation: JHK, JB, KIJ, CJK, HJC. Data analysis: JHK, HJC. Original draft preparation: JHK. Review and editing: CJK, HJC. All authors read and approve the final manuscript.

Corresponding author

Correspondence to Hee Jung Choi.

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Ethical statement

The study protocol was approved by the Institutional Review Board (number 2023-06-001) of Ewha Womans University Hospital, which waived the need for written informed consent. All personal identifiers were anonymized for confidentiality before data processing. This research was in compliance with the Helsinki Declaration.

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The authors declare no competing interests.

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Kim, JH., Bae, J., Bae, J.Y. et al. Impact of early infectious diseases consultation on the management of central line-associated bloodstream infection: a propensity score weighting retrospective cohort study. BMC Infect Dis 25, 526 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12879-025-10935-1

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12879-025-10935-1

Keywords

BMC Infectious Diseases

ISSN: 1471-2334

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