AN INTERVENTION STUDY TO REDUCE BLOOD STREAM

INFECTIONS DURING PEDIATRIC ECLS DOES SCRUB THE

HUB STOP THE BUG?
Robinson SG*, Cogswell A, Pitfield AF, Salt D, Chalmers M, Mintak R, Skippen P
British Columbia Childrens Hospital, Vancouver, British Columbia, Canada
Introduction: The introduction of central line management bundles has resulted in a significant reduction in
the incidence of Central Line Associated Blood Stream Infections (CLA-BSIs) in many pediatric and adult
populations. The application of these techniques to ECLS circuits may reduce BSIs in those requiring ECLS.
The incidence of ECLS circuit blood isolated infection at the British Columbia Childrens Hospital was recently
reported as 22.6% (13.1% after exclusion of coagulase negative staphylococcus (CoNS)). Published literature
suggests ECLS circuit infection rates are 0.9 19.5%. In 2011, the Extracorporeal Life Support Organisation
(ELSO) reported infection rates for respiratory ECLS as 6.0% (neonatal) and 18.2% (pediatric). For cardiac
ECLS, rates were 7.8% (neonatal) and 11.2% (pediatric). Whilst a clean technique was already employed to
access the circuit, the addition of a more rigorous policy of Scrub the Hub was adopted in November 2008 to
try to reduce infection rates further. Scrub the hub involves scrubbing the access hub with a 2%
chlorhexidine/70% alcohol swab for 30 seconds and letting it dry for 60 seconds before accessing the hub.
This process was used for medication administration (heparin bolusing), line changes and all ACT, arterial and
venous sampling.
Methods: Daily routine blood cultures were sampled whilst on ECLS. Routine antibiotic prophylaxis was not
used. A blood stream infection (BSI) was defined as any positive blood culture while on ECLS or within 48
hours of decannulation. Positive blood cultures were reviewed to ascertain the likelihood of contamination.
The time to positive culture was assessed, along with white blood cell, neutrophils and platelet counts during
the preceding 48 hours to BSI identification.
Results: Cohort 1: 1999 2005. Eighty-four pediatric and neonatal patients received ECLS and were found
to have a BSI rate of 22.6%. This reduced to 16.6% after exclusion of single coagulase negative
staphylococcus isolates (CoNS) and 13.1% when excluding all CoNS - previously published data. Patients
with BSI spent significantly longer on ECLS (157 vs 127 hrs, 95% CI 106 148). Overall survival of ECLS was
71%, with 58% surviving to discharge or transfer. Cohort 2: December 2008 December 2011 (37 Months).
Of thirty-eight patients receiving ECLS, 23.5% (8 BSI in 5 patients) had a BSI. Sixteen (47%) were neonates,
12 (35%) were > 28 days but < 1 year old, with 6 (18%) between 1 and 10 years of age no children over the
age of 10 received ECLS during this second time period. The majority received Veno-Arterial ECLS (n=29,
85%). Patients with positive blood cultures spent significantly longer on ECLS (220 vs 116 hrs, 95% CI 84
148). Excluding single CoNS isolates reduced the BSI rate to 10.5% (n=4). Overall survival of ECLS was
82.4%, with 64.7% surviving to discharge or transfer. Survival to hospital discharge reduced to 60% if an
organism was isolated and 50% once CoNS was excluded.
Conclusions: To maintain comparability to the previous data published by this institution, all isolates were
included in data analysis. However excluding all single CoNS isolates (n=4) associated with a benign clinical
picture probably provides a more accurate assessment of the BSI rate (10.5%). This is a comparable figure to
the ELSO data and a reduction when compared to the cohort prior to institution of Scrub the Hub. The high
rate of organism identification is maintained between cohorts with the policy of daily screening blood culture
sampling. Length of time on ECLS was significantly longer in both cohorts when a BSI was identified. Mortality
figures are reduced in the second cohort although other factors may have contributed to this besides infection
control. This study indicates a likely benefit of Scrub the Hub with no suggestion of any detrimental effect.