February 8, 2018

EJRC Article Review

Reducing CRBSIs in ICUs: What’s the best strategy?

EJRC Article Review



Healthcare-associated infections (HAIs) are associated with increased morbidity, mortality, and additional healthcare costs. Addressing modifiable factors including infection prevention and control (IPC) practices is a cost effective means of reducing the incidence of HAIs. The Prevention of Hospital Infections by Intervention and Training (PROHIBIT) project aimed to address and analyse the variation of IPC practices in Europe 1.


Adult ICUs from 14 hospitals in 11 European countries enrolled adult patients (≥ 16 years of age) with a CVC inserted.


Hospitals were computer-randomised to receive one of three interventions:

  1. A comprehensive CVC insertion strategy developed and successfully implemented at the University of Geneva Hospitals (CVCi) 2;
  2. A hand hygiene improvement strategy based on World Health Organisation (WHO) recommendations (HHi) targeting the entire ICU-unit 3
  3. Both interventions combined (COMBi)

Four hospitals were randomised to HHi, five to CVCi, and five to COMBi.


  • Participating centres took part in the a stepped-wedge, cluster randomised, controlled study, which allowed control for secular trends, and enabled the comparison of hospitals with other hospitals as well as themselves.
  • After a baseline of 6 months for all hospitals, every subsequent quarter, three hospitals were computer-randomised to receive one of the three interventions.


  • CRBSI was the primary outcome, process indicators, i.e. a CVC insertion score and hand hygiene compliance, were secondary outcomes.
  • A total of 25,348 patients with 35,831 CVCs were included in the study. Median CVC dwell times were between 5 and 7 days.
  • The overall CRBSI incidence density decreased from 2.4/1000 CVC-days at baseline to 0.9/1000 during the intervention
  • CVC insertion scores improved in all study arms between baseline and intervention period, the mean insertion scores in the CVCi-, HHi and COMBi arms improved from 69 to 92% [OR (95% CI): 4.0 (3.7–4.4); p       < 0.0001], from 66 to 85% [1.3 (1.2–1.5); p < 0.0001], and from 78 to 96% [6.0 (5.5 6.6); p < 0.0001], respectively.
  • Between baseline and intervention period, hand hygiene compliance in the CVCi-, HHi- and COMBi arms improved from 51% (50–52%) to 62% (61–63%; p < 0.0001), from 36% (34–37%) to 58% (57–59%; p < 0.0001), and from 54% (52–55%) to 63% (62–64%; p < 0.0001), respectively
  • Improving CVC insertion score and hand hygiene compliance was associated with decreasing CRBSI incidence density
  • When adjusted in the multivariable regression analysis, including possible underlying hospital-specific trends and taking into account an intervention-specific trend, CRBSI reduction remained significant in the HHi- and COMBi arms
  • The overall median CVC dwell time until infection was prolonged from 10 to 11.5 days between patients without and with an infection (p = 0.042).


  • Process indicators not only improved in allocated arms, but in all study arms (HH in the CVCi arm; CVC insertion score in the HHi arm).
  • Some patient- and CVC characteristics differed between baseline and intervention, and between the study arms. However, due to incomplete data, it was not possible to adjust for illness severity scores.

Take Home Message

A multimodal prevention approach to improve CVC insertion practice and hand hygiene compliance reduced CRBSIs in ICUs.


Article review prepared and submitted by EJRC member Nish Arulkumaran, MD (Centre for Intensive Care Medicine, University College London, London, UK).



  1. van der Kooi T, Sax H, Pittet D, et al. Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomised multicentre study to reduce central venous catheter-related bloodstream infections. Intensive Care Medicine. Dec 16 2017. https://doi.org/10.1007/s00134-017-5007-6
  2. Zingg W, Cartier V, Inan C, et al. Hospital-wide multidisciplinary, multimodal intervention programme to reduce central venous catheter-associated bloodstream infection. PloS one. 2014;9(4):e93898.
  3. Pittet D, Allegranzi B, Storr J. The WHO Clean Care is Safer Care programme: field-testing to enhance sustainability and spread of hand hygiene improvements. Journal of infection and public health. 2008;1(1):4-10.


Comment on this news