Articles
Profile of central line-associated bloodstream infections in adult, paediatric, and neonatal intensive care units of hospitals participating in a health-care-associated infection surveillance network in India: a 7-year multicentric study
Rasna Parveen, Arpan Kumar Thakur, Sharad Srivastav, et al
Lancet Global Health 2025; 13: e1564-e1573
https://doi.org/10.1016/S2214-109X(25)00221-9
Summary
Background
Central line-associated bloodstream infections (CLABSIs) are preventable health-care-associated infections (HAIs) that cause considerable morbidity and mortality. Understanding the epidemiology of CLABSIs through large, quality-assured, hospital-based datasets could help to enable development of preventive protocols suited to specific health-care systems. We aimed to describe the profile of CLABSIs in intensive care units (ICUs) at tertiary care centres in India.
Methods
We obtained data from around 200 adult, paediatric, and neonatal ICUs at 54 hospitals reporting to the Indian HAI surveillance network over a period of 7 years. All hospitals conducted bloodstream infection surveillance using standardised protocols. Cases of CLABSI were recorded on standard case report forms and were submitted to the HAI surveillance database. Denominator data (patient-days and central line-days) were entered monthly. Data quality was evaluated by a central team at the All-India Institute of Medical Sciences (New Delhi, India). We calculated CLABSI rates per 1000 central line-days and central-line utilisation ratio (CLUR) by year and ICU type (adult, paediatric, or neonatal). Commonly reported pathogens were ranked and the proportions of priority pathogens showing antimicrobial resistance were also estimated for each 1-year period and each ICU type.
Findings
During the surveillance period from May 1, 2017 to April 30, 2024, 8629 laboratory-confirmed CLABSI events, 3 054 124 patient-days, and 977 052 central line-days were recorded. The overall pooled CLABSI rate was 8·83 per 1000 central line-days and the pooled CLUR was 0·32. CLABSI rates were 8·68 per 1000 central line-days in adult ICUs (CLUR 0·38), 6·71 per 1000 central line-days in paediatric ICUs (0·27), and 13·86 per 1000 central line-days in neonatal ICUs (0·11). Among the total 10 042 pathogens reported, 8981 (89·4%) were bacterial and 1061 (10·6%) were fungal; Klebsiella pneumoniae (2294 [22·8%] isolates) and Acinetobacter baumannii (2047 [20·4%] isolates) were the most frequently reported for each ICU type. Among isolates tested, resistance to carbapenem was found to be highest in A baumannii (1607 [87·1%] resistant isolates of 1846 tested) and K pneumoniae (1589 [77·7%] of 2046).
Table 1. Distribution of ICUs in the health-care-associated infection surveillance network and ICU-wise distribution of CLABSI cases, 2017–24
| Empty Cell | ICUs (n=200) | CLABSI cases (n=8629) |
|---|---|---|
| Medical | 49 (24·5%) | 2103 (24·4%) |
| Medical and surgical | 15 (7·5%) | 1436 (16·6%) |
| Surgical | 18 (9·0%) | 1116 (12·9%) |
| Trauma | 11 (5·5%) | 971 (11·3%) |
| Neonatal | 23 (11·5%) | 857 (9·9%) |
| Anaesthesia | 4 (2·0%) | 415 (4·8%) |
| Paediatric | 17 (8·5%) | 469 (5·4%) |
| COVID-19 | 16 (8·0%) | 252 (2·9%) |
| Gastrointestinal | 5 (2·5%) | 256 (3·0%) |
| Cardiothoracic | 9 (4·5%) | 137 (1·6%) |
| High-dependency unit | 6 (3·0%) | 139 (1·6%) |
| Paediatric medical and surgical | 7 (3·5%) | 125 (1·4%) |
| Neurosurgical | 7 (3·5%) | 89 (1·0%) |
| Oncological medical | 1 (0·5%) | 87 (1·0%) |
| Respiratory | 6 (3·0%) | 72 (0·8%) |
| Burn | 1 (0·5%) | 24 (0·3%) |
| Oncological surgical | 1 (0·5%) | 40 (0·5%) |
| Neurological | 2 (1·0%) | 27 (0·3%) |
| Cardiac | 2 (1·0%) | 14 (0·2%) |
Table 2. CLABSI events reported by ICU type in the health-care-associated infection surveillance network, 2017–24
| Empty Cell | 2017–18 | 2018–19 | 2019–20 | 2020–21 | 2021–22 | 2022–23 | 2023–24 | Total |
|---|---|---|---|---|---|---|---|---|
| All ICUs combined | ||||||||
| Patient-days | 248 009 | 428 162 | 481 706 | 398 372 | 418 510 | 409 593 | 669 772 | 3 054 124 |
| Central line-days | 81 185 | 130 943 | 154 864 | 131 323 | 134 365 | 129 888 | 214 484 | 977 052 |
| CLABSI events | 689 | 1317 | 1528 | 1481 | 1084 | 763 | 1767 | 8629 |
| CLABSI rate per 1000 central line-days | 8·49 | 10·06 | 9·87 | 11·28 | 8·07 | 5·87 | 8·24 | 8·83 |
| CLUR | 0·33 | 0·31 | 0·32 | 0·33 | 0·32 | 0·32 | 0·32 | 0·32 |
| Adult ICUs | ||||||||
| Patient-days | 193 850 | 322 203 | 357 634 | 291 722 | 276 310 | 268 721 | 467 899 | 2 178 339 |
| Central line-days | 72 859 | 113 108 | 131 138 | 113 117 | 111 801 | 107 842 | 176 795 | 826 660 |
| CLABSI events | 588 | 1126 | 1249 | 1286 | 897 | 601 | 1431 | 7178 |
| CLABSI rate per 1000 central line-days | 8·07 | 9·96 | 9·52 | 11·37 | 8·02 | 5·57 | 8·09 | 8·68 |
| CLUR | 0·38 | 0·35 | 0·37 | 0·39 | 0·40 | 0·40 | 0·38 | 0·38 |
| Paediatric ICUs | ||||||||
| Patient-days | 25 359 | 37 949 | 47 514 | 41 400 | 48 539 | 50 229 | 73 681 | 324 671 |
| Central line-days | 6937 | 11 524 | 14 670 | 9802 | 11 686 | 13 581 | 20 349 | 88 549 |
| CLABSI events | 72 | 96 | 118 | 83 | 50 | 60 | 115 | 594 |
| CLABSI rate per 1000 central line-days | 10·38 | 8·33 | 8·04 | 8·47 | 4·28 | 4·42 | 5·65 | 6·71 |
| CLUR | 0·27 | 0·30 | 0·31 | 0·24 | 0·24 | 0·27 | 0·28 | 0·27 |
| Neonatal ICUs | ||||||||
| Patient-days | 28 800 | 68 010 | 76 558 | 65 250 | 93 661 | 90 643 | 128 192 | 551 114 |
| Central line-days | 1389 | 6311 | 9056 | 8404 | 10 878 | 8465 | 17 340 | 61 843 |
| CLABSI events | 29 | 95 | 161 | 112 | 137 | 102 | 221 | 857 |
| CLABSI rate per 1000 central line-days | 20·88 | 15·05 | 17·78 | 13·33 | 12·59 | 12·05 | 12·75 | 13·86 |
| CLUR | 0·05 | 0·09 | 0·12 | 0·13 | 0·12 | 0·09 | 0·14 | 0·11 |
Table 3. Event outcomes at 14 days and final outcomes* for cases of central line-associated bloodstream infection, 2017–24
| Empty Cell | 14-day outcome (n=8629) | Final outcome*(n=8629) |
|---|---|---|
| Died in hospital | 3506 (40·6%) | 4493 (52·1%) |
| Left against medical advice | 311 (3·6%) | 450 (5·2%) |
| Unknown | 9 (0·1%) | 787 (9·1%) |
| Discharged | 566 (6·6%) | 2743 (31·8%) |
| Still under surveillance in ICU | 2598 (30·1%) | NA |
| Transferred to another hospital | 97 (1·1%) | 156 (1·8%) |
| Transferred to other wards or units within the same hospital† | 1542 (17·9%) | NA |
*Final outcome represents the outcome at the end of a patient's surveillance.
†Final outcomes could be updated based on a hospital's electronic health records if patients died or were discharged, or were updated to “unknown” if a final outcome was not known.
Table 4. Year-wise ranking of the most common pathogens reported in adult, paediatric, and neonatal ICUs in the health-care-associated infection surveillance network, 2017–24
| Empty Cell | 2017–18 | 2018–19 | 2019–20 | 2020-21 | 2021–22 | 2022–23 | 2023–24 | Total | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Empty Cell | Rank | Isolates | Rank | Isolates | Rank | Isolates | Rank | Isolates | Rank | Isolates | Rank | Isolates | Rank | Isolates | Rank | Isolates |
| Adult ICUs | ||||||||||||||||
| All isolates | .. | 656 | .. | 1284 | .. | 1477 | .. | 1498 | .. | 1045 | .. | 688 | .. | 1712 | .. | 8360 |
| Klebsiellaspp | 1 | 125 (19·1%) | 2 | 242 (18·8%) | 1 | 301 (20·4%) | 1 | 360 (24·0%) | 1 | 217 (20·8%) | 1 | 159 (23·1%) | 1 | 385 (22·5%) | 1 | 1789 (21·4%) |
| Acinetobacterspp | 2 | 106 (16·2%) | 1 | 302 (23·5%) | 2 | 298 (20·2%) | 2 | 289 (19·3%) | 2 | 208 (19·9%) | 2 | 144 (20·9%) | 2 | 374 (21·8%) | 2 | 1721 (20·6%) |
| Enterococcusspp | 4 | 61 (9·3%) | 5 | 117 (9·1%) | 3 | 161 (10·9%) | 3 | 195 (13·0%) | 3 | 111 (10·6%) | 3 | 98 (14·2%) | 4 | 193 (11·3%) | 3 | 936 (11·2%) |
| Candida spp | 3 | 87 (13·3%) | 4 | 118 (9·2%) | 5 | 133 (9·0%) | 4 | 137 (9·1%) | 4 | 107 (10·2%) | 4 | 71 (10·3%) | 3 | 195 (11·4%) | 4 | 848 (10·1%) |
| Burkholderiaspp | 7 | 39 (5·9%) | 3 | 123 (9·6%) | 4 | 143 (9·7%) | 5 | 115 (7·7%) | 6 | 74 (7·1%) | 9 | 12 (1·7%) | 8 | 75 (4·4%) | 5 | 581 (6·9%) |
| Pseudomonasspp | 6 | 46 (7·0%) | 6 | 96 (7·5%) | 9 | 72 (4·9%) | 6 | 96 (6·4%) | 5 | 75 (7·2%) | 5 | 45 (6·5%) | 6 | 104 (6·1%) | 6 | 534 (6·4%) |
| S aureus | 5 | 47 (7·2%) | 7 | 90 (7·0%) | 7 | 85 (5·8%) | 8 | 69 (4·6%) | 7 | 64 (6·1%) | 6 | 38 (5·5%) | 5 | 110 (6·4%) | 7 | 503 (6·0%) |
| E coli | 9 | 33 (5·0%) | 8 | 53 (4·1%) | 8 | 79 (5·3%) | 9 | 65 (4·3%) | 8 | 63 (6·0%) | 7 | 27 (3·9%) | 7 | 100 (5·8%) | 8 | 420 (5·0%) |
| Enterobacterspp | 8 | 35 (5·3%) | 9 | 44 (3·4%) | 6 | 85 (5·8%) | 7 | 90 (6·0%) | 9 | 41 (3·9%) | 8 | 24 (3·5%) | 9 | 45 (2·6%) | 9 | 364 (4·4%) |
| Paediatric ICUs | ||||||||||||||||
| All isolates | .. | 80 | .. | 103 | .. | 135 | .. | 101 | .. | 54 | .. | 68 | .. | 137 | .. | 678 |
| Acinetobacterspp | 4 | 10 (12·5%) | 1 | 26 (25·2%) | 1 | 32 (23·7%) | 2 | 16 (15·8%) | 1 | 17 (31·5%) | 1 | 14 (20.6%) | 1 | 33 (24·1%) | 1 | 148 (21·8%) |
| Klebsiellaspp | 1 | 20 (25·0%) | 3 | 16 (15·5%) | 2 | 23 (17·0%) | 3 | 14 (13.9%) | 2 | 12 (22·2%) | 2 | 14 (20.6%) | 3 | 25 (18·2%) | 2 | 124 (18·3%) |
| Candida spp | 2 | 13 (16·3%) | 4 | 12 (11.7%) | 3 | 21 (15·6%) | 1 | 20 (19·8%) | 5 | 4 (7·4%) | 3 | 13 (19·1%) | 2 | 28 (20·4%) | 3 | 111 (16·4%) |
| Pseudomonasspp | 3 | 12 (15·0%) | 2 | 18 (17·5%) | 5 | 12 (8·9%) | 7 | 6 (5·9%) | 4 | 5 (9·3%) | 0 | 0 | 6 | 8 (5·8%) | 4 | 61 (9.0%) |
| S aureus | 10 | 2 (2·5%) | 6 | 7 (6·8%) | 4 | 17 (12·6%) | 4 | 11 (10·9%) | 7 | 3 (5.6%) | 6 | 4 (5.9%) | 5 | 11 (8·0%) | 5 | 55 (8·1%) |
| Neonatal ICUs | ||||||||||||||||
| All isolates | .. | 32 | .. | 105 | 177 | .. | 125 | .. | 151 | .. | 110 | .. | 304 | .. | 1004 | |
| Klebsiellaspp | 4 | 5 (15·6%) | 1 | 44 (41·9%) | 1 | 47 (26·6%) | 1 | 55 (44·0%) | 1 | 56 (37.1%) | 1 | 44 (40·0%) | 1 | 130 (42.8%) | 1 | 381 (37·9%) |
| Acinetobacterspp | 1 | 11 (34·4%) | 2 | 15 (14·3%) | 3 | 23 (13·0%) | 2 | 22 (17·6%) | 3 | 21 (13·9%) | 2 | 17 (15.5%) | 2 | 69 (22·7%) | 2 | 178 (17·7%) |
| Candida spp | 3 | 5 (15·6%) | 3 | 13 (12·4%) | 4 | 17 (9·6%) | 3 | 14 (11·2%) | 2 | 24 (15·9%) | 3 | 10 (9·1%) | 3 | 19 (6·3%) | 3 | 102 (10·2%) |
| Enterobacterspp | 2 | 6 (18·8%) | 4 | 13 (12·4%) | 2 | 24 (13·6%) | 7 | 4 (3·2%) | 5 | 9 (6·0%) | 11 | 1 (0·9%) | 11 | 2 (0·7%) | 4 | 59 (5·9%) |
| E coli | 5 | 3 (9·4%) | 7 | 3 (2·9%) | 6 | 13 (7·3%) | 5 | 6 (4·8%) | 4 | 10 (6·6%) | 7 | 6 (5·5%) | 5 | 14 (4·6%) | 5 | 55 (5·5%) |
Table 5. Year-wise numbers and proportions of priority resistant pathogens reported in ICUs in the health-care-associated infection surveillance network, 2017–24
| Empty Cell | 2017–18 | 2018–19 | 2019–20 | 2020–21 | 2021–22 | 2022–23 | 2023–24 | Total | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Empty Cell | Number reported | Resistant | Number Reported | Resistant | Number reported | Resistant | Number reported | Resistant | Number reported | Resistant | Number reported | Resistant | Number reported | Resistant | Number reported | Resistant |
| Adult ICUs | ||||||||||||||||
| Enterobacterales* | 193 | 123/165 (74·5%) | 339 | 218/304 (71·7%) | 468 | 262/386 (67·9%) | 516 | 310/448 (69·2%) | 321 | 196/305 (64·3%) | 210 | 142/181 (78·5%) | 528 | 343/456 (75·2%) | 2575 | 1594/2245 (71·0%) |
| K pneumoniae* | 125 | 87/111 (78·4%) | 242 | 170/218 (78·0%) | 301 | 204/262 (77·9%) | 360 | 254/320 (79·4%) | 217 | 152/206 (73·8%) | 159 | 117/136 (86·0%) | 385 | 275/333 (82·6%) | 1789 | 1259/1586 (79·4%) |
| A baumannii* | 106 | 80/92 (87·0%) | 302 | 231/281 (82·2%) | 298 | 226/262 (86·3%) | 289 | 240/262 (91·6%) | 208 | 163/195 (83·6%) | 144 | 120/130 (92·3%) | 374 | 314/336 (93·5%) | 1721 | 1374/1558 (88·2%) |
| P aeruginosa* | 46 | 18/36 (50·0%) | 96 | 57/86 (66·3%) | 72 | 38/59 (64·4%) | 96 | 40/78 (51·3%) | 75 | 33/64 (51·6%) | 45 | 27/40 (67·5%) | 104 | 60/92 (65·2%) | 534 | 273/455 (60·0%) |
| Enterobacterspp† | 35 | 2/29 (6·9%) | 44 | 2/15 (13·3%) | 85 | 3/9 (33·3%) | 90 | 0/14 | 41 | 1/7 (14·3%) | 24 | 2/9 (22·2%) | 45 | 0/15 | 364 | 10/98 (10·2%) |
| Paediatric ICUs | ||||||||||||||||
| Enterobacterales* | 23 | 11/19 (57·9%) | 23 | 10/18 (55·6%) | 31 | 17/20 (85·0%) | 22 | 12/20 (60·0%) | 12 | 9/10 (90·0%) | 16 | 13/15 (86·7%) | 36 | 25/30 (83·3%) | 163 | 97/132 (73·5%) |
| K pneumoniae* | 20 | 11/17 (64·7%) | 16 | 9/12 (75·0%) | 23 | 13/13 (100·0%) | 14 | 8/12 (66·7%) | 12 | 9/10 (90·0%) | 14 | 11/13 (84·6%) | 25 | 19/20 (95·0%) | 124 | 80/97 (82·5%) |
| A baumannii* | 10 | 5/6 (83·3%) | 26 | 18/23 (78·3%) | 32 | 25/29 (86·2%) | 16 | 10/13 (76·9%) | 17 | 11/15 (73·3%) | 14 | 10/10 (100·0%) | 33 | 28/30 (93·3%) | 148 | 107/126 (84·9%) |
| P aeruginosa* | 12 | 7/10 (70·0%) | 18 | 11/16 (68·8%) | 12 | 7/8 (87·5%) | 6 | 2/4 (50·0%) | 5 | 1/5 (20·0%) | 0 | 0/0 | 8 | 3/7 (42·9%) | 61 | 31/50 (62·0%) |
| Enterobacterspp† | 5 | 0/3 | 3 | 0/0 | 3 | 0/1 | 5 | 0/2 | 1 | 0/1 | 0 | 0/0 | 6 | 0/4 | 23 | 0/11 |
| Neonatal ICUs | ||||||||||||||||
| Enterobacterales* | 8 | 3/7 (42·9%) | 47 | 26/46 (56·5%) | 60 | 30/52 (57·7%) | 61 | 37/57 (64·9%) | 66 | 44/64 (68·8%) | 50 | 31/46 (67·4%) | 144 | 107/142 (75·4%) | 436 | 278/414 (67·1%) |
| K pneumoniae* | 5 | 1/4 (25·0%) | 44 | 26/43 (60·5%) | 47 | 25/42 (59·5%) | 55 | 34/52 (65·4%) | 56 | 38/54 (70·4%) | 44 | 27/40 (67·5%) | 130 | 99/128 (77·3%) | 381 | 250/363 (68·9%) |
| A baumannii* | 11 | 8/11 (72·7%) | 15 | 12/15 (80·0%) | 23 | 13/17 (76·5%) | 22 | 13/18 (72·2%) | 21 | 13/21 (61·9%) | 17 | 11/14 (78·6%) | 69 | 56/66 (84·8%) | 178 | 126/162 (77·8%) |
| P aeruginosa* | 1 | 1/1 (100·0%) | 3 | 1/2 (50·0%) | 6 | 1/4 (25·0%) | 4 | 0/2 | 6 | 1/6 (16·7%) | 7 | 1/5 (20·0%) | 13 | 3/12 (25·0%) | 40 | 8/32 (25·0%) |
| Enterobacterspp† | 6 | 1/3 (33·3%) | 13 | 0/1 | 24 | 0/16 | 4 | 1/4 (25·0%) | 9 | 0/6 | 1 | 0/1 | 2 | 0/2 | 59 | 2/33 (6·1%) |
*Tested for carbapenem resistance.
†Tested for colistin resistance.
Interpretation
This is the first large-scale observational study and standardised surveillance report of CLABSI in India. The data generated from this network provide a valuable opportunity for a quality improvement-based approach for the reduction of CLABSI.
Funding
US Centers for Disease Control and Prevention cooperative agreement with the All-India Institute of Medical Sciences (New Delhi, India).
