title: Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis.
abstract: BACKGROUND
  Central-line-associated bloodstream infections (CLABSIs) are a major problem in intensive care units (ICUs) worldwide. We aimed to quantify the effectiveness of central-line bundles (insertion or maintenance or both) to prevent these infections.
  
  
  METHODS
  We searched Embase, MEDLINE OvidSP, Web-of-Science, and Cochrane Library to identify studies reporting the implementation of central-line bundles in adult ICU, paediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 1990, and June 30, 2015. For the meta-analysis, crude estimates of infections were pooled by use of a DerSimonian and Laird random effect model. The primary outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Incidence risk ratios (IRRs) were obtained by use of random-effects models.
  
  
  RESULTS
  We initially identified 4337 records, and after excluding duplicates and those ineligible, 96 studies met the eligibility criteria, 79 of which contained sufficient information for a meta-analysis. Median CLABSIs incidence were 5·7 per 1000 catheter-days (range 1·2-46·3; IQR 3·1-9·5) on adult ICUs; 5·9 per 1000 catheter-days (range 2·6-31·1; 4·8-9·4) on PICUs; and 8·4 per 1000 catheter-days (range 2·6-24·1; 3·7-16·0) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 19·5 per 1000 catheter-days (median 2·6, IQR 1·2-4·4) in all types of ICUs. In our meta-analysis the incidence of infections decreased significantly from median 6·4 per 1000 catheter-days (IQR 3·8-10·9) to 2·5 per 1000 catheter-days (1·4-4·8) after implementation of bundles (IRR 0·44, 95% CI 0·39-0·50, p<0·0001; I(2)=89%).
  
  
  CONCLUSIONS
  Implementation of central-line bundles has the potential to reduce the incidence of CLABSIs.
  
  
  BACKGROUND
  None.
authors.affiliation: Intensive Care Unit, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands. Electronic address: w.ista@erasmusmc.nl.
authors.forename: Erwin
authors.initials: E
authors.lastname: Ista
authors.affiliation: Department of Intensive Care, Erasmus MC, Rotterdam, Netherlands.
authors.forename: Ben
authors.initials: B
authors.lastname: van der Hoven
authors.affiliation: Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.
authors.forename: René F
authors.initials: RF
authors.lastname: Kornelisse
authors.affiliation: Intensive Care Unit, Department of Paediatric Surgery, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands; Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.
authors.forename: Cynthia
authors.initials: C
authors.lastname: van der Starre
authors.affiliation: Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, Netherlands.
authors.forename: Margreet C
authors.initials: MC
authors.lastname: Vos
authors.affiliation: Department of Cardiology, Cardiovascular Research School COEUR, Erasmus MC, Rotterdam, Netherlands.
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.affiliation: Department of Paediatrics, Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, Netherlands.
authors.forename: Onno K
authors.initials: OK
authors.lastname: Helder
mesh_terms: D016470:Bacteremia / Q000453:epidemiology / Q000517:prevention & control*; D055499:Catheter-Related Infections / Q000188:drug therapy* / Q000517:prevention & control; D002405:Catheterization, Central Venous / Q000009:adverse effects*; D002710:Chlorhexidine / Q000737:chemistry; D016638:Critical Illness; D003428:Cross Infection / Q000517:prevention & control; D063373:Hand Hygiene; D006801:Humans; D015994:Incidence; D017053:Infection Control; D007362:Intensive Care Units; D007363:Intensive Care Units, Neonatal
chemical_list: D002710:Chlorhexidine