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CLABSI reduction using evidence based interventions and nurse empowerment: a quality improvement initiative from a tertiary care NICU in Pakistan
  1. Ali Shabbir Hussain1,
  2. Anjum Mohyuddin Ahmed1,
  3. Saba Arbab1,
  4. Shabina Ariff1,
  5. Rehan Ali2,
  6. Simon Demas1,
  7. Jehan Zeb1,
  8. Arjumand Rizvi1,
  9. Ali Saleem1,
  10. Joveria Farooqi1
  1. 1 Department of Pediatrics & Child Health, The Aga Khan University, Karachi, Sindh, Pakistan
  2. 2 Department of Pediatrics, The Indus Hospital, Karachi, Sindh, Pakistan
  1. Correspondence to Dr Ali Shabbir Hussain, Department of Pediatrics & Child health, The Aga Khan University, Karachi, Sindh, Pakistan; ali.hussain{at}


Objective Central line associated bloodstream infection (CLABSI) is an important cause of morbidity and mortality in the neonatal intensive care unit (NICU). We designed a CLABSI Prevention Package (CPP) to decrease NICU CLABSI rates, using evidence-proven interventions.

Design This was a quality improvement (QI) project. Data collection was divided into three phases (pre-implementation, implementation and post implementation). SQUIRE2.0 guidelines were used to design, implement and report this QI initiative.

Setting A tertiary care level 3 NICU at the Aga Khan University Hospital (AKUH), Karachi, Pakistan.

Patients All patients admitted to the AKUH NICU from 1 January 2016 to 31 March 2018 who had a central line in place during their NICU admission.

Interventions CPP used evidence-based interventions focusing on hand hygiene, aseptic central line insertion techniques and central line care, prevention of fungal infections and nurse empowerment.

Main outcome measures CLABSI rates pre and post intervention were recorded. Secondary outcomes were risk factors for CLABSI, device (central line) utilisation ratio, CLABSI related mortality and micro-organism profile.

Results CLABSI rates decreased from 17.1/1000 device days to 5.0/1000 device days (relative risk (RR)=0.36, CI=0.17–0.74). Device (central line) utilisation ratio declined from 0.30 to 0.25. Out of 613 patients enrolled in our study, 139 (22.7%) died. Mortality was higher in CLABSI group (n=20, 44%) as compared with non CLABSI group (n=119, 21.1%) (p<0.001). Gestational age of <27 weeks was an independent risk factor for CLABSI (RR=4.45, CI=1.10–18.25, p=0.03). A total of 158 pathogens were isolated among which 68 were associated with CLABSI. Gram-negative bacteria 31 (47.7%) were the most common cause of CLABSI. Ninety-seven (61%) micro-organisms were multi-drug resistant.

Conclusions CPP was effective in decreasing NICU CLABSI rates and can be used as a model to decrease NICU CLABSI rates in low or middle-income countries.

  • neonatology
  • infectious diseases
  • intensive care

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  • Collaborators Mr. Uzair Ansari (Data analyst), Ms.Zohra Rafiq (Infection control nurse specialist).

  • Contributors AH, SA, RA conceptualised and designed the project. SA, SD, AMA, JZ were involved in data collection, data entry and manuscript writting, AS and JF were involved as infectious disease and microbiology experts and supervised the project. AR analysed the data. All authors were equally involved in manuscript writing and critically revising.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Obtained from the Ethical Review Committee at AKUH prior to beginning the study (reference # 4675-Ped-ERC-17).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All collected data, proformas and analysis can be made available on request.