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Reduction of bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach

BMJ 2007; 334 doi: (Published 15 February 2007) Cite this as: BMJ 2007;334:362
  1. Adnan Bhutta, assistant professor1,
  2. Craig Gilliam, director of infection control2,
  3. Michele Honeycutt, infection control practitioner2,
  4. Stephen Schexnayder, professor1,
  5. Jerril Green, associate professor1,
  6. Michele Moss, professor1,
  7. K J S Anand, professor1
  1. 1Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, 800 Marshall Street, Slot 512-3, Little Rock, AR 72202, USA
  2. 2Epidemiology and Infection Control, Arkansas Children's Hospital
  1. Correspondence to: A Bhutta bhuttaadnant{at}
  • Accepted 1 December 2006


Problem Bloodstream infections associated with catheters were the most common nosocomial infections in one paediatric intensive care unit in 1994-7, with rates well above the national average.

Design Clinical data were collected prospectively to assess the rates of infection from 1994 onwards. The high rates in 1994-7 led to the stepwise introduction of interventions over a five year period. At quarterly intervals, prospective data continued to be collected during this period and an additional three year follow-up period.

Setting A 292 bed tertiary care children's hospital.

Key measures for improvement We aimed to reduce our infection rates to below the national mean rates for similar units by 2000 (a 25% reduction).

Strategies for change A stepwise introduction of interventions designed to reduce infection rates, including maximal barrier precautions, transition to antibiotic impregnated central venous catheters, annual handwashing campaigns, and changing the skin disinfectant from povidone-iodine to chlorhexidine.

Effects of change Significant decreases in rates of infection occurred over the intervention period. These were sustained over the three year follow-up. Annual rates decreased from 9.7/1000 days with a central venous catheter in 1997 to 3.0/1000 days in 2005, which translates to a relative risk reduction of 75% (95% confidence interval 35% to 126%), an absolute risk reduction of 6% (2% to 10%), and a number needed to treat of 16 (10 to 35).

Lessons learnt A stepwise introduction of interventions leading to a greater than threefold reduction in nosocomial infections can be implemented successfully. This requires a multidisciplinary team, support from hospital leadership, ongoing data collection, shared data interpretation, and introduction of evidence based interventions.


  • We thank Betty Lowe, former medical director, for her inspiration and the medical and nursing staff in the paediatric intensive care unit at Arkansas Children's Hospital for their clinical expertise in achieving these results to decrease bloodstream infections. Preliminary results from this project were recognised by the Child Health Corporation of America (CHCA) Race for Results award in 2004.

  • Contributors: AB, CG, KJSA, SS, MM, MH, and JG devised and conducted the project. AB and CG analysed data. AB and CG drafted the manuscript with help from all authors. AB is guarantor.

  • Funding: None.

  • Competing interests: None declared.

  • Ethical approval: Institutional Review Board (Human Research Advisory Committee) of the University of Arkansas for Medical Sciences (No 36898).

  • Accepted 1 December 2006
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