Efficacy & Cost Effectiveness of Antimicrobial-impregnated CVCs in CLABSI Prevention in a Malaysia Adult ICU

Efficacy & Health Economics of Antimicrobial-impregnated Central Venous Catheters (CVCs) Compared to Non-impregnated CVCs in Central Line-associated Bloodstream Infection Prevention in a Malaysia University Hospital Adult ICU

Central venous catheters (CVCs) are indispensable in modern critical care. However, CVC usage is associated with complications, including central line-associated bloodstream infections (CLABSIs), which in turn, is translated to higher healthcare costs and mortality.

The use of antimicrobial-impregnated CVCs is one of the strategies to reduce CLABSI.

Nevertheless, its' efficacy and beneficial effects, particularly in terms of patients' outcome had not been homogeneously demonstrated across literature. Moreover, antimicrobial-impregnated CVCs are more expensive compared to conventional non-impregnated ones, and hence its cost-effectiveness remains doubtful. To date, no local studies have been conducted to evaluate the efficacy and economic impact of antimicrobial-impregnated CVCs and on patients' outcome.

The goal of this clinical trial is to determine the efficacy and cost-effectiveness of antimicrobial-impregnated CVCs in preventing (CLABSI) among critically ill patients in a Malaysia University Hospital Adult Intensive Care Unit.

The main questions it aims to answer are:

1. Is there any difference in CLABSI rates between patients using antimicrobial-impregnated CVCs and non-impregnated CVCs in Malaysia adult ICU?
2. Does the use of antimicrobial-impregnated CVCs in CLABSI prevention in Malaysia adult ICU affect patient length of stay when compared to non- impregnated CVCs?
3. Does the use of antimicrobial-impregnated CVCs in CLABSI prevention in the adult ICU setting affect healthcare costs when compared to non-impregnated CVCs?
4. How antimicrobial resistance features of the bacteria causing CLABSI may differ in patients using antimicrobial-impregnated CVCs compared to non-impregnated CVCs?

Patients who require a CVC for critical care in ICU will be recruited and randomly assigned to one of the two different groups to receive either a conventional non-impregnated CVC or an antimicrobial-impregnated CVC, which will be inserted and handled by medical practitioners. Participants will then be monitored for symptoms and signs of CLABSI, alongside length of ICU stay & healthcare costs. Researchers will compare CLABSI rates and other relevant parameters among the 2 groups to see if antimicrobial-impregnated CVCs are useful and cost-effective in CLABSI prevention.

Central venous catheters (CVCs) are indispensable in modern critical care. The average central line utilisation ratios in the ICUs across 45 countries were reported at 0.525.

However, CVC usage is associated with complications, including central line-associated bloodstream infections (CLABSIs). The rate of CLABSI is reported at 4.45 per 1000 central line days in ICUs across 45 countries from 2013 - 2018. This in turn, is translated to higher healthcare costs and mortality.

Antimicrobial-impregnated CVCs are proposed to be able to reduce the incidence of CLABSI by inhibiting microorganism colonisation on CVCs. A meta-analysis published in 2018 concluded that antimicrobial-impregnated CVCs were significantly effective in reducing CLABSIs and catheter colonisations.

Nevertheless, its' efficacy and beneficial effects, particularly in terms of patients' outcome had not been homogeneously demonstrated across literature. Moreover, antimicrobial-impregnated CVCs are more expensive compared to conventional non-impregnated ones, and hence its' cost-effectiveness remains doubtful. To date, no local studies have been conducted to evaluate the efficacy and economic impact of antimicrobial-impregnated CVCs and on patients' outcome.

The goal of this clinical trial is to determine the efficacy and cost-effectiveness of antimicrobial-impregnated CVCs in preventing (CLABSI) among critically ill patients in a Malaysia University Hospital Adult Intensive Care Unit.

The main questions it aims to answer are:

1. Is there any difference in CLABSI rates between patients using antimicrobial-impregnated CVCs and non-impregnated CVCs in Malaysia adult ICU?
2. Does the use of antimicrobial-impregnated CVCs in CLABSI prevention in Malaysia adult ICU affect patient length of stay when compared to non-impregnated CVCs?
3. Does the use of antimicrobial-impregnated CVCs in CLABSI prevention in the adult ICU setting affect healthcare costs when compared to non-impregnated CVCs?
4. How antimicrobial resistance features of the bacteria causing CLABSI may differ in patients using antimicrobial-impregnated CVCs compared to non-impregnated CVCs?

The primary and secondary objectives of the study include the following:

- Primary objective: To compare the incidence of CLABSI rate in patients using antimicrobial-impregnated CVCs and non-impregnated CVCs in Malaysia adult ICU

- Secondary objectives:

1. To determine the length of stay of patients using antimicrobial-impregnated CVCs vs non-impregnated CVCs in Malaysia adult ICU
2. To undertake a cost-effectiveness analysis in prevention of CLABSI between patients using antimicrobial-impregnated CVCs and non-impregnated CVCs in Malaysia adult ICU
3. To compare the antimicrobial resistance features of the bacterial species that caused CLABSI between patients using antimicrobial-impregnated CVCs and that of non-impregnated CVCs in Malaysia adult ICU The study will be conducted in the adult Intensive Care Unit (ICU) of Universiti Malaya Medical Centre (UMMC), Malaysia, which is a mixed medical/surgical ICU, over a period of 1 year.

Patients who require a CVC for critical care in ICU will be recruited and randomly assigned to one of the two different groups to receive either a conventional non-impregnated CVC or an antimicrobial-impregnated CVC, which will be inserted and handled by medical practitioners. Participants will then be monitored for symptoms and signs of CLABSI, alongside length of ICU stay & healthcare costs. The diagnosis of CLABSI will be based on the CDC-NHSN (Centers for Disease Control and Prevention - National Healthcare Safety Network) definition. Researchers will then analyse and compare CLABSI rates and other relevant parameters among the 2 groups to see if antimicrobial-impregnated CVCs are useful and cost-effective in CLABSI prevention. Descriptive statistics will be expressed as percentages unless otherwise stated. Categorical variables will be expressed as percentages and compared using the Chi-square or Fisher's exact test, whichever is appropriate. Variables with a univariate test value of less than 0.05 (p-value) will be included in a multivariate analysis using a logistic regression model. Odds ratios (OR) and 95% confidence intervals (CI) will be calculated to identify the risk factors associated with the development of CLABSI in patients. In all instances, a p-value of less than or equal to 0.05 will be considered significant.

Local data at ICU, UMMC reported the incidence of CLABSI per 1000 catheter days in the first 6 months of 2022, to be 12.18. Using SAS (Statistical Analysis Software)® for sample size calculation, in order to detect a clinically significant reduction of CLABSI by 30%, and assuming a two-sided type I error protection of 0.05 and a power of 0.80, the calculated required sample size is 50 patients. To incorporate a 10% drop out rate, the study therefore aims to recruit 55 patients in each arm, making up to a total sample size of 110.

All data & information obtained in this study will be kept and handled in a confidential manner, in accordance with applicable laws and/or regulations.

The study hopes to demonstrate that the usage of antimicrobial-impregnated CVCs among adult critically ill patient in the ICU can reduce CLABSIs and this will translate to reduced patients' length of stay and healthcare costs.

Inclusion Criteria:

• Patients aged 18 years old and above who are admitted to the ICU of UMMC during the study period
• Patients who require a CVC during ICU stay

Exclusion Criteria:

• Patients who refuse to participate in the study
• Patients with known hypersensitivity reaction to CVC materials
• Patients with pre-existing diagnosis of CLABSI upon admission to the ICU
• Patients with pre-existing bloodstream infection upon admission to the ICU
• Patients with a pre-existing CVC, where sterility during placement may be compromised (e.g. in an emergency situation)
• Patients with indwelling CVC less than 48 hours
• Patients who had poor compliance to catheter bundle care during CVC handling throughout the indwelling catheter period
• Patients who require > 1 CVC or other central venous access