Introduction

Hospital-acquired infections (HAIs) remain a substantial burden to patients and healthcare systems, contributing to increased morbidity, mortality, hospital length of stay (LOS), and healthcare costs. ^{Reference Forrester, Maggio and Tennakoon1,Reference Markwart, Saito and Harder2} Among HAIs, central line-associated bloodstream infections (CLABSIs), a type of intravascular catheter-related or associated infections, are a serious concern due to their substantial impact on patient outcomes and healthcare resources, despite being largely preventable with strict adherence to clinical practice guidelines. ^{Reference Ziegler, Pellegrini and Safdar3–7}

Multiple studies have demonstrated the substantial clinical and economic burden associated with CLABSIs. In a meta-analysis of case control and cohort studies, most of which were conducted in intensive care unit settings, CLABSIs were associated with a significantly increased risk of death (odds ratio [OR], 2.75; 95% confidence interval ⁷ : 1.86 to 4.07) compared to no CLABSIs, and this association remained significant among the studies that were matched using illness severity index (OR, 1.51; 95% CI: 1.08 to 2.09). ^{Reference Ziegler, Pellegrini and Safdar3} Similarly, another meta-analysis reported that, compared with uninfected patients, CLABSIs were associated with higher odds of mortality (OR, 3.19; 95% CI: 2.55 to 4.16) and a longer hospital LOS, with a mean difference of 16.14 days (95% CI: 9.27 to 23.01). ^{Reference Elangovan, Lo, Xie, Mitchell, Graves and Cai4} In a retrospective study of acute-care hospital patients, a case-matched analysis comparing patients with CLABSIs to a control cohort found that CLABSIs were associated with significantly longer hospital LOS (difference, 15.6–17.4 d), higher costs (an additional $32,759–$55,001), and >3.5-fold increased risk of mortality. ^{Reference Yu, Jung and Ai8} Although surveillance data from the CDC’s National Healthcare Safety Network (NHSN) reported an approximately 13% decrease in CLABSI incidence from 2022 to 2023, this improvement was not observed in long-term acute care hospitals or inpatient rehabilitation facilities, highlighting the continued need for focused infection prevention efforts, especially outside acute care settings. ⁹ Evaluating patient outcomes and healthcare resource utilization is therefore essential to inform facility-level decision making in allocating appropriate and often limited resources to improve patient safety, reduce LOS and treatment costs, and ease burden across patients, staff, and healthcare systems.

In addition to their direct clinical and economic impact, CLABSIs contribute to the rising global burden of antimicrobial resistance and the increasing prevalence of untreatable or difficult-to-treat infections, which the World Health Organization has identified as requiring urgent action to reduce potentially avoidable antimicrobial treatments through effective infection prevention methods. ¹⁰ As a result, CLABSI surveillance and the reduction of potentially avoidable infections through effective prevention strategies are critical components of antimicrobial stewardship, patient safety initiatives, and quality of care. Although CLABSI surveillance criteria focus specifically on central venous catheters (CVCs), thereby excluding other vascular access devices (VADs) that also carry infection risk, CLABSI remains a widely adopted and internationally validated surveillance metric. ¹¹ Broader surveillance measures, such as catheter-associated bloodstream infection (CABSI), have been proposed to encompass all types of VADs, and more recently, hospital-onset bacteremia and fungemia (HOB) has been introduced to capture all types of HAIs beyond catheter-related infections. ¹² However, CABSI and HOB surveillance criteria are less established, whereas CLABSI remains the most prevalent and validated surveillance tool. ¹³

VAD-related infections are considered largely preventable, given that adherence to evidence-based insertion and maintenance bundles, including full barrier precautions, chlorhexidine skin antisepsis, appropriate hand hygiene, and prompt catheter removal, has been shown to dramatically reduce infection rates. ^{Reference Ista, van der Hoven and Kornelisse14} However, CLABSI or HOB can still occur despite adherence to best practices due to patient-related factors, such as severe underlying illness with immunosuppression, where infections may be attributable to patient’s vulnerability rather than lapses in care. Umscheid et al. (2011) estimated that approximately 65% of CLABSIs in intensive care settings were reasonably preventable with full implementation of evidence-based measures, implying that a portion might not be easily preventable. ^{Reference Umscheid, Mitchell, Doshi, Agarwal, Williams and Brennan15} Similarly, a recent pilot study of HOB found that while about one-third of bloodstream infections were judged potentially preventable, others were attributed to intrinsic patient factors (eg, neutropenia) and were less avoidable. ^{Reference Leekha, Robinson and Jacob16} Regardless of residual infection risk in high-risk patients, meticulous adherence to central line insertion and maintenance guidelines is essential for all patients, and any CLABSI should trigger prompt examination of potential gaps in care to uphold a goal of zero harm.

Implementing and sustaining effective infection prevention programs, including adequate staffing, training, auditing, and supportive technologies, requires investment of already limited healthcare resources. ^{Reference Nickel, Gorski and Kleidon17} Surveilling and quantifying the impact of CLABSIs on patient outcomes and resource utilization (eg, LOS, total cost of care [TCC], and discharge disposition) can support evidence-based decisions on resource allocation to improve patient safety and reduce the burden on limited resources. While prior studies have estimated the clinical and economic burden of CLABSI, many focus on intensive care settings or rely on older data, highlighting the need for contemporary, hospitalwide analyses. ^{Reference Ziegler, Pellegrini and Safdar3–Reference Alshahrani, Alhuwaishel and Alangari5,Reference Yu, Jung and Ai8,Reference Harris, Mehdiratta and Rosser18,Reference Aryan, Grigorian and Jeng19}

Therefore, this study used recent data from the Premier Healthcare Database (PHD) to analyze differences in TCC and LOS among patients with preventable catheter-related infections (PPCRIs) arising as a complication of the acute inpatient stay, used as a proxy for potentially preventable CLABSIs. Because PPCRI requires the qualifying infection not be present on admission (POA), this approach excludes infections tied to outpatient or community management of VADs (eg, dialysis catheters, chemotherapy infusion lines, home parenteral nutrition) that were already present at admission.