Management of enterococcal central line-associated bloodstream infections in patients with cancer

Hesham Awadh,Rita Deeba,Johny Fares,Issam I Raad,Shahnoor Ali,Anne-Marie Chaftari,Ying Jiang,Melissa Khalil,Ray Hachem

doi:10.1186/s12879-021-06328-9

Abstract

ObjectiveEnterococcus species are the third most common organisms causing central line-associated bloodstream infections (CLABSIs). The management of enterococcal CLABSI, including the need for and timing of catheter removal, is not well defined. We therefore conducted this study to determine the optimal management of enterococcal CLABSI in cancer patients.MethodsWe reviewed data for 542 patients diagnosed with Enterococcus bacteremia between September 2011 to December 2018. After excluding patients without an indwelling central venous catheter (CVC), polymicrobial bacteremia or with CVC placement less than 48 h from bacteremia onset we classified the remaining 397 patients into 3 groups: Group 1 (G1) consisted of patients with CLABSI with mucosal barrier injury (MBI), Group 2 (G2) included patients with either catheter-related bloodstream infection (CRBSI) as defined in 2009 Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection by the Infectious Diseases Society of America (IDSA) or CLABSI without MBI, and Group 3 (G3) consisted of patients who did not meet the CDC criteria for CLABSI. The impact of early (< 3 days after bacteremia onset) and late (3–7 days) CVC removal was compared. The composite primary outcome included absence of microbiologic recurrence, 90-day infection-related mortality, and 90-day infection-related complications.ResultsAmong patients in G2, CVC removal within 3 days of bacteremia onset was associated with a trend towards a better overall outcome than those whose CVCs were removed later between days 3 to 7 (success rate 88% vs 63%). However, those who had CVCs retained beyond 7 days had a similar successful outcome than those who had CVC removal < 3 days (92% vs. 88%). In G1, catheter retention (removal > 7 days) was associated with a better success rates than catheter removal between 3 and 7 days (93% vs. 67%, p = 0.003). In non-CLABSI cases (G3), CVC retention (withdrawal > 7 days) was significantly associated with a higher success rates compared to early CVC removal (< 3 days) (90% vs. 64%, p = 0.006).ConclusionCatheter management in patients with enterococcal bacteremia is challenging. When CVC removal is clinically indicated in patients with enterococcal CLABSI, earlier removal in less than 3 days may be associated with better outcomes.Based on our data, we cannot make firm conclusions about whether earlier removal (< 3 days) could be associated with better outcomes in patients with Enterococcal CLABSI whose CVC withdrawal is clinically indicated. In contrast, it seemed that catheter retention was associated to higher success outcome rates. Therefore, future studies are needed to clearly assess this aspect.

Highlights

Enterococcus species are the third most common cause of central line–associated bloodstream infections (CLABSIs), the optimal management of these infections remains unclear [1]
When central venous catheter (CVC) removal is clinically indicated in patients with enterococcal central line-associated bloodstream infections (CLABSIs), earlier removal in less than 3 days may be associated with better outcomes
In CLABSI with mucosal barrier injury (MBI), the bloodstream infection may result from bacterial translocation of gut organisms rather than CVC, whereas in CLABSI without MBI, the CVC is the likely source in the absence of any apparent other source

Summary

Introduction

Enterococcus species are the third most common cause of central line–associated bloodstream infections (CLABSIs), the optimal management of these infections remains unclear [1]. The incidence of Enterococcus bacteremia is increasing in the oncologic patient population, where it is emerging as an important nosocomial infection [2]. Enterococcus species have a high affinity to form biofilms, which contributes to their virulence, antibiotic resistance, and ability to attach to medical devices and cause device-related infections including CLABSI [3]. Studies evaluating the impact of CVC removal have been sparse and limited by small sample sizes and usually the lack of a comparator group, in the oncologic patient population. Our primary objective was to evaluate the management of Enterococcus species bloodstream infections (BSIs) and their outcomes in cancer patients by comparing patients with CLABSI to those with non-CLABSI

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