Catheter-related Bacteremia Research Articles

Pros and cons of catheter lock solutions

Catheter-related bacteremia (CRB) and catheter dysfunction are major sources of morbidity and mortality when central venous catheters are used as long-term vascular access in hemodialysis patients. Attempts have been made to minimize these complications by the prophylactic use of catheter locking solutions. This review aims to describe the recent advances in the field of lock solutions and to discuss the benefits and risks associated with the routine use of antimicrobial and/or antithrombotic lock solutions. Antithrombotic lock solutions may improve patency and CRB but may be cost-prohibitive. Antimicrobial lock solutions may decrease the incidence of CRB, but their routine use is concerning for the risk of systemic toxicity and the development of resistant organisms. Preliminary results suggest a novel antimicrobial and antithrombotic lock solution may be promising in maintaining patency, while decreasing catheter-related bacteremia. The ideal catheter lock solution would be one that prevents infections and thrombosis safely and effectively, while being economically viable. Recent developments have led to improvements in the development of catheter locking solutions, but the search for the perfect 'solution' is still ongoing.

Anticoagulant therapies for the prevention of intravascular catheters malfunction in patients undergoing haemodialysis: systematic review and meta-analysis of randomized, controlled trials

Catheter malfunction (CM), including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter-related bacteraemia (CRB) and mortality. The role of alternative anticoagulant regimens for CM prevention remains uncertain. A systematic review and meta-analysis were performed examining all randomized controlled trials (RCTs) assessing interventions acting via an anticoagulant mechanism compared with conventional care for the prevention of CM in adult patients receiving haemodialysis for end-stage kidney disease. Medline, EMBASE and the Cochrane Register were searched to November 2012. The primary outcome was CM. Secondary outcomes were CRB, all-cause mortality and bleeding events (all bleeding events reported or as defined by authors). Relative risks with 95% confidence intervals (CIs) for individual trials were pooled using random effects models for treatment classes. The search yielded 28 trials including 3081 patients. Therapies assessed were alternative anticoagulant locking solutions (ALSs), systemic warfarin and low/no dose heparin locking solutions (normal saline locks). No significant effect on CM (18 trials, 1579 participants) was observed for alternative ALSs (9 trials, 887 participants, RR 0.85, 95% CI 0.68-1.07), or low/no dose heparin (4 trials, 231 participants, RR 0.99, CI 0.60-1.62), compared with heparin locking solutions (5000 units). Similarly, no significant effect was observed for warfarin (5 trials, 479 participants, RR 0.59, 95% CI 0.28-1.22) compared with placebo. No significant effect on CRB was observed (15 trials, 2367 participants) for alternative ALSs (11 trials, 2010 participants, RR 0.57, 95% CI 0.30-1.10), warfarin (1 trial, 174 participants, RR 2.40, 95% CI 0.88-6.52) or low/no dose heparin (3 trials, 183 participants, RR 0.76, 95% CI 0.35-1.64). All-cause mortality was not affected by alternative ALSs (9 trials, 1719 participants, RR 0.83, 95% CI 0.56-1.24) or warfarin (3 trials, 403 participants, RR 0.78, 95% CI 0.37-1.65). Bleeding events were only reported in seven trials, including only two trials of warfarin, with no clear effect demonstrated. Within the alternative ALSs group, the only agent with a reduction in CM was recombinant tissue plasminogen activator (rt-PA)-locking solution (RR 0.52, 95% CI 0.32-0.86) based on the results of a single trial. Trials were mainly of high risk of bias. There is uncertainty on the benefits and harms of anticoagulant therapies over conventional care for prevention of CM. Further high-quality randomized trials, including safety outcomes, are needed.

Acquisition of resistant microorganisms and infections in HIV-infected patients admitted to the ICU

Whether critically ill human immunodeficiency virus (HIV)-infected patients are at risk of acquiring nosocomial infections and resistant or potentially resistant microorganisms (RPRMs) remains to be clarified. The aim was to compare the acquisition of RPRMs, infections and mortality in critically ill HIV-infected and non-infected patients. An observational, prospective cohort study of patients admitted to a medical intensive care unit (ICU) was undertaken. Swabbing of nares, pharynx and rectum, and culture of respiratory secretions were obtained within 48 h of admission and thrice weekly thereafter. Clinical samples were obtained as deemed necessary by the attending physician. Clinical variables, severity scores on admission and exposures during ICU stay were collected. Logistic regression was used to evaluate ICU mortality. Out of the 969 included patients, 64 (6.6%) were HIV-infected. These patients had a higher Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission (19.5 ± 6.6 vs. 21.1 ± 5.4, p = 0.02), stayed longer in the care unit and were more exposed to several invasive devices and antibiotics. There were no differences in the rate of acquisition of RPRMs and the only difference in ICU-acquired infections was a significantly higher incidence of catheter-related bacteraemia (3% vs. 9%, p = 0.03). The ICU-related mortality was similar in both groups (14% vs. 16%, p = 0.70) and in HIV-infected patients, it tended to be associated with a lower CD4 cell count (p = 0.06). Despite a longer ICU stay, critically ill HIV-infected patients did not show a higher rate of RPRMs acquisition. The rate of ICU-acquired infection was similar between HIV-infected and non-infected patients, except for catheter-related bacteraemia, which was higher in the HIV-infected population. Mortality was similar in both groups.

First Report of bla IMP-8 in Raoultella planticola

Two carbapenem-resistant Raoultella planticola clinical isolates were isolated from patients with pneumonia and Port-A catheter-related bacteremia, respectively, in Taiwan. These isolates remained susceptible to fluoroquinolone, aminoglycoside, and colistin. Though the two isolates had the same antibiogram, plasmidic carbapenemase blaIMP-8, class 1 integron cassette (dfrA12-orfF-aadA2), and qnrB2, they had different pulsed-field gel electrophoresis patterns, plasmid sizes, and outer membrane protein loss profiles. To our knowledge, this is the first report of blaIMP-8 found in R. planticola. Interestingly, blaIMP-8 is the most common carbapenemase found in Klebsiella pneumoniae in Taiwan. In the literature, carbapenemase genes in R. planticola in each country were also found in carbapenem-resistant Enterobacteriaceae in the same country.

Central Venous Catheter-Related Bacteremia in Chronic Hemodialysis Patients: Saudi Single Center Experience

Central vein catheters (CVC) are an important means of delivering hemodialysis (HD) to patients who require immediate initiation of dialysis but are without a mature functioning arterio-venous fistula or graft. The frequency of catheter-related bacteremia (CRB) reported in several large series ranged between 2.5 and 5.5 cases/1,000catheter-days. The aim of the study was to evaluate the incidence, spectrum of infecting organisms, risk factors, and optimal treatment for catheter-related bacteremia.This retrospective study of clinical records was conducted between January 2005 and January 2009 where all episodes of catheter related bacteremia in the preceding 4 years were a subject of our study. Data recorded for each patient included the number of catheter-days, episodes of suspected bacteremia, blood culture results, method of treatment, complications, and outcomes. All patients with CRB were treated with a 21-day course of intravenous antibiotics, with surveillance cultures obtained 1 week after completing the course of antibiotics. The CVC was removed if the patient had uncontrolled sepsis or if other vascular access was ready for use. Once the infection was controlled, catheter salvage was considered successful, leaving the original CVC in place. 93 chronic hemodialysis (HD) patients, 42 male (45.25%) and51 female (54.8%) were included, with median age51.67 years. During this study, there were 37087catheter-days, with 52 episodes of CRB, or 1.4 episodes/1,000 catheterdays. Thirty- five infections (67.3%) were caused by gram-positive cocci only, including Staphylococcus aureus, Staphylococcus simulans, and Staphylococcus haemolyticus. Seventeen infections (32.7%) were caused by gram-negative rods only, including a wide variety of enteric organisms. Five CVCs were removed because of severe uncontrolled sepsis, of the remaining 47 cases; attempted CVC salvage was successful in (90.3%). The only important complication of CRB was endocarditis, occurring in 1 of 52 episodes (1.9%). We conclude that in our study, CRB is relatively near the lower limit of normal range with low incidence of complication and frequently involves gram-positive bacteria. CVC salvage is significantly improved when CVC was treated by antibiotic based on blood culture results.

Leclercia adecarboxylata and catheter-related bacteraemia: review of the literature and outcome with regard to catheters and patients

Infection is a common complication in patients carrying a central venous catheter (CVC) and is associated with increased morbidity and mortality. Leclercia adecarboxylata is an unusual but emerging pathogen in healthy and immunocompromised patients. We report a case of L. adecarboxylata bacteraemia in a patient with a haemodialysis tunnelled CVC. In accordance with the susceptibility to the tested antimicrobials, a long-course treatment with intravenous gentamicin plus amoxicillin-clavulanic acid and gentamicin-lock therapy was adopted. The patient had a full recovery and the catheter was not removed. We also performed a systematic PubMed/Medline and Scopus review of peer-reviewed English papers on L. adecarboxylata infections, focusing on bacteraemia in patients with different types of CVCs. Moreover, we suggest a treatment algorithm to preserve the patient and maintain the CVC.

Efficacy of Taurolock® solution for preventing catheter-related bacteremia (CRB)

Efficacy of Taurolock® solution for preventing catheter-related bacteremia (CRB)

Noncontiguous Genome Sequence of Mycobacterium septicum Strain DSM 44393 T

The rapidly growing Mycobacterium septicum rarely causes pulmonary infections. We report here the draft genome sequence of M. septicum strain DSM 44393T, isolated from catheter-related bacteremia and initially identified as a member of Mycobacterium fortuitum.

Approach to prophylactic measures for central venous catheter‐related infections in hemodialysis: A critical review

Vascular access is the major risk factor for bacteremia, hospitalization, and mortality among hemodialysis (HD) patients. The type of vascular access most associated with bloodstream infection is central venous catheter (CVC). The incidence of catheter-related bacteremia ranges between 0.6 and 6.5 episodes per 1000 catheter days and increases linearly with the duration of catheter use. Given the high prevalence of CVC use and its direct association with catheter-related bacteremia, which adversely impacts morbidity and mortality rates and costs among HD patients, several prevention measures aimed at reducing the rates of CVC-related infections have been proposed and implemented. As a result, a large number of clinical trials, systematic reviews, and meta-analyses have been conducted in order to assess the effectiveness, clinical applicability, and long-term adverse effects of such measures. In the following article, prophylactic measures against CVC-related infections in HD patients and their possible advantages and limitations will be discussed, and the more recent literature on clinical experience with prophylactic antimicrobial lock therapy in HD CVCs will be reviewed.

The First Case of Septicemia Caused by Imipenem-Susceptible, Meropenem-Resistant Klebsiella pneumoniae

The First Case of Septicemia Caused by Imipenem-Susceptible, Meropenem-Resistant <i>Klebsiella pneumoniae</i>

Natural History of Tunneled Dialysis Catheters Placed for Hemodialysis Initiation

PurposeMore than 80% of hemodialysis recipients in the United States initiate hemodialysis with a tunneled dialysis catheter (TDC). Published data on TDC outcomes are based on a case mix of prevalent and incident TDCs. The present study analyzes factors affecting patency and complications of first TDCs placed in a large cohort of incident hemodialysis recipients. Materials and MethodsA prospective, computerized vascular access database was retrospectively queried to identify 472 patients receiving a first-ever TDC. Multiple-variable survival analysis was used to identify clinical parameters affecting TDC patency (from placement to nonelective removal) and infection (from placement to first episode of catheter-related bacteremia [CRB]). ResultsThe median patency of all TDCs was 202 days. Left-sided placement of TDCs was the only variable associated with inferior TDC patency (hazard ratio, 1.98; 95% confidence interval, 1.39–2.81; P < .0001). The 6-month TDC patency rate was 37% for left internal jugular vein (LIJV) catheters, versus 54% for right internal jugular vein (RIJV) catheters. The 1-year patency rate was 6% for LIJV catheters, versus 35% for RIJV catheters. Catheter patency was not associated with patient age, sex, race, hypertension, diabetes, coronary artery disease, peripheral vascular disease, cerebrovascular disease, or heart failure. The median time to the first episode of CRB was 163 days. None of the clinical variables was associated with TDC infection. ConclusionsTDCs are plagued by high rates of infection. RIJV TDCs should be used preferentially to maximize catheter patency.

Comparing normal saline versus diluted heparin to lock non-valved totally implantable venous access devices in cancer patients: a randomised, non-inferiority, open trial

BackgroundHeparin has been used for years as a locking solution in totally implantable venous access devices. Normal saline (NS) might be a safe alternative for heparin. However, evidence of non-inferiority of NS versus heparin is lacking. Patients and methodsWe randomly allocated 802 cancer patients with a newly inserted port either to heparin lock (300 U/3 ml) or to NS lock groups in a 1:1 assignment ratio. The primary outcome was the number of functional complications, which was defined as ‘easy injection, impossible aspiration’ at port access. Secondary outcomes included all functional problems and catheter-related bacteraemia. We hypothesised that NS locks do not cause more functional problems and catheter-related bacteraemia than heparin locks. Non-inferiority is established if the upper limit of the confidence interval (CI) for the relative risk of NS versus heparin is <1.4. ResultsThree hundred and eighty-two patients from the NS group and 383 from the heparin lock group were included in the analysis. The incidence rate of our primary outcome (easy injection, impossible aspiration) was 3.70% (95% CI 2.91%–4.69%) and 3.92% (95% CI 3.09%–4.96%) of accesses in the NS and heparin groups, respectively. The relative risk was 0.94% (95% CI 0.67%–1.32%). Catheter-related bloodstream infection was 0.03 per 1000 catheter days in the NS group and 0.10 per 1000 catheter days in the heparin group. ConclusionNS is a safe and effective locking solution in implantable ports if combined with a strict protocol for device insertion and maintenance.

Catheter-Related Bacteremia Caused by Aeromonas hydrophila in a Hemodialysis Patient

Catheter-Related Bacteremia Caused by <i>Aeromonas hydrophila</i> in a Hemodialysis Patient

P007: Risk factors for mortality among non-icu patients with catheter-related bacteraemia

The number of episodes of vascular catheter related bacteraemia (CRB) observed in non-Intensive Care Unit (ICU) patients may be similar or even higher than those observed in ICUs. While we have a lot of information regarding the impact of CRB among ICU patients, there is still lack of information concerning non-ICU patients.

Comparison of four skin preparation strategies to prevent catheter-related infection in intensive care unit (CLEAN trial): a study protocol for a randomized controlled trial

BackgroundCatheter-related infection is the third cause of infections in intensive care units (ICU), increasing the length of stay in ICU and hospital, mortality, and costs. Skin antisepsis is one of the most prevalent preventive measures. In this respect, it would appear preferable to recommend the use of alcoholic povidone iodine or chlorhexidine rather than aqueous povidone iodine. However, the data comparing chlorhexidine to povidone-iodine, both of them in alcoholic solutions, remain limited. Moreover, the benefits of enhanced cleaning prior to disinfection of skin that is not visibly soiled have yet to be confirmed in a randomized study.MethodsA prospective multicenter, 2×2 factorial, randomized-controlled, assessor-blind trial will be conducted in 11 intensive care units in six French hospitals. All adult patients aged over 18 years requiring the insertion of at least one peripheral arterial catheter and/or a non-tunneled central venous catheter and/or a hemodialysis catheter and/or an arterial pulmonary catheter will be randomly assigned to have all their catheters cared with one of four skin preparation strategies (2% chlorhexidine/70% isopropyl alcohol or 5% povidone iodine/69% ethanol with or without prior skin scrubbing). At catheter removal, catheter tips will be quantitatively cultured. Sets of aerobic and anaerobic blood cultures will be routinely obtained when a patient has fever, hypothermia, or other indications. In case of suspected catheter-related infection the patient’s form will be reviewed by an independent adjudication committee. We plan to enroll 2,400 patients (4,800 catheters). The main objective is to demonstrate that use of 2% alcoholic chlorhexidine compared to 5% alcoholic povidone iodine in skin preparation lowers the rate of catheter-related infection. The second endpoint is to demonstrate that enhanced skin cleaning prior to disinfection of skin that is not visibly soiled does not reduce catheter colonization. Other outcomes include comparison of skin colonization at catheter insertion site, comparison of catheter colonization and catheter-related bacteremia taking place during implementation of the four strategies of skin preparation, and cutaneous tolerance, length of hospitalization, mortality, and costs.DiscussionThis study will help to update recommendations on the choice of an antiseptic agent to use in skin preparation prior to insertion of a vascular catheter and, by extension, of an epidural catheter and it will likewise help to update recommendations on the usefulness of skin scrubbing prior to disinfection when the skin is not visibly soiled.Trial registrationClinicaltrials.gov number NCT01629550

Abstract No. 327 - TETHC—a novel technique for treatment of tunnel/exit site infections in catheter dependent hemodialysis patients with central venous stenosis and limited venous access options

Purpose To evaluate the viability and effectiveness of a novel technique of temporary externalization of a tunneled hemodialysis catheter (TETHC) in catheter-dependent hemodialysis patients presenting with catheter-related tunnel/exit site infection, central venous stenosis and limited alternative venous access. Materials and Methods All catheter-dependent hemodialysis patients with documented central venous stenosis presenting with catheter-related infection of the exit site or tunnel who had subsequently undergone TETHC between February 2008 and May 2012 were reviewed. Patients were concurrently treated with intravenous antibiotics prior to reinsertion of a new tunneled hemodialysis catheter. Treatment outcomes were collected, with treatment failures defined as re-infection with the same organism within 45 days of catheter reinsertion. Results Forty-two TETHC procedures were performed in 26 patients. Indications included 20 tunnel infections and 22 exit site infections. The technical success rate for temporary catheter placement was 100%, with no intra-procedural complications and preservation of the original venous access site in all patients. Treatment failure occurred in 9.8 % (4/41) of cases. One patient died prior to reinsertion of the new tunnelled dialysis catheter due to catheter related bacteremia unrelated to the procedure. The median infection free survival of the new tunneled dialysis catheters was 80 days. Post-procedural complications were encountered in four patients and included 3 cases of a small persistent wound at the temporary supraclavicular access site and 1 non-functioning temporary externalized catheter. Conclusion The novel use of TETHC appears safe and is both viable and effective in the treatment of exit-site and tunnel infections while allowing preservation of the venous access site in catheter-dependent hemodialysis patients with central venous stenosis and limited alternative venous access.

Comparative Epidemiology of Staphylococcus epidermidis Isolates from Patients with Catheter-Related Bacteremia and from Healthy Volunteers

Staphylococcus epidermidis is a major cause of catheter-related bloodstream infections (CRBSIs). Recent studies suggested the existence of well-adapted, highly resistant, hospital-associated S. epidermidis clones. The molecular epidemiology of S. epidermidis in Belgian hospitals and the Belgian community has not been explored yet. We compared a set of 33 S. epidermidis isolates causing CRBSI in hospitalized patients with a set of 33 commensal S. epidermidis isolates. The factors analyzed included resistance to antibiotics and genetic diversity as determined by pulsed-field gel electrophoresis (PFGE), multilocus sequence typing (MLST), and SCCmec typing. Additionally, the presence of virulence-associated mobile genetic elements, the ica operon and the arginine catabolic mobile element (ACME), was assessed and compared against clinical data. CRBSI S. epidermidis isolates were significantly resistant to more antibiotics than commensal S. epidermidis isolates. The two populations studied were very diverse and genetically distinct as only 23% of the 37 PFGE types observed were harbored by both CRBSI and commensal isolates. ACME was found in 76% of S. epidermidis strains, regardless of their origin, while the ica operon was significantly more prevalent in CRBSI isolates than in commensal isolates (P < 0.05). Nine patients presented a clinically severe CRBSI, eight cases of which were due to an ica-positive multiresistant isolate belonging to sequence type 2 (ST2) or ST54. S. epidermidis isolates causing CRBSI were more resistant and more often ica positive than commensal S. epidermidis isolates, which were genetically heterogeneous and susceptible to the majority of antibiotics tested. Clinically severe CRBSIs were due to isolates belonging to two closely related MLST types, ST2 and ST54.

GRP-037 Catheter Related Infection Treatment Protocol Compliance in the Intensive Care Unit

BackgroundThe Hospital Infections and Antibiotic Policy Committee guidelines recommend antibiotics to cover coagulase-negative staphylococcus and Gram-negative bacilli with vancomycin + aminoglycoside or aztreonam if Catheter-Related Bacteraemia (CRB) is suspected. Fungal...

OHP-076 The Incidence of Bacteremia Due to Catheters and the Cost of Antibiotics Before and After Implementation of the Zero Bacteremia Project

BackgroundPrimary bacteraemia and bacteraemia caused by catheter infections entail a high pharmaceutical cost. The ‘Zero Bacteraemia Project’ (BZP) for central intravenous catheter (CVC) use in invasive therapies showed a decrease...

Empiric guideline-recommended weight-based vancomycin dosing and nephrotoxicity rates in patients with methicillin-resistant Staphylococcus aureus bacteremia: a retrospective cohort study

BackgroundPrevious studies have established a correlation between vancomycin troughs and nephrotoxicity. However, data are currently lacking regarding the effect of guideline-recommended weight-based dosing on nephrotoxicity in methicillin-resistant Staphylococcus aureus bacteremia (MRSAB).MethodsAdults who were at least 18 years of age with methicillin-resistant Staphylococcus aureus bacteremia and received of empiric vancomycin therapy for at least 48 hours (01/07/2002 and 30/06/2008) were included in this multicenter, retrospective cohort study. The association between guideline-recommended, weight-based vancomycin dosing (at least 15 mg/kg/dose) and nephrotoxicity (increase in serum creatinine (SCr) by more than 0.5 mg/dl or at least a 50% increase from baseline on at least two consecutive laboratory tests) was evaluated. Potential independent associations were evaluated using a multivariable general linear mixed-effect model.ResultsOverall, 23% of patients developed nephrotoxicity. Thirty-four percent of the 337 patients who met study criteria received weight-based dosing. The cohort was composed of 69% males with a median age of 55 years. The most common sources of MRSAB included skin/soft tissue (32%), catheter-related bloodstream bacteremia (20%), pulmonary (18%). Eighty-six percent of patients received twice daily dosing. Similar rates of nephrotoxicity were observed regardless of the receipt of guideline-recommended dosing (22% vs. 24%, OR 0.91 [95% CI 0.53-1.56]). This finding was confirmed in the multivariable analysis (OR 1.52 [95% CI 0.75-3.08]). Independent predictors of nephrotoxicity were (OR, 95% CI) vancomycin duration of greater than 15 days (3.36, 1.79-6.34), weight over 100 kg (2.74, 1.27-5.91), Pitt bacteremia score of 4 or greater (2.73, 1.29-5.79), vancomycin trough higher than 20 mcg/ml (2.36, 1.07-5.20), and age over 52 years (2.10, 1.08-4.08).ConclusionsOver one out of five patients in this study developed nephrotoxicity while receiving vancomycin for MRSAB. The receipt of guideline-recommended, weight-based vancomycin was not an independent risk factor for the development of nephrotoxicity.