Central Venous Catheter Removal Research Articles

A lower fibrinogen threshold does not lead to increased bleeding risk in patients receiving therapeutic plasma exchange: A prospective single‐center analysis

AbstractBackgroundPlasma exchange (PLEX) therapy is indicated for several disorders. The 5% albumin is often used as a sole replacement fluid during most PLEX. However, each 1.0 plasma volume exchange depletes coagulation factors by ~65%. Although most coagulation factors recover to hemostatic levels within 24 h post‐PLEX, fibrinogen requires 48–72 h to recover. Fibrinogen is the key coagulation protein for hemostasis. Therefore, fibrinogen is often monitored during the acute course of PLEX, and plasma is supplemented to prevent bleeding if fibrinogen is <100 mg/dL.Study Design and MethodsWe conducted a prospective, single‐center, observational study to evaluate bleeding risk in adults who received an acute course of PLEX with a fibrinogen level of 80–100 mg/dL without plasma supplementation during the procedure or before central venous catheter removal. The study group was compared to patients with plasma fibrinogen >100 mg/dL.ResultsAmong the 275 patients who received 1406 PLEXes, 62 patients (23%) who underwent 323 PLEXes met the inclusion criteria, and only 2 (3%) patients had bleeding while on oral anticoagulants. In contrast, out of 275 patients, 143 (52%) with fibrinogen levels >100 mg/dL received 751 PLEX treatments, and bleeding occurred in 2 (1%) while on low‐molecular‐weight heparin.ConclusionsOur findings suggest that a pre‐procedure fibrinogen threshold of 80–100 mg/dL without plasma supplementation does not increase bleeding risk unless patients were on anticoagulation.

Guideline Adherence and Outcomes of Patients with Candidemia in Brazil.

Candidemia is a significant cause of mortality among hospitalized patients, both worldwide and in Brazil. Prompt and appropriate treatment are essential to mitigate mortality, and clinical practice guidelines aim to optimize patient care based on the best scientific evidence. This study aims to examine the management of candidemia, assessing adherence to the guidelines of the Brazilian Society of Infectious Diseases in a single center located at São Paulo, Brazil. All adult patients hospitalized from 2016 to 2018 who presented one positive blood culture for Candida spp. were included. Electronic medical records were retrospectively reviewed to collect information relevant to the treatment for candidemia, in order to assess the adherence to the Brazilian guideline for the management of candidemia in relation to nine defined outcomes, and we correlated those findings with 30-day mortality by using uni- and multivariate analyses. A total of 115 patients were included; 68 patients (59.1%) were male, with a mean age of 55 years. C. albicans, C. tropicalis and C. glabrata were the most prevalent species. In total, 80 patients (69.5%) received antifungal treatment. The adherence to Brazilian guideline recommendations was determined as described in the following: initial treatment with echinocandin in 48 (60%); step-down to fluconazole in 21 (26.2%); collection of first control blood culture in 43 (58.9%); collection of second control blood culture, if the first one had been positive, in 14 (73.6%); treatment for 14 days after the first negative blood culture in 53 (65.4%); central venous catheter (CVC) removal in 66 (82.5%); CVC removal if the first control blood culture had been positive in 17 (89.4%); performance of a transthoracic echocardiogram in 51 (63.7%) and performance of a fundoscopy in 59 (73.7%). Univariate analysis showed that CVC removal and initial echinocandin therapy were more prevalent in the surviving group, but with no statistically significant difference. On the other hand, step-down to fluconazole demonstrated higher survival rate in the multivariate analysis OR 0.15 (95% CI 0.03-0.8); p = 0.02. The analysis of these nine recommendations demonstrates that it is necessary to improve adherence to specific recommendations and also disseminate strategies of the initial use of echinocandin as the drug of choice and addressing length of treatment and follow-up and complementary exams. Our study provides reassurance that the step-down to fluconazole is safe and may be recommended, if the preexisting conditions are present.

Superior Vena Cava Thrombosis in A Young Hemodialysis Patient After 1 year of Central Venous Catheter Removal: A Case Report

Introduction:
 Superior vena cava (SVC) syndrome is a rare but serious condition resulting from obstruction of the superior vena cava or its tributaries. Although often associated with malignancy, it can also occur due to central venous catheterization(1). Acute SVC syndrome following catheter removal is uncommon. 
 Case Report: 
 We present a 35-year-old hemodialysis patient with a history of central venous catheterization for hemodialysis one year prior. During a routine hemodialysis session, the patient developed symptoms of shortness of breath, neck swelling, and cyanosis of the lips. Physical examination revealed neck edema and prominent superficial vascular bifurcations. Without imaging studies, it was confused with cellulitis, but CT angiography later confirmed SVC thrombosis. The patient was started on anticoagulation and transferred to a tertiary hospital for further management. 
 Conclusion: 
 Emergency physicians should be aware of SVC syndrome, especially in hemodialysis patients with a history of central venous catheterization. Although it is often associated with malignancy, this case highlights the importance of considering SVC thrombosis even after catheter removal. Prompt diagnosis and appropriate management are essential to prevent life-threatening complications. Therefore, recognition and inclusion of SVC syndrome in the differential diagnosis is essential for timely intervention and improved patient outcomes.

Invasive candidiasis.

Invasive candidiasis is an important fungal disease caused by Candida albicans and, increasingly, non-albicans Candida pathogens. Invasive Candida infections originate most frequently from endogenous human reservoirs and are triggered by impaired host defences. Signs and symptoms of invasive candidiasis are non-specific; candidaemia is the most diagnosed manifestation, with disseminated candidiasis affecting single or multiple organs. Diagnosis poses many challenges, and conventional culture techniques are frequently supplemented by non-culture-based assays. The attributable mortality from candidaemia and disseminated infections is ~30%. Fluconazole resistance is a concern for Nakaseomyces glabratus, Candida parapsilosis, and Candida auris and less so in Candida tropicalis infection; acquired echinocandin resistance remains uncommon. The epidemiology of invasive candidiasis varies in different geographical areas and within various patient populations. Risk factors include intensive care unit stay, central venous catheter use, broad-spectrum antibiotics use, abdominal surgery and immune suppression. Early antifungal treatment and central venous catheter removal form the cornerstones to decrease mortality. The landscape of novel therapeutics is growing; however, the application of new drugs requires careful selection of eligible patients as the spectrum of activity is limited to a few fungal species. Unanswered questions and knowledge gaps define future research priorities and a personalized approach to diagnosis and treatment of invasive candidiasis is of paramount importance.

Characterizing Patients Presenting on Hospital Admission with Central Line-Associated Bloodstream Infections: A Multicenter Study.

There are no systematic measures of central line-associated bloodstream infections (CLABSIs) in patients maintaining central venous catheters (CVCs) outside acute care hospitals. To improve understanding of the burden of CLABSIs outside acute care hospitals, we characterized patients with CLABSI present on hospital admission (POA). Retrospective cross-sectional analysis of patients with CLABSI-POA in three health systems covering eleven hospitals across Maryland, Washington DC, and Missouri from November 2020 to October 2021. CLABSI-POA was defined using an adaptation of the acute care CLABSI definition. Patient demographics, clinical characteristics, and outcomes were collected via chart review. Cox proportional hazard analysis was used to assess factors associated with all-cause mortality within 30 days. 461 patients were identified as having CLABSI-POA. CVCs were most commonly maintained in home infusion therapy (32.8%) or oncology clinics (31.2%). Enterobacterales were the most common etiologic agent (29.2%). Recurrent CLABSIs occurred in a quarter of patients (25%). Eleven percent of patients died during the hospital admission. Among CLABSI-POA patients, mortality risk increased with age (versus ages <20: ages 20-44 years: HR: 11.21, 95% CI: 1.46-86.22; ages 45-64: HR: 20.88, 95% CI: 2.84-153.58; at least 65 years of age: HR: 22.50, 95% CI: 2.98-169.93), and lack of insurance (HR: 2.46; 95% CI: 1.08-5.59), and decreased with CVC removal (HR: 0.57, 95% CI: 0.39-0.84). CLABSI-POA is associated with significant in-hospital mortality. Surveillance is required to understand the burden of CLABSI in the community to identify targets for CLABSI prevention initiatives outside acute care settings.

Staphylococcus capitis Central-Line-Associated Bloodstream Infections in the Neonatal Intensive Care Unit: A Single-Center, Four-Year Experience in Central-Line Management during Sepsis Treatment.

Coagulase-negative staphylococci (CoNS) are reportedly responsible for 50-60% of bloodstream infections in very preterm (<1500 g) infants in neonatal intensive care units (NICUs). Staphylococcus capitis is an increasingly prevalent pathogen in the neonatal setting, frequently causing central-line-associated bloodstream infections (CLABSIs) that can be difficult to eradicate. Central venous catheter (CVC) removal versus in situ treatment with CoNS CLABSIs is a controversial treatment strategy with no clear consensus. We reviewed all S. capitis CLABSIs in our NICU between 2019 and 2022, focusing on the role of catheter removal in eradication. Among the 25 patients, 17 CVCs were removed after diagnosis, leading to a 76.5% eradication rate in this group. Three infants had a persistently positive blood culture after CVC substitution. A new catheter was then inserted after a 48 h washout period, resulting in resolution of the infection. Only two of the eight patients (25%) who retained their catheter after diagnosis achieved infection eradication with antibiotic therapy alone. When feasible, catheter removal seems to be the most effective strategy for eradicating S. capitis CLABSIs, sometimes even requiring a 48 h washout period before reinsertion. Further studies on this topic are needed to better standardize the management of this type of infection.

Antibiotic use at planned central line removal in reducing neonatal post-catheter removal sepsis: a systematic review and meta-analysis.

Post-catheter removal sepsis (PCRS) is a notable complication of indwelling central venous catheters (CVCs) in neonates, which is postulated to be secondary to the disruption of biofilms formed along catheter tips up on CVCs removal. It remains controversial whether this could be prevented by antibiotic use upon CVCs removal. We aimed to evaluate the protective effect of antibiotic administration at the time of CVCs removal. We searched through PubMed, EMBASE, Cochrane databases and reference lists of review articles for studies comparing the use of antibiotics versus no use within 12 h of CVCs removal. Risk of bias was assessed using the modified Newcastle-Ottawa Scale and Cochrane risk-of-bias tool accordingly. Results of quantitative analyses were presented as mean differences (MD) or odds ratio (OR). Subgroup and univariate meta-regression analyses were performed to identify heterogeneity. The review included 470 CVCs in the antibiotic group and 658 in the control group. Antibiotic use within 12 h of CVCs removal did not significantly reduce the incidence of PCRS (OR = 0.35, 95% CI: 0.08-1.53), but was associated with a lower incidence of post-catheter removal blood stream infection (OR = 0.31, 95% CI: 0.11-0.86). Dosage of vancomycin and world region were major sources of heterogeneity. Antibiotic administration upon CVCs removal does not significantly reduce the incidence of PCRS but offers less post-catheter removal blood stream infection. Whether this will be converted to better clinical outcomes lacks evidential support. Further randomized controlled studies with longer follow-up are needed. Results of our meta-analysis suggest that antibiotic use at planned central line removal removal does not significantly reduce the incidence of PCRS but offers less blood stream infection, which might contribute to future management of central lines in neonates. https://www.crd.york.ac.uk/, PROSPERO (CRD42022359677).

Removal of stuck tunnelled dialysis line requiring cardiopulmonary bypass and venous repair.

Tunnelled central venous dialysis catheters can usually be removed easily. However, their removal can become rarely complicated requiring more invasive techniques. We report a case in which cardiopulmonary bypass and repair of great veins was required for safe removal. A 38-year-old female with end-stage renal failure and a 3-year-old Hickman line inserted into her right internal jugular vein was referred to our cardiac surgical unit following failed attempts of line removal by local vascular surgical team using open vascular surgical techniques. As a result, an MDT decision was made that it was safer to proceed to a cardiothoracic surgical approach rather than other techniques. Investigations showed significant calcification surrounding the line which was adherent to the venous wall. Removal of the retained catheter required median sternotomy and the use of cardiopulmonary bypass as the great veins had to be opened to free the line and allow complete removal. The line was successfully removed with its encircling calcified sheath, and the veins were closed primarily without needing a patch repair. The integrity of the great veins was maintained to meet the on-going need this young patient has for central venous access. The patient made an uneventful recovery. When other measures fail, sternotomy and cardiopulmonary bypass provide a safe option for complete removal of stuck central venous catheters with low risk to the patient.

AHP P06 Optimizing Coagulation Screen Practices in CVC Removal Amongst Surgical Patients: A Retrospective Audit Assessing Necessity, Compliance, and Implications

Abstract Background Conflicting findings in recent literature question the significance of traditional coagulation variables in predicting bleeding associated with central venous catheter (CVC) removal. This audit evaluates the necessity and compliance of conducting same-day coagulation screens at Churchill Hospital. The study assesses the practice's relevance, compliance rates, and associated costs, offering implications for clinical decision-making, resource utilization, and potential modifications to current practices. The findings may lead to the adoption of new predictive factors or a targeted approach to coagulation testing, optimizing patient care and resource allocation in CVC removals. Methods This retrospective audit focused on surgical patients in the upper gastrointestinal, hepatobiliary and pancreatic, lower gastrointestinal, and transplant surgery departments at the Churchill Hospital. The study encompassed all instances of central venous catheter (CVC) removal that occurred between January 1st, 2022, and December 31st, 2022. Data retrieval was conducted using electronic patient records, and coagulation test results were interpreted utilizing the reference ranges available in the electronic patient record system (INR 0.9-1.2, PT 9-12, APTT 20-30). Results 78 patients had an average age of 53 years and a mean hospital stay of 35 days. The average duration of CVC in-situ was 8.9 days. Patients underwent an average of 5.07 coagulation tests per stay, equivalent to 0.28 tests per admission day. Among the audited patients (n=67), 41.8% had same-day coagulation screens, 17.9% had the screen one day prior to CVC removal, and 40.3% had the screen more than one day before removal. Analysis showed that 88% had normal INR values, with only eight patients having abnormal values. Furthermore, 74.6% and 58.2% had normal PT and APTT values, respectively. Conclusions This retrospective audit of CVC removals in surgical patients at Churchill Hospital revealed a concerning in-compliance rate of 44% with coagulation screens during CVC removals. Most patients had normal coagulation parameters, questioning the need for same-day screens. Delays and high costs (£64.76 per patient, £12.95 per screen) were incurred. Individualized risk-based approach, considering bleeding history, could be more efficient. Implementing targeted coagulation testing saves costs and optimizes resource utilization. Further evaluation required to improve patient care and resource allocation in CVC removals, reducing reliance on routine same-day screens.

Use of 2% taurolidine lock solution for treatment and prevention of catheter-related bloodstream infections in neonates: a feasibility study

Taurolidine lock, a technique used to prevent or treat catheter-related bloodstream infection (CRBSI), is effective in adult and paediatric patients but has been described rarely in neonates. The aim of this descriptive retrospective study, was to determine the feasibility and direct outcomes of prophylactic and therapeutic taurolidine locks in term and preterm neonates. We implemented the use of therapeutic taurolidine lock in addition to antibiotic treatment with the aim of catheter salvage in critical neonates with difficult vascular access (group 1). In addition, we introduced taurolidine lock as a preventive measure in neonates with a central venous catheter (CVC) at high risk of developing CRBSI (group 2). Every 24h (in the treatment group) a 2% taurolidine solution was injected and the catheter locked for at least 120min, until infection clearance (group 1). In the preventive group, the catheter was locked for 30min every 48h until CVC removal (group 2). Thirty-seven neonates who received taurolidine were included in this study. We did not observe any major adverse events. In group 1 (21 cases), clinical symptom disappearance and bacteraemia clearance were achieved without catheter removal in 18 cases (85.7%); in the other three neonates the catheter was removed shortly after the start of the locks as it was possible to replace the CVC. In group 2 (16 neonates), no CRBSI was observed during the duration of the catheter placement. In this retrospective study, taurolidine was successfully used in neonates both for prevention and treatment of CRBSI, without major undesired effects. A larger cohort and a randomized clinical trial is warranted in order to establish its efficacy and safety in neonates.

Early Central Venous Catheter Replacement After Candida in Pediatric Intestinal Failure Patients.

Deferred central venous catheter (CVC) replacement places children with intestinal failure (IF) at risk of complications. We hypothesized that early CVC replacement after uncomplicated candidemia is safe and beneficial. We performed a retrospective review of children with IF. Patients were divided into early (<7 days after their first negative culture), and late (≥7 days after their first negative culture) CVC replacement following uncomplicated candidemia. We calculated the median time to CVC removal, clearance of infection, CVC replacement or exchange, and duration of the initial hospitalization. The proportion of patients readmitted within 30 days was also calculated, taking note of the number of candida reinfections. Early replacement occurred in 18 encounters and late replacement in 21 encounters. The median time in both groups to CVC removal was 3 days (P = 0.949), and clearance of infection was 4 days (P = 0.466). The median time to CVC replacement or exchange in the early group was 4 days, compared to 10 days in the late group (P < 0.001). The median duration of the hospitalization in the early group was 12 days compared to 21 days in the late group (P = 0.011). In total 39% of patients from the early group were readmitted within 30 days compared to 57% from the late group (P = 0.359). None of the patients were reinfected with candida within 30 days. Early CVC replacement after uncomplicated candidemia in children with IF decreases hospital stay without increased risk of readmission or reinfection.

Predictors of outcomes in patients with candidemia in an Intensive Care Unit

Objective: Candidemia is a life-threatening infection that causes high mortality rates in intensive care units (ICUs). This study aims to&#x0D; evaluate predictors of the outcome of patients with candidemia in ICU.&#x0D; Patients and Methods: This observational, retrospective study included patients with Candida bloodstream infection (BSI) in ICUs&#x0D; between 6 years of the episode. A binary logistic regression analysis was conducted to inspect the association with mortality.&#x0D; Results: The median age of 74 patients was 68.5, and 53.8% were men. C. parapsilosis was the most frequently isolated fungal species.&#x0D; The 30-day mortality rate was 50%. In the logistic regression model the Acute Physiology and Chronic Health Evaluation (APACHE)&#x0D; II score, positive blood culture on the seventh day, inotropes needed on the day of blood culture positivity, and ventilator-associated&#x0D; pneumonia (VAP) were significant risk factors for the outcome of patients. There was no difference in mortality between an early start&#x0D; of antifungal treatment or central venous catheter removal time.&#x0D; Conclusion: A shift to C. parapsilosis is observed in this study. Host-related factors such as APACHE II score, need for mechanical&#x0D; ventilation or need for inotropes affect mortality more than early treatment and source control in patients with Candida BSI.

Time From Vascular Access Maturation to Central Venous Catheter Removal Is a Modifiable Period of Risk

Time From Vascular Access Maturation to Central Venous Catheter Removal Is a Modifiable Period of Risk

Central venous catheter (CVC) salvage in case of central line-associated bloodstream infection (CLABSI): A monocentric prospective study in patients on long-term home parenteral nutrition (HPN)

CLABSI is a major complication in HPN and frequently leads to central venous catheter (CVC) removal. We developed a salvaging attitude in long term HPN patients due to the necessity of venous preservation. The main objective of this study is to determine the prognosis of CLABSI. We followed-up for three months, in an approved HPN centre, a cohort of 250 adult patients receiving HPN with CLABSI from 2018 to 2020. CLABSI was defined by a blood culture growth differential [peripheral blood] - [CVC blood]≥2h. A therapeutic approach to conserve CVC was established according to the department's protocol. The primary endpoint was conservation of CVC with negative CVC and peripheral blood cultures at 3 months without complications. Data from 30 CLABSIs were collected for 22 HPN patients. The incidence rate of CLABSIs was 0.28 infections/1000 catheter days. Sixteen CVCs were removed immediately, with causes due to the type of germ (staphylococcus aureus: n=6, candida parapsilosis: n=4, klebsiella: n=2), chronic colonization (n=4) or initial complications (n=4). Among the 14 non-removed CVC, 11 were maintained at 3 months with blood cultures on CVC and peripheral negative for 9 (80%) of them. 3 CVC were removed during the 3 months follow-up (non-CVC-related sepsis n=2, and resistant pseudomonas aeruginosa n=1). The incidence rate of CLABSIs in an expert HPN centre remains low. In case of CLABSIs, according to specific protocol, approximately 50% of CVC were removed immediately (essentially due to bacteriological characteristics). In case of CLABSIs and without initial complication, 80% of CVCs can be maintained at 3 months. These results justify a conservative attitude according to standardized protocol.

Central Venous Catheter-related Bloodstream Infections Caused by Enterobacterales in Pediatric Oncology Patients: Catheter Salvage or Removal.

The aim was to determine whether salvage treatment with systemic antibiotics is a safe and effective strategy for Enterobacterales bloodstream infections (BSI) in pediatric oncology patients with a central venous catheter (CVC). A retrospective study was performed on oncology and stem cell recipient patients with a CVC and blood culture with Enterobacterales, at the Princess Máxima Centre for Pediatric Oncology, Utrecht, the Netherlands. Analyses were performed for all BSI and for episodes meeting central line-associated bloodstream infection (CLABSI) criteria. The cumulative incidence of an event (ie, removal, intensive care admission or death) was estimated after blood culture collection for episodes primarily treated with antibiotics. The effect of prognostic factors on the hazard of the event of interest was assessed by estimating a Cox proportional hazard regression model. In total, 95 CVC-related Enterobacterales BSIs in 82 patients were included; 12 (13%) BSIs required immediate CVC removal and for 83 (87%) BSIs CVC salvage was attempted. The cumulative incidence of events at 60 days was 53.0% [95% confidence interval (CI): 41.7-63.1] for BSIs (n = 83), and 64.4% (95% CI: 48.3-76.7) for CLABSIs (n = 45). The events occurred after a median of 6 (Q1-Q3: 2-15) and 6 (Q1-Q3: 2-20) days for BSIs and CLABSIs, respectively. Intensive care admission after salvage treatment was required in 16% of the BSIs and CLABSIs, resulting in death in 5% and 2% of cases, respectively. No significant association between risk factors and events was found. The cumulative incidence of an event at 60 days after salvage treatment for Enterobacterales CLABSIs and BSIs in pediatric oncology patients is high. Immediate CVC removal appears recommendable for this patient group.

Non-cuffed central venous catheter for unplanned and urgent start haemodialysis in chronic kidney disease: A multi-centre experience from India.

Central Venous Catheter (CVC) is indispensable to unplanned and urgent start haemodialysis in chronic kidney disease (CKD). While cuffed CVC is preferred to non-cuffed CVC for urgent start haemodialysis, patient's clinical condition might warrant immediate insertion of non-cuffed CVC. In the resource poor setting, non-cuffed CVCs might have to be retained longer than guideline recommended limit of 2 weeks. In this multi-centre retrospective observational study, the real-world survival of non-cuffed CVC was assessed among CKD patients who initiated dialysis urgently. CVC survival was assessed by Kaplan-Meier survival estimate. Predictors of premature CVC loss were assessed using multi-level multi-variate Cox frailty model wherein, each centre was provided with a random intercept to account for within-centre correlation of practice patterns. Among 433 non-cuffed CVCs, there were 393 removals out of which 80% were elective and 20% were premature. The median CVC survival was 37 days (95% CI: 35-41). The rate of premature CVC removal was 4.5/1000 CVC-days (95% CI: 3.6-5.6). Mechanical complications followed by central line associated blood stream infection (CLABSI) were the most common reasons for premature removal. Rate of CLABSI was 1.7/1000 CVC-days (95% CI: 1.2-2.5). Diabetic CKD significantly increased the hazard of premature CVC removal (HR 1.91, 95% CI: 1.01-3.63, p = 0.04) while right internal-jugular location decreased the hazard (HR 0.22, 95% CI: 0.13-0.38, p < 0.001). Prolonged retention of non-cuffed CVC (median 37 days) is common in resource-poor setting. It is worrisome and calls for pre-emptive access creation.

#6597 THE EFFECT OF PATHOGEN ON THE OUTCOME OF HEMODIALYSIS CATHETER-RELATED BLOODSTREAM INFECTIONS IN HOSPITALIZED PATIENTS: A SINGLE CENTER ANNUAL RECORD

Abstract Background and Aims Tunneled double-lumen catheters are increasingly used as permanent vascular access in hemodialysis patients, particularly in those with limited vascular access options. Catheter-related bloodstream infection (CRBSI) is a major cause of hospitalization with increased mortality and cost. The purpose is to study the effect of the pathogen on the clinical course of the hemodialysis patients with CRBSI. Method Patients hospitalized in our department from 11/2021 to 12/2022 with established CRBSI were retrospectively studied. Their demographics, duration of hospitalization, microbiological data, central venous catheter management and hospital outcome were recorded. Results A total of 27 patients with median age (SD) 68,03 (16,93) years were treated, 12 (44.4%) were men. The following pathogens were isolated from the blood cultures: Staphylococcus aureus in 7 (25.9%) patients, coagulase-negative Staphylococcus in 10 (37%) patients, Gram-positive bacteria in 4 (14.8%) patients, Gram-negative bacteria in 3 (11.1%) patients, candida in one (3.7%) patient, while 2 (7.4%) patients had negative cultures. Mean (SD) duration of hospitalization was 16,85 (13,15) days for all patients. Patients in whom Staphylococcus aureus and Candida were isolated had longer hospital stay than other infections with a mean (SD) 29 (18) days and 41 days respectively (p = 0.014). Metastatic infections occurred in 4 (14,8%) patients, of whom 2 had endocarditis, one endocarditis and pulmonary abscess, and one endocarditis, lung abscess and brain abscess. All 4 patients isolated Staphylococcus aureus in blood culture out of a total of 7 (57,1%) patients with this pathogen (p = 0.02). 3 of 7 (42,8%) patients with Staphylococcus aureus, 1 of 10 (10%) with coagulase-negative Staphylococcus, and 1 of 3 (33,3%) with Gram-negative bacteria died (p = 0.385). In 26 of the 27 patients (96.3%) central venous catheter was removed. Conclusion The majority of patients in the present sample required central venous catheter removal. The type of pathogen seems to play an important role both in the duration of hospitalization and in the occurrence of metastatic infections.

Effect of the implementation of clinical guidelines on management of candidemia in elderly patients.

Mortality from candidemia is higher in elderly population than in younger patients, which may be related to suboptimal management. The aim of the present study is to evaluate adherence to the recommendations for the clinical management of candidemia in a population over 75 years before and after implementing specific training. We recorded retrospectively data from candidemia episodes in elderly patients during two periods of time: 2010-2015 years (before training) and 2017-2022 years (after training), as well as adherence to the recommendations of the clinical practice guidelines, mortality and consultation to infectious disease specialists. Forty-five episodes of candidemia were recorded in the first period and 29 episodes in the second period. A better compliance to the recommendations of the clinical practice guidelines was observed in the second period: echocardiogram performance (75.9% vs. 48.9% p = .021), fundoscopy (65.5% vs. 44.4% p = .076), follow-up blood cultures (72.4% vs. 42.2% p = .011), removal of central venous catheter (80% vs. 52.9% p = .080) and adequate antifungal treatment (82.6% vs. 52.6% p = .018). A trend towards lower mortality was observed during the second period (27.6% vs. 44.4% p = .144). The improvement of knowledge of clinical guidelines on candidemia and the participation of infectious disease specialists may increase the quality of care in elderly patients with candidemia. It would be necessary to enlarge the sample size to evaluate the real impact of this intervention on mortality.

Catheter-related bloodstream infections in patients receiving hemodialysis in a single Philippine tertiary-care center

Background: Information regarding catheter-related bloodstream infections (CRBSIs) among patients on hemodialysis in the Philippines is lacking. Objective: In this study, we described the clinical profile, CRBSI incidence density, and outcomes of patients in a single-center hemodialysis unit. Methods: A retrospective review of patients receiving hemodialysis (HD) through a central venous catheter (CVC) from January 2016 to December 2020 in a tertiary-care, private hospital was performed. Baseline demographic data were recorded, and CRBSI incidence density rates (no. of CRBSIs per 1,000 catheter days) were calculated. Results: Of 868 hemodialysis patients (57%), 499 used a CVC and were followed for 182,135 catheter days. Half were male (248 of 499, 49.7%) with a median age of 62 years (range, 24–90). Only 48 (9.6%) of 499 developed CRBSI, with an overall CRBSI incidence of 2.63 per 1,000 catheter days. Of those with CRBSI, 31 (64.6%) of 48 were female. The median age was 74.5 years (range, 30–90). Hypertension (40 of 48, 83.3%) and diabetes mellitus (26 of 48, 54.2%) were frequent comorbidities. Fever with chills was the most common symptom, occurring in 30 (62.5%) of 48 patients. Both gram-positive (n = 24) and gram-negative (n = 25) organisms were isolated. Staphylococcus aureus was the most common gram-positive isolate (14 of 25, 56%); isolates from the order Enterobacterales (12 of 24, 50%) were the most common gram-negative organisms. More CRBSIs occurred among those with a nontunneled versus tunneled CVCs (28 vs 20). The median time to CRBSI occurrence was 7 weeks (range, 0.43–280) from CVC insertion. The most common empiric treatment was either vancomycin (n = 28) or piperacillin-tazobactam (n = 26), which were also used in combination (11 of 28, 39.3%). Treatment involved CVC removal in most patients (34 of 48, 70.8%), either alone (n = 1), or with systemic antibiotic therapy (SAT; n = 16), or SAT plus antibiotic lock therapy (ALT; n = 17). The remainder (14 of 48, 29.2%) retained their CVCs because of difficult access, and received both SAT and ALT. Attributable mortality (6 of 9, 33%) and overall mortality (9 of 48, 18.5%) were high. Mortality of those whose CVC was retained was lower compared to those whose line was removed: (3 of 9, 33%) versus (6 of 9, 66%). Conclusions: The overall CRBSI rate in our hemodialysis unit was low and occurred more commonly in the older age group with a nontunneled CVC. Both gram-positive and gram-negative pathogens were common. CRBSI was associated with high attributable mortality. Successful treatment often required CVC, SAT, and ALT. However, CVC retention was a viable option in some patients with specific limiting factors such as difficult access.Disclosures: None

Early Follow-Up after Arteriovenous Fistula Creation is Associated with Improved Access-Related Outcomes

Up to 60% of arteriovenous fistulas (AVF) require intervention to assist maturation, which prolongs the time until it can be used for hemodialysis (HD). Current guidelines recommend early postoperative AVF examination to detect and address immaturity to decrease time to maturation. This study evaluates how the timing of postoperative follow-up to assess AVF maturity affects patients' outcomes. All patients who underwent AVF creation between 2017 and 2021 in an academic medical center were retrospectively reviewed, excluding patients lost to follow-up or not on HD. Outcomes were compared between patients that had delayed follow-up to assess AVF maturity, >8 weeks post-surgery, versus early follow-up, <8 weeks post-surgery. AVF evaluation for maturity consisted of physical exam and duplex ultrasound. Primary endpoints were time to first cannulation (interval from AVF creation to first successful cannulation) and time to catheter-free dialysis (interval from AVF creation to central venous catheter removal). A total of 400 patients were identified: 111 in the delayed follow-up group and 289 in the early follow-up group. The median time to follow-up was 78 days (IQR 66-125) in the delayed follow-up group vs. 39 days (IQR 36-47) in the early follow-up group, (p<0.0001). The maturation rate was 87% in the delayed follow-up group vs. 81% in the early follow-up group, (p=0.1) and both groups had similar rates of interventions to assist maturation (66% vs. 57%, p=0.2). The early follow-up group had a significantly shorter median time to first cannulation (50 vs. 88 days, p<0.0001) and shorter time to catheter-free HD (75 vs. 118 days, <0.0001). At 4 months after AVF creation, the incidence of first cannulation was 74% in the early follow-up group vs 63% in the delayed follow-up group (p=0.001). Similarly, the incidence of catheter-free dialysis was 65% in the early follow-up group vs. 50% in the delayed follow-up group at 4 months postoperatively, (p = 0.036). Early post-operative follow up for evaluation of fistula maturation with is associated with reduced time to first successful cannulation of AVF for hemodialysis, and reduced time to catheter-free dialysis.