Central Venous Catheter Removal Research Articles

Presence of retained calcified fibrin sheath after central venous catheter removal: A systematic literature review.

Central venous catheters (CVC) are used in many clinical settings for a variety of indications. We performed a systematic literature review concerning case reports of retained calcified fibrin sheaths after dialysis CVC removal. The aim of our study was to systematize the knowledge regarding clinical management of this phenomenon, placing special emphasis on diagnostic radiological features in different imaging modalities, including chest radiography, echocardiography, computed tomography, and magnetic resonance imaging. We discuss the most common risk factors associated with this CVC complication. In our review, we found eight cases of hemodialysis patients. The most common risk factors associated with calcified fibrin sheath formation in the analyzed cases were pro-thrombotic and pro-calcification factors related to patient comorbidities, and prolonged catheter dwell time. Differentiating between a calcified fibrin sheath (present in about 6% of patients with long-term indwelling CVC as diagnosed by computed tomography) and a retained catheter tip can be challenging. The initial diagnosis based on imaging methods was incorrect in most of the analyzed cases. This suggests that some cases of retained fibrin sheaths may remain undetected or misinterpreted. This is important in patients with known pro-thrombotic and pro-calcification risk factors and prolonged catheter dwell time. Therefore, implementation of preventive strategies, familiarity with radiological findings of this phenomenon, comparison with previous imaging studies, and an overall comprehensive assessment with clinical data is imperative.

Antimicrobial-impregnated central venous catheters for preventing neonatal bloodstream infection: the PREVAIL RCT.

Clinical trials show that antimicrobial-impregnated central venous catheters reduce catheter-related bloodstream infection in adults and children receiving intensive care, but there is insufficient evidence for use in newborn babies. The objectives were (1) to determine clinical effectiveness by conducting a randomised controlled trial comparing antimicrobial-impregnated peripherally inserted central venous catheters with standard peripherally inserted central venous catheters for reducing bloodstream or cerebrospinal fluid infections (referred to as bloodstream infections); (2) to conduct an economic evaluation of the costs, cost-effectiveness and value of conducting additional research; and (3) to conduct a generalisability analysis of trial findings to neonatal care in the NHS. Three separate studies were undertaken, each addressing one of the three objectives. (1) This was a multicentre, open-label, pragmatic randomised controlled trial; (2) an analysis was undertaken of hospital care costs, lifetime cost-effectiveness and value of information from an NHS perspective; and (3) this was a retrospective cohort study of bloodstream infection rates in neonatal units in England. The randomised controlled trial was conducted in 18 neonatal intensive care units in England. Participants were babies who required a peripherally inserted central venous catheter (of 1 French gauge in size). The interventions were an antimicrobial-impregnated peripherally inserted central venous catheter (coated with rifampicin-miconazole) or a standard peripherally inserted central venous catheter, allocated randomly (1 : 1) using web randomisation. Study 1 - time to first bloodstream infection, sampled between 24 hours after randomisation and 48 hours after peripherally inserted central venous catheter removal. Study 2 - cost-effectiveness of the antimicrobial-impregnated peripherally inserted central venous catheter compared with the standard peripherally inserted central venous catheters. Study 3 - risk-adjusted bloodstream rates in the trial compared with those in neonatal units in England. For study 3, the data used were as follows: (1) case report forms and linked death registrations; (2) case report forms and linked death registrations linked to administrative health records with 6-month follow-up; and (3) neonatal health records linked to infection surveillance data. Study 1, clinical effectiveness - 861 babies were randomised (antimicrobial-impregnated peripherally inserted central venous catheter, n = 430; standard peripherally inserted central venous catheter, n = 431). Bloodstream infections occurred in 46 babies (10.7%) randomised to antimicrobial-impregnated peripherally inserted central venous catheters and in 44 (10.2%) babies randomised to standard peripherally inserted central venous catheters. No difference in time to bloodstream infection was detected (hazard ratio 1.11, 95% confidence interval 0.73 to 1.67; p = 0.63). Secondary outcomes of rifampicin resistance in positive blood/cerebrospinal fluid cultures, mortality, clinical outcomes at neonatal unit discharge and time to peripherally inserted central venous catheter removal were similar in both groups. Rifampicin resistance in positive peripherally inserted central venous catheter tip cultures was higher in the antimicrobial-impregnated peripherally inserted central venous catheter group (relative risk 3.51, 95% confidence interval 1.16 to 10.57; p = 0.02) than in the standard peripherally inserted central venous catheter group. Adverse events were similar in both groups. Study 2, economic evaluation - the mean cost of babies' hospital care was £83,473. Antimicrobial-impregnated peripherally inserted central venous catheters were not cost-effective. Given the increased price, compared with standard peripherally inserted central venous catheters, the minimum reduction in risk of bloodstream infection for antimicrobial-impregnated peripherally inserted central venous catheters to be cost-effective was 3% and 15% for babies born at 23-27 and 28-32 weeks' gestation, respectively. Study 3, generalisability analysis - risk-adjusted bloodstream infection rates per 1000 peripherally inserted central venous catheter days were similar among babies in the trial and in all neonatal units. Of all bloodstream infections in babies receiving intensive or high-dependency care in neonatal units, 46% occurred during peripherally inserted central venous catheter days. The trial was open label as antimicrobial-impregnated and standard peripherally inserted central venous catheters are different colours. There was insufficient power to determine differences in rifampicin resistance. No evidence of benefit or harm was found of peripherally inserted central venous catheters impregnated with rifampicin-miconazole during neonatal care. Interventions with small effects on bloodstream infections could be cost-effective over a child's life course. Findings were generalisable to neonatal units in England. Future research should focus on other types of antimicrobial impregnation of peripherally inserted central venous catheters and alternative approaches for preventing bloodstream infections in neonatal care. Current Controlled Trials ISRCTN81931394. This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 57. See the NIHR Journals Library website for further project information.

Clinical Features and Mortality of Nosocomial Candidemia in Very Old Patients: A Multicentre Italian Study

Introduction: Being elderly is a well-known risk factor for candidemia, but few data are available on the prognostic impact of candidemia in the very old (VO) subjects, as defined as people aged ≥75 years. Objective: The aim of this study was to assess risk factors for nosocomial candidemia in two groups of candidemia patients, consisting of VO patients (≥75 years) and adult and old (AO) patients (18–74 years). In addition, risk factors for death (30-day mortality) were analysed separately in the two groups. Methods: We included all consecutive candidemia episodes from January 2011 to December 2013 occurring in six referral hospitals in north-eastern Italy. Results: A total of 683 nosocomial candidemia episodes occurred. Of those, 293 (42.9%) episodes were in VO and 390 (57.1%) in AO patients. Hospitalization in medical wards, chronic renal failure, urinary catheter, and peripheral parenteral nutrition (PPN) were more common in VO than in AO patients. In the former patient group, adequate antifungal therapy (73.2%) and central venous catheter (CVC) removal (67.6%) occurred less frequently than in AO patients (82.5 and 80%, p < 0.002 and p < 0.004, respectively). Thirty-day mortality was higher in VO compared to AO patients (47.8 vs. 23.6%, p < 0.0001). In AO patients, independent risk factors for death were age (OR 1.04, 95% CI 1.00–1.09, p = 0.038), recent history of chemotherapy (OR 22.01, 95% CI 3.12–155.20, p = 0.002), and severity of sepsis (OR 40.68, 95% CI 7.42–223.10, p < 0.001); CVC removal was associated with higher probability of survival (OR 0.10, 95% CI 0.03–0.33, p < 0.001). In VO patients, independent risk factors for death were PPN (OR 3.5, 95% CI 1.17–10.47, p = 0.025) and hospitalization in medical wards (OR 2.58, 95% CI 1.02–6.53, p = 0.046), while CVC removal was associated with improved survival (OR 0.40, 95% CI 0.16–1.00, p = 0.050). Conclusion: Thirty-day mortality was high among VO patients and was associated with inadequate management of candidemia, especially in medical wards.

A BREATHTAKING CENTRAL LINE

SESSION TITLE: Medical Student/Resident Imaging Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Central venous catheters (CVC) are used commonly in critically ill patients. It is common practice done daily in the Intensive Care Units. Complications such as arrhythmias, arterial puncture, pneumothorax, thrombosis and rarely, but most lethal, air emboli can occur. We present a case of systemic air embolism after removal of CVC, where direct visualization of right atrium with point of care ultrasound (POCUS) showed presence of air bubbles. CASE PRESENTATION: 53-year-old female with history of IV drug abuse and COPD was admitted for sepsis, septic arthritis and skin abscesses, for which she required a prolonged course of IV antibiotics. Right internal jugular CVC was placed due to contraindication of peripheral IV access. CVC was no longer needed and removed, within a few seconds, patient became restless, tachycardic and tachypneic, with significant accessory muscles use. CXR was negative for pneumothorax or other abnormalities. Patient was placed on non-rebreather mask with 100% oxygen, only achieving 78% saturation. Initial ABG showed acute hypoxemic hypercarbic respiratory failure. It came to our knowledge that removal was done in upright position; air emboli was suspected and confirmed on POCUS (Figure 1). She was emergently intubated, mechanically ventilated on 100% FiO2 and placed in Trendelenburg position. Follow up echocardiogram showed no evidence of air emboli. No neurologic deficits were identified, patient was weaned off high FiO2 and extubated. DISCUSSION: Air emboli can occur during insertion, while within patient or during removal. Air embolism is managed mainly with supportive care. Incidence can be as low as 0.13%, despite using optimal positioning and placement techniques. True incidence is uncertain due to absorption of air prior to confirmation. The presence of air in vasculature results in acute hypoxemia and hypercapnia. If suspected, treatment includes stopping air entry into the system, aspiration of air from the right ventricle if possible, placing in Trendelenburg and left lateral decubitus position. This positioning allows for entrapped air in the heart to stabilize within the apex of the ventricle and relieve obstruction of pulmonary outflow tract. If severe, cardiac ischemia, arrhythmias, hypotension, and cardiac arrest can ensue. Rapid recognition and treatment can prevent this. CONCLUSIONS: Air embolism is a fatal complication during insertion/removal of CVC. Clinical manifestations range from none to cardiovascular collapse and death. Therefore education on proper care and technique is essential. These include explaining the procedure to the patient, laying them supine in Trendelenburg position and instructing to perform Valsalva maneuver on removal. Utilization of POCUS may facilitate early diagnosis and improve outcomes. Physicians and nursing staff should be aware of this iatrogenic complication and be able to identify it in a timely fashion. Reference #1: Marek A. Mirski, Abhijit Vijay Lele, Lunei Fitzsimmons, Thomas J. K. Toung; Diagnosis and Treatment of Vascular Air Embolism. Anesthesiology2007;106(1):164-177. doi: https://doi.org/. Reference #2: J Emerg Trauma Shock. 2009 Sep-Dec; 2(3): 180–185. doi: 10.4103/0974-2700.55330 Reference #3: Khan H, Zaidi A Paradoxical air embolism following central venous catheter removal Case Reports 2013;2013:bcr2013200630. DISCLOSURES: No relevant relationships by Lakshmi Alahari, source=Web Response No relevant relationships by Ammar Aliuddin, source=Web Response No relevant relationships by Gerardo Catalasan, source=Web Response No relevant relationships by Gabriela Orellana, source=Web Response

Clinical impact of early reinsertion of a central venous catheter after catheter removal in patients with catheter-related bloodstream infections.

Early replacement of a new central venous catheter (CVC) may pose a risk of persistent or recurrent infection in patients with a catheter-related bloodstream infection (CRBSI). We evaluated the clinical impact of early CVC reinsertion after catheter removal in patients with CRBSIs. We conducted a retrospective chart review of adult patients with confirmed CRBSIs in 2 tertiary-care hospitals over a 7-year period. To treat their infections, 316 patients with CRBSIs underwent CVC removal. Among them, 130 (41.1%) underwent early CVC reinsertion (≤3 days after CVC removal), 39 (12.4%) underwent delayed reinsertion (>3 days), and 147 (46.5%) did not undergo CVC reinsertion. There were no differences in baseline characteristics among the 3 groups, except for nontunneled CVC, presence of septic shock, and reason for CVC reinsertion. The rate of persistent CRBSI in the early CVC reinsertion group (22.3%) was higher than that in the no CVC reinsertion group (7.5%; P = .002) but was similar to that in the delayed CVC reinsertion group (17.9%; P > .99). The other clinical outcomes did not differ among the 3 groups, including rates of 30-day mortality, complicated infection, and recurrence. After controlling for several confounding factors, early CVC reinsertion was not significantly associated with persistent CRBSI (OR, 1.59; P = .35) or 30-day mortality compared with delayed CVC reinsertion (OR, 0.81; P = .68). Early CVC reinsertion in the setting of CRBSI may be safe. Replacement of a new CVC should not be delayed in patients who still require a CVC for ongoing management.

Insertion site of central venous catheter correlates with catheter-related infectious events in patients undergoing intensive chemotherapy.

Patients undergoing intensive chemotherapy are usually in need for central venous catheters (CVC). Due to contradictory study results, relation of insertion site and CVC-associated complication rate in these patients is not clear. We therefore retrospectively analyzed CVC-related data of all patients undergoing intensive chemotherapy with high risk of febrile neutropenia according to NCCN criteria, who received a CVC at our bone marrow transplantation unit between May 2016 and December 2019. In total, 210 patients received 281 CVC. CVC were placed via either the subclavian-vein (SCV, n = 58; 20%) or the internal-jugular-vein (IJV, n = 223; 80%). Median duration of CVC-lifetime and neutropenic days per CVC were comparable between the two groups (IJV vs SCV: 23 days vs 21 days (p = 0.16) and 12 days vs 11 days (p = 0.65)). Both, time to CVC removal due to local inflammation and time to central line-associated bloodstream infection was significantly shorter in patients with SCV catheters (p = 0.013 and p = 0.045). CVC placed in the IJV were associated with significantly less catheter-related infectious events compared with CVC placed in the SCV. This difference was consistent across different subgroups including 88 patients undergoing allogeneic stem cell transplantation.

Haemothorax following removal of an internal jugular central venous catheter

Haemothorax following removal of an internal jugular central venous catheter

Impact of duration of antibiotic therapy in central venous catheter-related bloodstream infection due to Gram-negative bacilli.

A progressive increase in the incidence of catheter-related bloodstream infection (CRBSI) due to Gram-negative bacilli (GNB) has been reported. Current guidelines recommend antibiotic treatment for at least 7-14 days, although the supporting evidence is limited. We performed a retrospective single-centre study including all patients with a definite diagnosis of GNB CRBSI from January 2012 to October 2018 in which the central venous catheter (CVC) was removed. The occurrence of therapeutic failure [clinical failure (persistence of symptoms and laboratory signs of infection), microbiological failure (persistent bacteraemia or relapse) and/or all-cause 30 day mortality] was compared between episodes receiving short [≤7 days (SC)] or long courses [>7 days (LC)] of appropriate antibiotic therapy following CVC removal. We included 54 GNB CRBSI episodes with an overall rate of therapeutic failure of 27.8% (15/54). Episodes receiving SC therapy were more frequently due to MDR GNB [60.9% (14/23) versus 34.5% (10/29); P = 0.058] and had higher Pitt scores [median (IQR) 1 (0-4) versus 0 (0-2); P = 0.086]. There were no significant differences in the rate of therapeutic failure between episodes treated with SC or LC therapy [30.4% (7/23) versus 27.6% (8/29); OR 1.15; 95% CI 0.34-3.83; P = 0.822]. The use of SCs was not associated with increased odds of therapeutic failure in any of the exploratory models performed. The administration of appropriate antibiotic therapy for ≤7 days may be as safe and effective as longer courses in episodes of GNB CRBSI once the CVC has been removed.

Antibiotic Administration Prior to Central Venous Catheter Removal in Neonates

Background: Central venous catheter infection and sepsis are significant causes of morbidity and mortality in neonatal intensive care unit patients. This complication may result in a significant cost burden, prolonged antibiotic treatment, and increased length of stay. Objectives: The objective of this study was to determine the difference in post-catheter removal clinical sepsis (PCRCS) in neonatal intensive care unit patients who received antibiotics prior to central venous catheter removal when compared to those who did not. Methods: This was a retrospective cohort study of 200 critically ill neonates comparing those who received one-time doses of vancomycin and cefazolin prior to central venous catheter removal to those who did not. Results: There was no statistically significant association between antibiotic treatment and PCRCS when the analysis was controlled for gender, time the catheter was in place, birth weight, gestational age, or type of central catheter (OR 1.19; 95% CI: 0.18-8.00; P = .8558). No statistical difference was seen in adverse renal outcomes or total antibiotic treatment received for the treatment of PCRCS. Conclusions: Administration of one-time doses of vancomycin and cefazolin did not reduce the incidence of PCRCS when administered to critically ill neonates prior to umbilical venous catheter or peripherally inserted central catheter removal.

Management and outcomes of Burkholderia cepacia complex bacteremia in patients without cystic fibrosis: a retrospective observational study.

Burkholderia cepacia complex (BCC) is an emerging pathogen of nosocomial infection in chronic or critically ill patients without cystic fibrosis (CF). The objective was to evaluate the management and outcomes of BCC bacteremia in patients without CF. We conducted a retrospective study of non-CF adult patients with BCC bacteremia between January 1997 and December 2016 at 4 tertiary hospitals in South Korea. A total of 216 non-CF patients with BCC bacteremia were identified. Most cases were hospital-acquired (79.2%), and the most common source was a central venous catheter (CVC) (42.1%). The rates of susceptibility to trimethoprim-sulfamethoxazole and piperacillin-tazobactam of BCC isolates were high as 92.8% and 90.3%, respectively. The rates of susceptibility to ceftazidime, meropenem, and levofloxacin were 75.5%, 72.3%, and 64.1%, respectively. The 14-day, 30-day, and in-hospital mortality rate was 19.4%, 23.1%, and 31.0%, respectively. Female (OR = 3.1; 95% CI, 1.4-6.8), liver cirrhosis (OR = 6.2; 95% CI, 1.6-16.6), septic shock (OR = 11.2; 95% CI, 5.1-24.8), and catheter-related infection (OR = 2.6, 95% CI, 1.2-5.8) were the independent risk factors for 30-day mortality. The outcome did not differ according to type of antibiotics used. Among 91 patients with CVC-related BCC bacteremia, delayed CVC removal (> 3days) had a higher rate of persistent bacteremia (54.5 vs. 26.1%; P = 0.03) and lower rate of clinical response (49.0 vs. 71.9%; P = 0.04), compared with early CVC removal (within 3days). BCC bacteremia occurring in non-CF patients was mostly hospital-acquired and CVC-related. Early removal of the catheter is crucial in treatment of CVC-related BCC bacteremia.

Description of a pharmacist-driven safety algorithm in Staphylococcus aureus bacteremia: Compliance, interventions, and good saves.

To evaluate the impact of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) safety bundle supported by leadership and to compare compliance before and after implementation. Retrospective cohort study with descriptive and before-and-after analyses. Tertiary-care academic medical center. All patients with documented SAB, regardless of the source of infection, were included. Patients transitioned to palliative care were excluded from before-and-after analysis. A pharmacist-driven safety bundle including documented clearance of bacteremia, echocardiography, removal of central venous catheters, and targeted intravenous therapy of at least 2 weeks duration was implemented in November 2015 and was supported by leadership with stepwise escalation for nonresponse. A descriptive analysis of all patients with SAB during the study period included pharmacy interventions, acceptance rates, and escalation rates. A pre-post implementation analysis of 100 sequential patients compared bundle compliance and descriptive parameters. Overall, 391 interventions were made in the 20-month period following implementation, including 20 "good saves" avoiding potentially major adverse events. No statistically significant differences in complete bundle compliance were detected between the periods (74% vs 84%; P = .08). However, we detected a significant increase in echocardiography after the bundle was implemented (83% vs 94%; P = .02) and fewer patients received suboptimal definitive therapy after the bundle was implemented (10% vs 3%; P = .045). This pharmacist-driven SAB safety bundle with leadership support showed improvement in process measures, which may have prevented major adverse events, even with available infectious diseases (ID) consultation. It provides a critical safety net for institutions without mandatory ID consultation or with limited antimicrobial stewardship resources.

Antibiotic Lock Therapy with Linezolid for the Treatment of Persistent Catheter-Related Infection in Children with Cancer

Abstract Objective Central venous catheter (CVC) colonization is a common problem in the pediatric oncology department. Initial colonization of CVC by coagulase-negative staphylococci (CoNS), Staphylococcus aureus, and enterococci is followed by the growth of intraluminal biofilm formation, and results in antibiotic therapy failure. The removal of the old CVC and insertion of new CVC is a difficult and expensive procedure in small children with cancer. The present article aimed to study our treatment results of antibiotic lock therapy (ALT) with linezolid in pediatric cancer patients. Methods This study was planned as retrospective presentation of case series with eight pediatric cancer patients treated with 11 courses of systemic and linezolid lock therapy. Demographic information, clinical findings, laboratory data, blood culture results, complications, and outcome were collected for each patient retrospectively and descriptive statistical methods were used. Results Prior to treatment, peripheral and CVC blood culture results showed Staphylococcus epidermidis in seven patients and Staphylococcus hominis in four patients. All pathogens were susceptible to vancomycin and teicoplanin; first-line treatment was vancomycin in six and teicoplanin in five patients. After first-line treatment, peripheral blood cultures of all patients were negative, whereas blood cultures from CVC remained positive. During second-line therapy with linezolid, microbiological eradication was achieved on the fourth day of treatment in each patient. Median catheter survival time for all patients was 14 (range: 8–30) months. No side effects were observed during the treatment and no resistant organisms were documented. Conclusion Although multicentric prospective controlled trials will be required to provide more generalizable results, we suggest that systemic antibiotics combined with linezolid lock therapy used in pediatric cancer patients may be an effective option in treating catheter-related bloodstream infection (CRBSI) and prolonging CVC survival when CoNS are identified.

Adherence to standards of care and mortality in the management of Staphylococcus aureus bacteraemia in Peru: A prospective cohort study

BackgroundDespite high mortality rates, physicians can alter the course of the Staphylococcus aureus bacteraemia (SAB) by following recommended standards of care. We aim to assess the adherence of these guidelines and their impact on mortality. MethodsSubstudy from a prospective cohort of hospitalized patients with SAB from three hospitals from Peru. Hazard ratios were calculated using Cox proportional regression to evaluate the association between 30-day mortality and the performance of standards of care: removal of central venous catheters (CVC), follow-up blood cultures, echocardiography, correct duration, and appropriate definitive antibiotic therapy. Results150 cases of SAB were evaluated; 61.33% were MRSA. 30-day attributable mortality was 22.39%. CVC removal was done in 42.86% of patients. Follow-up blood cultures and echocardiograms were performed in 8% and 29.33% of cases, respectively. 81.33% of cases had appropriate empirical treatment, however, only 22.41% of MSSA cases were given appropriate definitive treatment, compared to 93.47% of MRSA. The adjusted regression for all-cause mortality found a substantial decrease in hazards when removing CVC (aHR 0.28, 95% CI: 0.10 - 0.74) and instituting appropriate definitive treatment (aHR 0.27, 95% CI: 0.08 - 0.86), while adjusting for standards of care, qPitt bacteraemia score, comorbidities, and methicillin susceptibility; similar results were found in the attributable mortality model (aHR 0.24, 95% CI: 0.08 - 0.70 and aHR 0.21, 95% CI: 0.06 - 0.71, respectively). ConclusionsDeficient adherence to standards of care was observed, especially definitive treatment for MSSA. CVC removal and the use of appropriate definitive antibiotic therapy reduced the hazard mortality of SAB.

Point-of-care ultrasound for assessing arteriovenous fistula maturity in outpatient hemodialysis.

Point-of-care ultrasound in end-stage renal disease is on the rise. Presently the decision to cannulate an arteriovenous fistula is based on its duration since surgery and physical exam. This study examines the effects of point-of-care ultrasound on decreasing the time to arteriovenous fistula cannulation, time spent with a central venous catheter, and the complications and infections that arise. Prospective point-of-care ultrasound patients were recruited between January 2015 and January 2018, while retrospective data (non-point-of-care ultrasound) were collected via chart review from patients who had fistula creation between November 2011 and May 2014. Patients had point-of-care ultrasound within 3 weeks after arteriovenous fistula creation and were followed for 1 year. Arteriovenous fistula cannulation was initiated when the following parameters were met: diameter > 6 mm (with no depreciable narrowing of more than 20% throughout), depth < 6 mm, and length > 6 cm. Demographic data, as well as time to cannulation and central venous catheter removal, number of infections, complications, and interventions were compared between point-of-care ultrasound and non-point-of-care ultrasound groups using unpaired t-test, chi-square, and Fisher exact test statistical analysis. A total of 37 patients with new arteriovenous fistulas were followed by point-of-care ultrasound compared to 29 non-point-of-care ultrasound patients. Point-of-care ultrasound patients had earlier cannulations (35.5 vs 63.3 days, p < 0.05), shorter central venous catheter duration (68.2 vs 98.3 days, p < 0.05), and less infections (12 vs 19) without differences in complication compared to the non-point-of-care ultrasound. Point-of-care ultrasound facilitates early and safe arteriovenous fistula cannulation leading to a reduction in central venous catheter time and risk of infection. Point-of-care ultrasound may also aid in earlier identification of complications and difficult cannulations.

Impact of host- and early treatment-related factors on mortality in ICU patients with candidemia: a bicentric retrospective observational study

BackgroundCandidemia is one of the most life-threatening infections among critically ill patients in the intensive care unit. However, the number of studies on the impact of host- and early treatment-related factors on mortality in this cohort is limited. The aim of this study was to investigate the relationship between clinically relevant factors, including early treatment (appropriate antifungal therapy and/or central venous catheter removal) and mortality in intensive care unit patients with candidemia.MethodsWe performed a retrospective observational study in two Japanese University hospitals between January 2007 and December 2016. Adult intensive care unit patients with candidemia who met the following inclusion criteria: (1) ≥ 18 years old; (2) admitted in intensive care unit at the time of onset; and (3) central venous catheter in situ at the time of onset were included. We performed univariate and multivariate logistic regression analysis to identify factors associated with 30-day crude mortality.ResultsA total of 68 patients met the inclusion criteria, 47 (69%) of whom were males. The median age was 68.0 (interquartile range, 61.0–76.0) years. The most common causative Candida species was Candida albicans (40 [59%] patients). With respect to the source of infection, central venous catheter-related candidemia was the most frequent (30 [44%] patients). Thirty-day crude mortality was 54% (37 patients). In multivariate logistic regression analysis, Acute Physiology and Chronic Health Evaluation II score (1-point increments) was the only factor that was independently associated with higher 30-day crude mortality. Other variables, including appropriate antifungal therapy and/or central venous catheter removal ≤ 24 h and ≤ 48 h following onset, did not significantly influence mortality.ConclusionsCandidemia in intensive care unit patients is still associated with high 30-day crude mortality rates. The only predictor of death was Acute Physiology and Chronic Health Evaluation II score ≤ 24 h following candidemia onset. Early empiric antifungal therapy and/or early CVC removal conferred no significant clinical benefit on survival in this patient population.

Persistent vs non-persistent candidaemia in adult patients in 2007-2016: A retrospective cohort study.

Persistent candidaemia (PC) is a recognised complication of candidaemia. Our objective was to evaluate risk factors and clinical significance of PC in adult patients. This is a retrospective, cohort study. We compared PC with non-PC. All patients with blood cultures positive for Candida species were identified from a microbiological database in the hospital district of Helsinki and Uusimaa from 2007 to 2016. PC was defined as an isolation of the same Candida species from positive blood culture for ≥5days. PC criteria were fulfilled by 75/350 patients (21.4%). No significant difference emerged between persistent and non-persistent cases caused by non-albicans Candida species (37.3% vs 35.1%, P=.742). The length of hospital stay before onset of candidaemia was longer before PC (hospital stay>7days; 73.3% vs 59.6%, P=.043). No significant impact on 30-day mortality was observed (20.0% vs 15.5%, P=.422). Using multivariable regression analysis, we found the presence of central venous catheter (CVC) (OR=2.71, 95% CI 1.31-5.59), metastatic infection foci (OR 3.60, 95% CI 1.66-7.79) and ineffective empirical treatment (OR=3.31, 95% CI 1.43-7.65) to be independent risk factors for PC. In subgroup analysis, early source control was identified as a protective factor against PC (30.5% vs 57.7%, P=.002). The presence of CVC, metastatic infection foci and ineffective empirical treatment were independently associated with PC in adult patients. Active search for and treatment of metastatic infection foci and removal of CVC are key elements for preventing PC.

A prospective study on the incidence and risk factors of central venous catheter-related thrombosis after gastrointestinal surgery

Objective To investigate the incidence and risk factors of central venous catheter-related thrombosis after gastrointestinal surgery. Methods From May 2018 to May 2019, 124 patients who received surgical treatment with central venous catheter placement in gastrointestinal surgery department at Harrsion International Peace Hospital were prospectively analyzed, and the factors that may be related to catheter-related thrombosis were collected.And performed ultrasound screening before the removal of central venous catheter, According to whether there was thrombosis or not, they were divided into thrombosis group(n=66) and non-thrombosis group(n=58). Multivariate logistic regression analysis was performed for the factors with statistical differences between the two groups. Results A total of 66 patients were diagnosed with catheter-related thrombus by ultrasonography, with an incidence of 53.2%(66/124), 63 cases with no clinical symptoms(50.8%), only 3 cases with clinical symptoms, and the incidence of catheter-related thrombus with symptoms was 2.4%(3/124). The operation type, central venous catheter indwelling time, fibrinogen on the 3rd day after surgery and D-dimer on the 3rd day after surgery between the two groups had statistically significant differences (χ2=21.415, 7.651, t=5.7181, 0.418, all P<0.05). Multivariable logistic regression analysis showed that operation type(OR=0.157, 95%CI: 0.040-0.612, P=0.008), fibrinogen on the 3rd day after surgery(OR=7.371, 95%CI: 2.318-23.442, P=0.001), D-dimer on the 3rd day after surgery(OR=6.920, 95%CI: 2.854-16.783, P=0.000) were independent risk factors of catheter-related thrombosis. Conclusion The incidence of central venous catheter-related thrombosis is higher after gastrointestinal surgery, and most patients have no obvious clinical symptoms.The patients who undergoing tumor surgery or with abnormal levels of fibrinogen and D-dimer on the 3rd day after surgery should aware of catheter-related thrombosis. Key words: Gastrointestinal diseases; Surgery; Central venous catheters; Venous thrombosis; Risk factor; Neoplasms; Fibrinogen; Fibrin fragment D

Abstract No. 654 Evaluating the value of clinical predictors in determining catheter-related infections

Patients with central venous catheters (CVCs) that show signs of infection may undergo CVC removal and catheter tip culture for confirmation of catheter-related infections (CRI). When suspicious of a CRI, a clinician’s decision-making is influenced by various physical examination and lab findings. Thus, it is helpful to understand the utility of certain risk factors and tests. To study the advantages of each, we assessed the sensitivity, specificity, and association of common clinical findings using CVC-tip culture as our primary endpoint. Under an IRB-approved protocol, 151 patients in the inpatient setting, who underwent tunneled CVC removal and tip culture, were retrospectively analyzed. Outcomes were stratified based on CRI, defined as a positive catheter-tip culture. All analyses were performed using χ2, sensitivity and specificity analysis in SPSS 24. In this cohort, the median age at placement was 52 years, and 43 CVC tip cultures (29%) were found to be positive; only 32 (21%) exhibited concurrent bacteremia. None of the physical examination findings (purulence, erythema, tenderness, fever, and cutaneous/systemic signs) were individually associated with a CRI. However, owing to their high specificity and low P values on χ2 testing, fever, purulence, and tenderness were grouped into their criteria, defined by presence of at least one of such findings. The resultant variable demonstrated a χ2 value of 4.5 (P = 0.03), a sensitivity of 77%, and a specificity of 42%. Presence of a gram-positive BCx was associated with CRIs (P = 0.04), and gram-negative BCx results were associated with no growth on catheter-tip culture (P = 0.04). Neither high nor low white counts were associated with CRIs. This analysis suggests that physical exam findings should be used in summation rather than individually when determining a patient’s CRI risk. When deciding their course of action, clinicians may consider removing CVCs in the presence of gram-positive bacteremia, and conversely, deferring CVC removal and treating through confirmed gram-negative bacteremia. Study limitations include cohort size and inconsistency of physical examination reporting.

3:45 PM Abstract No. 360 Predictors of catheter-related infections of tunneled lines in the inpatient setting

Inpatients with central venous catheters (CVCs) that show signs of local or systemic infection may undergo CVC removal followed by catheter tip culture for confirmation of catheter-related infections (CRI) and catheter-related bloodstream infections (CRBSI), as defined by positive catheter tip culture with a congruent positive blood culture. The use of this test has dwindled over the past decade, owing to factors including reimbursement penalties, poor predictive value, and increased reliance on blood cultures (BCx). We aim to develop a clinical risk calculator to reduce unnecessary removal and catheter tip culture. This IRB-approved retrospective study examined 151 patients in the inpatient setting who underwent tunneled CVC removal and tip culture. The primary outcome was the presence of CRI as defined by a positive catheter tip culture. Subgroup analysis was performed to determine which clinical factors results influenced the presence of CRI. All analyses were performed using χ2 analysis, and binary logistic regression with backward elimination. In this cohort, the median age at placement was 52 years, and median catheter-days was 98 days. Of the 151 lines removed, 32 patients (21%) had CRBSI and 43(29%) of catheter tips were culture positive. Variables predictive of CRI were gram-positive BCx prior to line removal and access site purulence (OR = 2.2 and OR = 4.0, P < 0.05). Variables that were not predictive of CRI included: fungal BCx, access site and laterality, CVC type, white count, placement indication, catheter tip location, signs of systemic infection, tenderness, and erythema. While not in the final model, CVC cultures with gram-negative organisms were related to the absence of CRIs (χ2 value = 3.6, P < 0.05). In this population, it is important to discern high-risk patients. Our model demonstrates feasibility of a risk calculator in the setting of possible CRI. When choosing a course of action, clinicians may consider removing CVCs in the presence of purulence or gram-positive BCx, and conversely, treating through non-gram positive BCx infections. Limitations of the study include cohort size and antibiotics given before cultures.

Management of Staphylococcus aureus bacteraemia (SAB) in the oncology patient: Further evidence supports prompt removal of central venous catheters and shorter duration of intravenous antimicrobial therapy

SummaryBackgroundStaphylococcus aureus bacteraemia (SAB) is associated with relatively high risk of complications and high levels of mortality. Internationally, SAB management guidelines lack consensus and especially so regarding oncology patients. This is likely a reflection of insufficient randomised control trials (RCT) and the diversity of SAB patient populations. However, there are 2011 guidelines recommending a minimum of 14 days of appropriate IV antibiotic therapy for SAB.ObjectiveWe wished to determine whether our practice of shortened duration of intravenous antimicrobial therapy in favour of oral administration proved as effective as recommended guidelines in a mixed oncology patient cohort.MethodsRetrospective review of patient records that included any SAB episode among oncology patients from January 2002 to December 2015. Medical chart reviews were undertaken to determine patient demographics, clinical management & antimicrobial therapy, duration of stay, presence of a central venous catheter (CVC) and outcome.ResultsOur CVC removal rate was just 73% in SAB where CVC was the identified source of infection, with an attributable mortality rate (<4%) far lower than would be expected. Antimicrobial therapy durations were considerably lower (10 days) than current recommendations of 14 days IV therapy. The recurrence rate of 15% was also significantly lower than has been reported previously.ConclusionsOur observations contribute new insights concerning the management of SAB in oncology patients. Our findings suggest that therapeutic approaches should perhaps remain individualised and reflective of patient characteristics taking into consideration the complex nature of oncology patients.