Central Venous Catheter Removal Research Articles

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.

Reaching consensus on a home infusion central line-associated bloodstream infection surveillance definition via a modified Delphi approach

A consensus on a central line-associated bloodstream infection (CLABSI) surveillance definition in home infusion is needed to standardize measurement and benchmark CLABSI to provide data to drive improvement initiatives METHODS: Experts across fields including home infusion therapy, infectious diseases, and healthcare epidemiology convened to perform a 3-step modified Delphi approach to obtain input and achieve consensus on a candidate home infusion CLABSI definition. The numerator criterion was identified by participants as involving one of the 2 following: (1) recognized pathogen isolated from blood culture and pathogen is not related to infection at another site, or (2) one of the following signs or symptoms: fever of 38°C (100.4°F), chills, or hypotension (systolic blood pressure ≤90 mm Hg), and one of the 2 following: (A) common skin contaminant isolated from 2 blood cultures drawn on separate occasions and organism is not related to infection at another site, or (B) common skin contaminant isolated from blood culture from patient with intravascular access device and provider institutes appropriate antimicrobial therapy. The criteria for a denominator included days from the day of admission with a central venous catheter to day of removal of central venous catheter. In addition, 11 inclusion criteria and 4 exclusion criteria were included. Home infusion therapy and healthcare epidemiology experts developed candidate criteria for a home infusion CLABSI surveillance definition. Home care and home infusion agencies can use this definition to monitor their own CLABSI rates and implement preventative strategies.

Calcification and abscess formation around the catheter tip of a central venous access port: a case report

BackgroundThrombosis of the internal jugular vein occasionally occurs in association with long-term placement of a central venous catheter; however, such complications rarely involve calcification within the blood vessels. We report a case of calcification and abscess formation around a central venous catheter tip.Case presentationOur patient was an 84-year-old Asian woman who developed a fever that had started approximately 5 months after the placement of a central venous catheter. At the time of presentation, blood tests showed a marked inflammatory response, and chest computed tomography showed a high absorption area and air density around the catheter tip. Therefore, the patient was diagnosed with abnormal intravascular calcification and a deep neck abscess associated with long-term central venous catheter placement. The initial plan was to administer antibiotics and remove the central venous catheter. However, central venous catheter removal was deemed difficult due to the calcification and therefore required an incision. Because of the patient’s advanced age and dementia, her family requested antibiotic treatment only. Following antibiotic treatment, the patient’s inflammatory response normalized, and her fever resolved. The treatment was discontinued, and the patient’s condition gradually stabilized.ConclusionsCatheter-related complications of central venous catheter placement include vascular occlusion, extravasation of the infusion, and infection. However, abnormal calcification in the blood vessels is extremely rare, and there has been only one case report of a neonate with central venous catheter-related vascular calcification in Japan. The etiology of intravascular calcification is considered to be related to the infusion content and the infusion rate of high caloric infusions and blood products. The incidence of complications associated with long-term central venous catheter placement is expected to increase with the increasing aging of the population and advances in chemotherapy. The report of the clinical course of this rare case adds to the body of knowledge in this area.

Central Venous Catheter Management in High-risk Children With Bloodstream Infections.

National guidelines recommend removal of central venous catheters (CVCs) for central line-associated bloodstream infections (CLABSIs) caused by Staphylococcus aureus, Pseudomonas aeruginosa, and fungi. Data regarding guideline compliance and rates of associated treatment failures in pediatric patients with attempted CVC salvage are limited. We performed a retrospective analysis of high-risk children (age ≤ 21 years) hospitalized from 1/2009 to 12/2015 with a long-term CVC and CLABSI due to S. aureus, Pseudomonas spp., and Candida spp. Enterococcus spp. was included given differing management recommendations between short and long-term CVCs. Compliance with national guideline recommendations, as well as treatment failures including infection relapse, recurrence, and death were evaluated in relation to CVC retention or removal. Multivariate logistic regression modeling was performed to account for confounders impacting treatment failure. Fifty-three children had 108 CLABSI episodes requiring 84 hospitalizations. CVCs were removed in 36 (33%) CLABSI episodes per guideline recommendations. Optimal antimicrobial management, including targeted agent and adequate duration was provided in 54 (50%) of 106 treated episodes; no significant difference in treatment failure rates were noted compared with episodes with suboptimal management. The treatment failure rate was significantly higher in patients with CVC retention compared those with CVC removal within 7 days of the first positive blood culture (31% vs. 6%, P = 0.003). Despite pathogen-specific guideline recommendations for CVC removal, compliance with national guidelines was poor. CVC salvage was attempted in the majority of CLABSI episodes in our cohort and resulted in a significantly higher treatment failure rate.

Safety Checklist Implementation Did Not Reduce Central Venous Catheter Duration in Pediatric Cardiac ICU Patients.

Introduction:The Center for Disease Control recommends prompt removal of nonessential central venous catheters (CVCs) to reduce the risk for central line–associated bloodstream infections. Safety checklists have been trialed to reduce nonessential CVC days, but pediatric studies are lacking. Our specific aim was to detect >10% reduction in mean CVC duration after implementation of a safety checklist addressing CVCs in our unit.Methods:All patients admitted to the Congenital Cardiovascular Care Unit at New York University Langone Medical Center who had a CVC placed between January 1, 2012, and December 31, 2017, were included. We implemented a checklist addressing CVC use in our unit on June 7, 2013, and modified it on March 10, 2016. We analyzed quarterly mean CVC duration and postsurgical CVC duration over the study period using statistical process control charts.Results:We placed 778 CVCs for 7,947 CVC days during the study period. We noted special cause variation from Q4 2013 to Q2 2014 and a centerline shift in mean CVC duration from 8.91 to 11.10 days in Q1 2015. In a subgroup analysis of the 657 lines placed in surgical patients, there was a centerline shift in mean CVC duration from 6.48 to 8.86 days in Q4 2013.Conclusions:Our study demonstrated an unexpected increase in mean CVC duration after the implementation of a safety checklist designed to decrease nonessential CVC days. Additional studies are needed to identify the ideal method to detect and remove nonessential CVCs and reduce the risk of preventable harm.

MONITORING OF PERIPHERAL VENOUS CATHETERIZATION AT THE SURGICAL HOSPITAL

Introduction. Peripheral venous catheters are widely used in medical practice to provide continuous venous access for therapeutic and diagnostic purposes. Peripheral vascular catheterization can be accompanied by infectious complications, including catheter-related bloodstream infections. An effective system of epidemiological surveillance and infection control of catheter-related bloodstream infections has not been developed at the state level in Ukraine; there is no proper monitoring for administration site and no registration of complications associated with the vascular catheterization. The purpose of this work was to assess the validity and propriety of the use of peripheral venous catheters in patients who receive inpatient treatment. Materials and methods: Between October 2019 and April 2020, 93 adult patients who were peripheral venous catheterized in a surgical hospital in Kharkiv were included in a prospective epidemiological study. The author's observation card was used for data collection for each patient daily. The catheter site was observed daily, and the following symptoms were entered into the card: flushed skin, swelling, discharge, and pain at the administration site at rest and on palpation. Interpretation of symptoms was conducted using the visual infusion phlebitis scale by A. Jackson. Statistical processing of data was carried out using descriptive statistics methods. To identify the relationship between the nominative values, Pearson's criterion χ2 was determined with P &lt; 0.01. Research results: 51 women (54.8%) and 42 men (45.2%) aged 18 to 84 were enrolled. In total, patients spent 619 bed-days in the hospital, of which the proportion of days with vascular catheters equaled 90.8% (n = 562). The main indication for the catheterization procedure was multicomponent therapy or the use of incompatible medications (98.9% / n = 92). In total, 148 peripheral venous catheters were inserted in these patients. The number of vascular catheters per patient ranged 1 to 3. According to the data of daily monitoring of the administration site, the signs of inflammation were observed in 65.5% of cases (n = 97). The incidence of signs of inflammation at the administration site with the first catheterization was significantly higher (χ2 = 25.2804; p &lt; 0.00001) than that with the second or third catheterization. The signs of local inflammation, which were more common in patients with vascular catheters, included flushed skin in the area of the catheter site (65.5% / n = 97), complaints of pain on palpation in the area of the catheter site (60.8% / n = 90) and swelling in the area of the catheter site (57.4% / n = 85). It was found that for more than half of the cases (55.4% / n = 82), the patients had symptoms of middle-stage phlebitis. It was also revealed that the most common reason for the removal of a peripheral venous catheter (n = 148) in the studied hospital were signs of local inflammation at the catheter site (61.5% / n = 91). However, in 16.9% of cases (n = 25), the occurrence of at least two signs of local inflammation at the catheter site, which indicated the initial stage of phlebitis and required to rearrange the catheter, was not the reason for immediate catheter removal. Conclusions: Health care workers make mistakes when working with peripheral venous catheters; in particular, there is no timely replacement of vascular catheters in the event of signs of infusion phlebitis. To reduce the risk of infectious complications of vascular catheterization at a health facility, the indications for insertion and removal of peripheral venous catheters and central venous catheters should be clearly defined, and standard operating procedures for ensuring vascular access and algorithms for managing patients with vascular catheters should be developed and implemented. Keywords intravascular catheter, prospective epidemiological study, assessment of the catheter insertion site, infusion phlebitis, catheter-related bloodstream infections, infection control.

Removal versus retention of vascular access devices (VADs) suspected of infection in the intensive care unit (ICU): a narrative review of the literature

Background: Whether to remove or retain vascular access devices (VADs) when they are suspected of infection is an important clinical question with no certain answer. This review aims to explore current literature related to removal versus retention of central venous catheters (CVCs) and intra-arterial lines (IALs) suspected of infection in the adult intensive care population. Methods: A narrative review of studies describing management of VADs suspected of infection in the intensive care unit (ICU) was undertaken. After a systematic search, two clinical studies were included in the review. The methodological rigour of these studies was assessed per the Mixed Methods Appraisal Tool (MMAT). Results: The two eligible studies consisted of one randomised control trial and one prospective observational study, including a total of 448 patients. Both studies scored highly on the MMAT, but only pertained to CVCs. No studies relating to other VAD types were identified. No significant differences in outcome were identified between patients whose VADs were removed or retained in the adult ICU cohort, apart from a reduction in number of CVC replacements in patients whose VAD was retained after infection was suspected. Conclusions: There is minimal evidence pertaining to removal versus retention of VADs suspected of infection in the adult ICU patient cohort, and there are limited recommendations specific to suspected infection guiding clinical practice. As a result, VADs may be unnecessarily removed. Further research assessing these important patient outcomes are urgently needed to inform clinical practice.

1171. Impact of Catheter Management on the Clinical Outcome in Adult Cancer Patients with Gram-Negative Bacteremia

BackgroundOver the last 2 decades, Gram-negative organisms have been on the rise as an etiology of bloodstream infections (BSI) in cancer patients. Management of the central venous catheter (CVC) in the setting of Gram-negative BSI remains challenging. The aim of our study was to evaluate cancer patients with different types of Gram-negative BSI, in the presence of an indwelling CVC, and assess the impact of line management on the outcome of the BSI.MethodsWe identified all the patients older than 14 years with CVC who had a documented BSI with a Gram-negative organism at M.D Anderson Cancer Center, from May 2017 until May 2018. Patients were divided into three groups. Group 1 (G1) included patients with central-line associated bloodstream infection and no mucosal barrier injury (non-MBI CLABSI) and/or those who met the catheter-related bloodstream infection (CRBSI) criteria; Group 2 (G2) consisted of patients who had a CLABSI with a mucosal barrier injury that did not meet the CRBSI definition; and Group 3 (G3) consisted of patients who had a non-line-related BSI. We assessed catheter management (CVC removed/exchanged or retained) at 2 days after the onset of bacteremia. We then determined the effect of line management on clinical and microbiologic outcomes through various measures.ResultsA total of 300 patients were included with 100 patients in each group. The univariate analyses showed that in G1, CVC removal within 2 days of bacteremia was significantly associated with higher rate of microbiologic eradiation of the bacteremia compared with delayed CVC removal (3 to 5 days) or CVC retention (98% vs. 72% vs. 78% respectively, P = 0.002; P < 0.001), and lower overall mortality rate at 3 months follow-up (3% vs. 22% vs. 17% respectively, P = 0.02; P = 0.01). By multivariate analysis, this association persisted (P = 0.018 and P = 0.016, respectively). CVC removal within 2 days of bacteremia did not affect the outcome of BSI in G2 and G3.ConclusionCVC removal within 48 hours of the onset of Gram-negative bacteremia significantly improved the infectious outcome and the overall mortality in adult cancer patients with definite CRBSI and CLABSI without MBI.Disclosures All authors: No reported disclosures.

120. The Impact of Early Central Venous Catheter Removal in the Management of Enterococcus Central Line-Associated Bloodstream Infections

BackgroundThere has been a rise in Enterococcus species Central Line-Associated Bloodstream Infections (CLABSI) ranking as the third overall causative organism according to the Center for Disease Control and Prevention (CDC) report issued in 2014. Central Venous Catheter (CVC) management including the need and timing of CVC removal is not well defined for enterococcus bacteremia (EB) in the 2009 Infectious Diseases Society of America (IDSA) management guidelines given the paucity of studies addressing CVC management.MethodsWe conducted a retrospective chart review on 543 patients diagnosed with EB between 2010 and 2018. We excluded patients without an indwelling CVC and those with mucosal barrier injury (MBI). We further evaluated 90 patients with EB that met the CDC definition for CLABSI without MBI or the IDSA definition for catheter-related bloodstream infections (CRBSI) and 90 patients with an indwelling CVC in place with documented non-CLABSI with another source.ResultsEarly CVC removal (within 3 days of EB) was significantly higher in the CLABSI without MBI/CRBSI group compared with the non-CLABSI (43% vs. 27%; P = 0.02). Microbiological eradication associated with early CVC removal within 3 days of EB was significantly higher in the CLABSI without MBI/CRBSI group compared with the non-CLABSI (78% vs. 48%; P = 0.016). Complications were lower in the CLABSI without MBI/CRBSI compared with the non-CLABSI group (0% vs. 18%; P = 0.017). Defervescence, mortality (all-cause and infection-related mortality) and relapse were similar in both groups. Within each group, the outcome was similar irrespective of CVC management (removal within 3 days vs. retention).ConclusionIn cases of EB, early CVC removal within 3 days of bacteremia is associated with a favorable outcome in the CLABSI without MBI/CRBSI group compared with the non-CLABSI group.Disclosures All authors: No reported disclosures.

1981. Implementation of an Antifungal Stewardship Bundle Focused on Candidemia in an Indian Hospital

BackgroundIn India, Candida bloodstream infections have a reported incidence of 1–12 per 1,000 admissions and a mortality rate of up to 60%. Antimicrobial stewardship programs (ASP) can improve quality of care and clinical outcomes. This study evaluates the impact of a comprehensive candidemia ASP bundle in a hospital in southern India with an established stewardship program.MethodsA single-center, pre-post quasi-experimental study was conducted at a tertiary-care center in southern India to analyze the impact of an ASP care bundle for the management of adults with candidemia. During the intervention period (October 2017–December 2018), the ASP provided recommendations to providers in accordance with the 2016 IDSA Guidelines for the Management of Candidemia, which included the following bundle: (1) appropriate selection and dosing of antifungal therapy; (2) repeat blood cultures every 48 hours until clearance; (3) removal of central venous catheters and other potential removable foci of infection; (4) echocardiogram; (5) ophthalmologic evaluation; and (6) appropriate duration of therapy. The primary outcome was initiation of appropriate antifungal therapy. Additional clinical outcomes were also compared with a historical cohort.ResultsOne hundred and four patients with candidemia were included: 52 in the pre-intervention and 52 in the post-intervention group. Overall, baseline demographics were similar between the two groups (Table 1). Candida tropicalis (26.9%) and Candida parapsilosis (29.8%) were the most common causes of candidemia in the cohort. Following intervention, administration of appropriate antifungal therapy improved by 40.4% (28.8% pre vs. 69.2% post, P < 0.01). Average time to effective treatment initiation following culture positivity decreased from 57.6 hours to 12 hours in the post-intervention group (P < 0.01). Thirty-day all-cause mortality was similar between the two groups (34.6% 38.4%, P = 0.84).ConclusionImplementation of a comprehensive candidemia care bundle by the ASP significantly improved the use and timing of initiation of appropriate antifungal therapy. Disclosures All authors: No reported disclosures.

1706. Use of Management Bundles as a Checklist for Candidemia: Impact of Compliance on Clinical Outcomes in a Multicenter Study in Japan

BackgroundWe previously developed management bundles for candidemia and beneficial effects on clinical outcomes were shown in compliant patients (JAC 2015). However, there is a risk for bias because some elements cannot be achieved in patients who have an early death.MethodsPatients with candidemia who were treated at six medical centers between 2015 and 2017 were prospectively evaluated. Bundle elements consisted of removal of central venous catheters within 24 hours, initial appropriate selection and dosing of antifungals, an ophthalmological examination, follow-up blood cultures, consideration of alternative antifungals on the 3rd to 5th days, and at least 2 weeks of therapy. To exclude bias by early death, we investigated the clinical results in patients who survived ≥2 weeks.ResultsAmong 221 patients with candidemia, 190 patients were analyzed (31 patients were excluded because of early death). Clinical success and the 28-day mortality rate were 77.4% (171/221) and 22.2% (49/221) in all patients with candidemia and 88.9% (167/190) and 9.5% (18/190) in eligible patients, respectively. Compliance in achieving all bundle elements was accomplished in 67.9% of eligible patients. In multivariate analysis, compliance with the bundles was an independent factor for 28-day mortality (4.7% vs. 19.7%, odds ratio 0.19, 95% confidence interval 0.05–0.63). However, compliance did not affect clinical success (92.2% vs. 82.0%, odds ratio 2.13, 95% CI 0.77–5.86). Non-Candida albicans, disseminated candidiasis, and total parenteral nutrition were independent factors for poor clinical success. Severe severity and total parenteral nutrition were independent factors for 28-day mortality.ConclusionWith prospective use of bundles as a checklist in patients with candidemia, compliance of bundles has a beneficial effect on clinical outcomes. This research was supported by AMED (JP18fk0108045).Disclosures All authors: No reported disclosures.

Novel Strategy to Encourage Early Removal of Central Venous Catheters

Novel Strategy to Encourage Early Removal of Central Venous Catheters

579. Machine-Learning Based Models for Prediction of Recurrence-free Catheter Retention After ALT Treatment of CLABSI in a Pediatric Population

BackgroundDeciding whether to attempt salvage of an infected central venous catheter (CVC) can be challenging. While line removal is the definitive treatment for central-line associated bloodstream infection (CLABSI), salvage may be attempted with systemic antibiotics and antibiotic lock therapy (ALT). Weighing risk and benefit of CVC salvage is limited by uncertainty in the future viability of salvaged CVCs. If a CVC is likely to require subsequent removal (e.g., due to recurrent infection) salvage may not be beneficial, whereas discarding a viable CVC is also not desirable. Here we describe a machine learning approach to predicting outcomes in CVC salvage.MethodsEpisodes of pediatric CLABSI cleared with ALT were identified by retrospective record review between January 1, 2008 and December 31, 2018 and were defined by a single positive central blood culture of a known pathogen or two matching cultures of a possible contaminant. Clearance was defined as 48-hours of negative cultures and relapse was defined as a matching positive blood culture after clearance. Predictive models [logistic regression (LR), random forest (RF), support vector machine (SVM) and an ensemble combining the three] were used to predict recurrence-free CVC retention (RFCR) at various time points using a training and test set approach.ResultsOverall, 712 instances CLABSI cleared with ALT were identified. Demographic and microbiological data are summarized in Tables 1 and 2. Few (8%) instances recurred in the first 28 days. 58% recurred at any time within the study period. Rates of RFCR were 75%, 43%, 22% and 10% at 28, 91, 182 and 365 days. Machine learning (ML) models varied in their ability to predict RFCR (Table 3). RF models performed best overall, although no model performed well at 91 days.ConclusionML models provide an opportunity to augment clinical decision making by learning patterns from data. In this case, estimating the likelihood of useful line retention in the future could help guide informed decisions on salvage vs. removal of infected CVCs. Limitations include the heterogeneity of clinical data and the use of an outcome capturing both clinical decision making (line removal) and infection recurrence. With further model development and prospective validation, practical machine learning models may prove useful to clinicians. Disclosures All authors: No reported disclosures.

183. Candidaemia in Children and Importance of Central Venous Catheter Removal

BackgroundCandida is the most common cause of invasive fungal infection in healthcare settings and is associated with significant increases in healthcare resource utilization and attributable mortality.MethodsThis study was conducted in a pediatric tertiary care hospital from Turkey. We conducted a retrospective analysis in children ≤18 years with blood culture-proven candidaemia identified between December 2013 and November 2017. Sociodemographic variables,underlying condition, mortality, additional risk factors, origin of specimens were all recorded.ResultsA total of 236 episodes of candidaemia were identified over the study period. The median age of the patients was 600 days (4-6482). 106 specimens (44.9%) were cultured from patients under 1 year of age and 15 of 106 specimens were cultured from neonates. The most frequently isolated Candida spp. were C. albicans (42.%), followed by C. parapsilosis (30.5%), C. glabrata (7.6%), C. tropicalis (6.4%), C. krusei (2.5%), C. lusitaine (2.5%), C. dubliniensis (2.1%), C. kefir (0.8%), and C. pelliculosa (0.4%). In 11 of the 236 episodes (4.5%), two Candida spp were cultured at the same time.The most common coinfection was C. albicans and C. parapsilosis. 112 of the 236 episodes (47.5%) was due to central venous catheter-related blood stream infection. 47.5% of these patients were receiving total parenteral nutrition at the time of candidemia. Concomitant coagulase negatif staphylococcus bacteremia was present in 50 of 236 candidemia episodes (21.2%). Of 236 isolates, 74 (31.4%) was cultured from peripheral blood culture only, 95 (40.3%) from central venous catheter only, 67 (28.4%) from both peripheral and central catheter blood culture.Trombocytopenia was noted in 117 episodes (49.6%) and neutropenia in 45 episodes (19.1 Of the 112 central venous catheter-related candidemia, 35 (31.3%) resulted in death within 30 days from the onset of candidaemia (Figure 1). In 49 (45.%) episodes of central venous catheter-related candidemia, catheter was not removed and 40% of these episodes resulted as death.Catheter removal, thrombocytopenia, total parenteral nutrion were found to be associated with increased mortality in children under 1 year of age (P < 0.001).ConclusionClinicians must be aware of candidemia in children due to high risk of mortality. Disclosures All authors: No reported disclosures.

MANAGEMENT OF ACUTE DECOMPENSATION FROM AIR EMBOLISM WITH BEDSIDE ULTRASONOGRAPHY AND MANUAL ASPIRATION

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: Vascular air embolism (VAE) is often iatrogenic and associated with high mortality and morbidity depending on the volume of air that has entered circulation. We describe a case of VAE occurring after removal of a central venous catheter (CVC) with rapid clinical improvement after aspiration of air from circulation. CASE PRESENTATION: A 75 year-old male patient with history of pancreatic cancer, coronary artery disease and atrial fibrillation was admitted to the intensive care unit (ICU) with septic shock, rapid ventricular rhythm and severe hypoxia due to multi-lobar pneumonia. He required vasopressor support with a CVC in the right internal jugular vein (RIJ). He received appropriate goal directed therapy. Although over the course of four days, he continued to require Hi-Flow 100% FiO2 and 55 liters per minute to maintain peripheral oxygen saturation (spO2) above 88%, pulmonary infiltrates on X-ray improved and shock resolved. Patient was weaned off of vasopressors and decision was made to remove the CVC. Within 15 minutes of CVC removal, he became unresponsive with agonal breathing and desaturation to spO2 55%. He developed right facial droop and right arm paralysis. A bedside ultrasound revealed a large amount of air in all four heart chambers. He was placed in Trendelenburg and left lateral position. A new CVC was inserted into the RIJ with the tip advanced into the right atrium. 150ml of blood was rapidly aspirated. After 15 minutes, the patient became responsive, his oxygenation improved, and he demonstrated neurological recovery. DISCUSSION: VAE is a rare and under-recognized complication of central venous access. As such, there may be a delay in detection as formal imaging is obtained and interpreted. We hypothesize that in this case, paradoxical transfer of bubbles to left heart chambers was possibly associated to undetected PFO. In mild cases, only supportive care may be necessary. In patients with hemodynamic instability, neurological changes, cardiopulmonary compromise, or end organ damage, hyperbaric oxygen therapy (HBOT) is the recommended definitive therapy to reduce air bubble size and vascular obstruction. However, HBOT is not available at every healthcare facility. In instances where it is available, even then, arrangement for HBOT takes time and transportation may be risky in unstable patients. Manual aspiration has been attempted previously but use of a multi-orifice catheter was recommended for that purpose. Unfortunately, multi-orifice catheters are not easily accessible. In this case, swift action using bedside cardiac ultrasound and intra-cardiac aspiration by a single orifice CVC lead to rapid clinical improvement. CONCLUSIONS: VAE is a serious iatrogenic complication that should be managed with appropriate acuity. Bedside ultrasonography and manual intra-cardiac aspiration has the potential to efficiently and effectively improve patient outcomes. Reference #1: Muth CM, Shank ES. Gas embolism. N Engl J Med. 2000 Feb 17;342(7):476-82. Reference #2: Palmon SC, Moore LE, Lundberg J, Toung T. Venous air embolism: a review. J Clin Anesth 1997;9:251-257 Reference #3: Hicks HC, Hummel JC. A new catheter for detection and treatment of venous air embolism. Technical note. J Neurosurg 1980;52:595-8. DISCLOSURES: no disclosure on file for Hector Cajigas; No relevant relationships by Kavitha Golpalratnam, source=Web Response No relevant relationships by Trinh Nguyen, source=Web Response

Impact of Catheter Management on Clinical Outcome in Adult Cancer Patients With Gram-Negative Bacteremia.

ObjectiveGram-negative organisms have become a major etiology of bloodstream infections. We evaluated the effect of central venous catheter management on cancer patients with gram-negative bloodstream infections.MethodWe retrospectively identified patients older than 14 years with central venous catheters who were diagnosed with gram-negative bloodstream infections to determine the effect of catheter management on outcome. Patients were divided into 3 groups: Group 1 included patients with central line-associated bloodstream infections (CLABSI) without mucosal barrier injury and those whose infection met the criteria for catheter-related bloodstream infection; group 2 included patients with CLABSI with mucosal barrier injury who did not meet the criteria for catheter-related bloodstream infection; and group 3 included patients with non-CLABSI.ResultsThe study included 300 patients, with 100 patients in each group. Only in group 1 was central venous catheter removal within 2 days of bloodstream infection significantly associated with a higher rate of microbiologic resolution at 4 days compared to delayed central venous catheter removal (3–5 days) or retention (98% vs 82%, P = .006) and a lower overall mortality rate at 3-month follow-up (3% vs 19%, P = .01). Both associations persisted in multivariate analyses (P = .018 and P = .016, respectively).ConclusionsCentral venous catheter removal within 2 days of the onset of gram-negative bloodstream infections significantly improved the infectious outcome and overall mortality of adult cancer patients with catheter-related bloodstream infections and CLABSI without mucosal barrier injury.