Central Venous Line Infection Research Articles

<i>Ochrobactrum anthropi</i>: a rare case of endocarditis

Ochrobactrum anthropi is an aerobic Gram-negative bacillus, formerly known as “Achromobacter group Vd”. It is increasingly recognized as a potentially problematic, opportunistic, and nosocomial pathogen. Most cases of human diseases due to O. anthropi are associated with central venous catheter line infection; few case reports about infective endocarditis, pancreatic abscess, puncture wound osteochondritis, endophthalmitis, urinary tract infection, meningitis, pelvic abscess, and osteomyelitis are present in the literature. Among the previously stated infections it can cause, infective endocarditis is very rare; only four cases have been described in the literature. Here, we report the case of an immunocompromised man who developed native valve endocarditis with septic cerebral embolization due to O. anthropi.

THE EFFECT OF APPLYING NURSING CARE BUNDLE ON CONTROLLING CENTRAL VENOUS LINE INFECTION IN NEONATAL INTENSIVE CARE UNITS

Central venous line (CVL) is a necessary device used frequently in neonatal intensive care units (NICUs) for critically ill neonates who need continuous monitoring and resuscitation treatment. Significant evidence has accumulated indicating that CVL nursing care bundle is considered as an essential component of CVL infection prevention practice to combat the incidence of CVL infection. Aim: This study aimed to examine the effect of applying nursing care bundle on controlling central venous line infection in neonatal intensive care units. Subject and method: A quasi-experimental design was used. The study was conducted at NICU at Kafr El Sheikh General Hospital. The study included a convenience sample of all available bedside/ working nurses (n= 30), 79 preterm infant (recruited for 3 months’ period). Tools: Three tools were used to collect data. Tool 1: An interview questionnaire for nurse's knowledge. Tool 2: Observational checklist used to assess nurses’ performance regarding CVL care bundle. Tool 3: Laboratory investigations tool for preterm infants. Results: More than half of studied nurses (56.7%) didn't receive any training program about CVL care bundle for controlling CVL infection in NICU and the majority of the studied nurses had insufficient knowledge, as well as the majority of the studied nurses, had an unsatisfactory practice regarding CVL care bundle preprogram. The sufficient knowledge level and satisfactory practices had improved immediately post and 3 months post program implementation. About half (51,9%) had negative CRP post-program implementation, while (54,4%) of neonates had negative blood culture post-program. Conclusion: The program had a positive effect on the NICU nurses’ knowledge & practices immediately post& post 3 months of the program implementation. Recommendation: Including CVL nursing care bundle practices into nurses’ routine care and developing regular and continuous educational programs for the nurses in NICU according to their needs aiming to upgrading their knowledge and improving their practice for critically ill neonates.

202. The effectiveness of combination therapy of anti-methicillin-resistant Staphylococcus aureus agents and β-lactam agents in patients complicated with febrile neutropenia after bone marrow transplantation

BackgroundFebrile neutropenia (FN) is one of the most frequent and serious complications of hematopoietic stem cell transplantation such as bone marrow transplantation (BMT). Anti-Pseudomonas agents should be initiated in all patients complicated with FN without delay, while anti–methicillin-resistant Staphylococcus aureus (MRSA) agents are exclusively recommended in the case of central venous (CV) line infection. Most BMT patients have the potential risk of catheter-related blood stream infection because of long-lasting catheterization including indwelling CV line. Therefore, the patients may also be received anti-MRSA agents empirically in addition to anti-Pseudomonas agents. So far, there are little reports that verify the effectiveness of the combination therapy under FN condition after BMT. The purpose of this study was to address the effectiveness.MethodsBMT was performed at Yokohama City University Medical Center between April 2012 and March 2018, and 44 patients who developed FN after BMT were enrolled. We analyzed patient information retrospectively. We used the duration of fever to evaluate the additive effect of anti-MRSA agents to β-lactam anti-Pseudomonas agents. We classified the patients during FN period into two groups whether anti-MRSA agents were administered (Ad group; 34 patients) or not (non-Ad group; 10 patients). Fever is defined as a single axillary temperature measurement of over 37.5 Celsius degrees. The study design and protocol were approved by the ethics committee at the Review Board of our hospital (ID：D1602011).ResultsBaseline characteristics were similar between the two groups. Blood cultures were performed onset of FN in all cases, in which five showed positive (11.4%). Bacteria requiring administration of anti-MRSA drugs were detected in the four cases. Nonetheless, duration of fever was not significantly shorten (6.8 ± 4.0 vs. 5.2 ± 2.5, P = 0.171) and there was no difference in the hospitalization period. The renal dysfunction was significantly higher in Ad group and the cost of anti-MRSA agents totaled about $ 36,000.ConclusionOur study indicates that no use of empirical combination therapy of anti-MRSA agents in addition to anti-Pseudomonas agents under FN condition after BMT, even if CV line is inserted. Disclosures All authors: No reported disclosures.

A Protocol to Set Up Needle-Free Connector with Positive Displacement on Central Venous Catheter in Intensive Care Unit.

Needle-free connectors were initially designed and promoted to avoid blood exposure for healthcare workers. Some recent data suggest that the latest generation of connectors (with positive displacement) may be of interest for reducing central venous line infections. We have been using needle-free connectors for several years in our intensive care unit and here we present a protocol for installing these connectors on central venous catheters. After insertion of the catheter and control of the permeability of the lines, the connectors must be purged with 0.9% NaCl before being connected. The connectors replace all disposable caps used on infusion stopcocks and manifolds. All the connectors are changed every 7 days as recommended by the manufacturer (except when there is macroscopic contamination, which requires an immediate change of the connector). Before each injection, the connector must be disinfected for at least 3 seconds with 70% isopropyl alcohol. The connectors must not be disconnected (unless changed), as the injection is done through the device. Setting up the connectors slightly increases the total time required to place the catheter and there is no formal evidence that these connectors reduce the incidence of infectious or thrombotic complications. However, these devices simplify the management of central venous lines and prevent the catheter circuit from "opening" once it has been sterilely installed.

Low-dose methotrexate in sickle-cell disease: a pilot study with rationale borrowed from rheumatoid arthritis

BackgroundInflammation is a major feature of sickle cell disease (SCD). Low-dose methotrexate (MTX) has long been used in chronic inflammatory diseases. This pilot study examined the MTX effect on acute vaso-occlusive pain crises (VOC) in SCD patients.MethodsFourteen adults on hydroxyurea with severe and refractory VOC received one intramuscular injection of 10 mg of MTX per week for 12 weeks. A single weekly dose of 5 mg of leucovorin was administered orally 48 h after each MTX injection. The primary outcome was reduction in number/intensity of acute pain episodes. The secondary outcomes were improvement of quality of life (QOL) and reduction of the inflammatory status.ResultsMTX did not significantly change the median VOC frequency (12 before vs 10.5 during treatment, P = 0.6240) or the median McGill pain index (45 at week 0 vs 39.5 at week 12, P = 0.9311). However, there was a decrease of ≥50% in chronic pain resulting from avascular osteonecrosis (AVN) in 5 out of 7 patients with radiologic evidence of AVN, with the perception of longer pain-free periods. There was a 44.4% median gain in physical function in the SF-36 QOL questionnaire (P = 0.0198). MTX treatment up-regulated two C-X-C motif chemokines (CXCL), CXCL10 (P = 0.0463) and CXCL12 (P < 0.0001), without significant effect on 14 additional plasma inflammatory markers. Adverse events: One individual had fever of unknown origin. Respiratory tract infections were recorded in five patients. Among the latter, one also had dengue fever and another had a central venous line infection and died of pneumonia and septic shock. Three patients with previous history of hydroxyurea-induced hematological toxicity developed low blood platelet counts while receiving simultaneously MTX and hydroxyurea.ConclusionsAlthough MTX did not reduce acute VOC frequency/intensity, it decreased chronic pain and led to QOL improvement.Trial registrationhttp://www.who.int/ictrp/en/ and http://www.ensaiosclinicos.gov.br, RBR-2s9xvn, 19 December 2016, retrospectively registered

Impact of Care in a Multidisciplinary Clinic on a Child With Ultrashort Gut

Abstract Short bowel syndrome (SBS) is a condition characterized by dependence on total parenteral nutrition due to the inability of the intestines to absorb adequate nutrients, electrolytes, and water. SBS is most commonly seen in pediatric patients after extensive small bowel resection due to necrotizing enteroclolitis, intestinal atresias, gastroschisis, or volvulus (Cummings &amp; Mercurio, 2012). The management of children with SBS focuses on maximizing enteral nutrition while mitigating the potential life-threatening complications of central venous line infections and liver failure. The process of slowly advancing enteral feedings and promoting enterocyte proliferation and villus height is termed adaptation (Warner, 2013). These changes provide an increased surface area for nutrient absorption. The promotion of adaptation is the cornerstone of pediatric intestinal rehabilitation. In the following paragraphs, a case study is presented describing the experiences of a child with ultrashort gut and her journey to independence from total parenteral nutrition at 3 years old. Key interventions that may have played a role in this child's success will be discussed.

It is time to address ambulatory central venous line infections in pediatric hematology/oncology patients.

It is time to address ambulatory central venous line infections in pediatric hematology/oncology patients.

Hemodialysis in children with ventriculoperitoneal shunts: prevalence, management and outcomes.

Hemodialysis (HD) in children with a concomitant ventriculoperitoneal shunt (VPS) is rare. Registry data suggest that peritoneal dialysis with a VPS is safe, but little is known about HD in the presence of a VPS. We performed a 10-year survey to determine the prevalence of a VPS, complications and outcome in children with a VPS on HD in 15 dialysis units from the 13 countries participating in the European Pediatric Dialysis Working Group. Eleven cases of HD with a VPS were reported (prevalence 1.33 %; 328 patient-months) and compared with prospective Registry data. The median age at start of dialysis was 9.6 [inter-quartile range (IQR) 1.0-15.0] years and median HD vintage was 2.4 (IQR 1.7-3.0) years. Dialysis was performed through a central venous line (CVL) and through an arteriovenous fistula in six and five children, respectively. Three CVL infections occurred in two children, but these children did not develop VPS infections or meningitis. Symptoms of hemodynamic instability were reported in six (55 %) children at least once per week, with hypotension or hypertension occurring in four of these children and nausea, vomiting and headaches occurring in two; four other children reported less frequent symptoms. Seizures on dialysis occurred in two children, at a frequency of less than once per month, with one child also experiencing visual disturbances. During follow-up (median 4.0; IQR 0.38-7.63 years), three children remained on HD and eight had a functioning transplant. No patients were switched to PD. Hemodialysis in children with a VPS is safe, but associated with frequent symptoms of hemodynamic instability. No episodes of VPS infection or meningitis were seen among the children in the survey, not even in those with CVL sepsis.

Mycobacterium mucogenicum Central Venous Line Infection: Successful Treatment in a 2-Year-Old Child without Line Removal

We report the first case of successful treatment of Mycobacterium mucogenicum central venous line (CVL) infection which did not require removal and replacement of the line. A 2-year-old boy with type 3 intestinal failure on long-term home parenteral nutrition via CVL, presented to the emergency department with fever and tachycardia. CVL infection was suspected and amikacin and piperacillin/tazobactam were started immediately in line with local protocol. Consecutive blood cultures grew M. mucogenicum, a rapidly growing nontuberculous mycobacterium species. Following consultation with microbiology, the agreed course of action was to treat the infection with antibiotics while leaving the CVL in place. Clarithromycin and ciprofloxacin were added, and subsequent blood culture on day 6 of treatment showed no bacterial growth. He completed 14 days of antibiotics and has remained well with no further line infection to date (6 months postpresentation). Knowledge that this infection may be successfully treated with the appropriate antibiotics could give clinicians confidence to leave a CVL in place if the patient is clinically stable and immunocompetent. This is of significant importance when preserving vascular access is crucial.

Central venous line complications with chronic ambulatory infusion of prostacyclin analogues in pediatric patients with pulmonary arterial hypertension.

Chronic infusion of prostacyclin (PGI2) via a Broviac central venous line (CVL) is attended by risk of CVL-related complications, but we know of only one report regarding CVL-associated bloodstream infection (BSI) with PGI2 in children and none regarding other complications. We conducted a retrospective cohort study involving pediatric patients with pulmonary hypertension treated with chronic intravenous infusion of PGI2 at Boston Children's Hospital and determined the rate (per 1,000 line-days) of various CVL-related complications. We also determined how often complications necessitated line replacement and hospitalization, time to replacement of CVLs, and interpatient variability in the incidence of complications. From 1999 until 2014, 26 patients meeting follow-up criteria had PGI2 infusion, representing 43,855 line-days; mean follow-up was 56 months (range, 1.4-161 months). The CVL complication rates (per 1,000 line-days) were as follows: CVL-BSI, 0.25; superficial line infection, 0.48; impaired integrity, 0.59; occlusion, 0.09; and malposition, 0.32. The total complication rate was 1.73 cases per 1,000 line-days. All CVL-BSI and malposition cases were treated with CVL removal and replacement. Of CVLs with impaired integrity, 23 could be repaired and 3 required replacement. Six of 21 superficial CVL infections required replacement of the CVL. Three of 4 occluded CVLs were replaced. CVL complications occasioned 65 hospitalizations. There was marked interpatient variability in the rate of complications, much but not all of which appeared to be related to duration of CVL placement. We conclude that non-BSI complications are very significant and that efforts to teach and emphasize other aspects of line care are therefore very important.

The prevention, diagnosis and management of central venous line infections in children

With advancing paediatric healthcare, the use of central venous lines has become a fundamental part of management of neonates and children. Uses include haemodynamic monitoring and the delivery of lifesaving treatments such as intravenous fluids, blood products, antibiotics, chemotherapy, haemodialysis and total parenteral nutrition (TPN). Despite preventative measures, central venous catheter-related infections are common, with rates of 0.5-2.8/1000 catheter days in children and 0.6-2.5/1000 catheter days in neonates. Central line infections in children are associated with increased mortality, increased length of hospital and intensive care unit stay, treatment interruptions, and increased complications. Prevention is paramount, using a variety of measures including tunnelling of long-term devices, chlorhexidine antisepsis, maximum sterile barriers, aseptic non-touch technique, minimal line accessing, and evidence-based care bundles. Diagnosis of central line infections in children is challenging. Available samples are often limited to a single central line blood culture, as clinicians are reluctant to perform painful venepuncture on children with a central, pain-free, access device. With the advancing evidence basis for antibiotic lock therapy for treatment, paediatricians are pushing the boundaries of line retention if safe to do so, due to among other reasons, often limited venous access sites. This review evaluates the available paediatric studies on management of central venous line infections and refers to consensus guidelines such as those of the Infectious Diseases Society of America (IDSA).

Allogeneic blood transfusions and postoperative infections after lumbar spine surgery

Background contextAllogeneic blood transfusions have an immunomodulating effect, and the previous studies in other fields of medicine demonstrated an increased risk of infections after administration of allogeneic blood transfusions. PurposeOur primary null hypothesis is that exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery is not associated with postoperative infections after controlling for patient and treatment characteristics. Second, we assessed if there was a dose-response relationship per unit of blood transfused. Study design/SettingThis is a retrospective cohort study from a tertiary care spine referral center. Patient SampleA total of 3,721 patients underwent laminectomy and/or arthrodesis of the lumbar spine. Outcomes measuresPostoperative infections, pneumonia, endocarditis, meningitis, urinary tract infection, central venous line infection, surgical site infection, and sepsis, within 90 days after lumbar spine surgery were included. MethodsMultivariable logistic regression analyses were used to assess the relationship of perioperative allogeneic blood transfusion with specific and overall postoperative infections accounting for age, duration of surgery, duration of hospital stay, comorbidity status, preoperative hemoglobin, sex, type of operation, multilevel treatment, operative approach, and year of surgery. ResultsThe adjusted odds ratio for exposure to allogeneic blood transfusion from multivariable logistic regression analysis was 2.6 for any postoperative infection (95% confidence interval [CI]: 1.7–3.9, p<.001); 2.2 for urinary tract infections (95% CI: 1.3–3.9, p=.004); 2.3 for pneumonia (95% CI: 0.96–5.3, p=.062); and 2.6 for surgical site infection requiring incision and drainage (95% CI: 1.3–5.3, p=.007). Secondary analyses demonstrated no dose-response relationship between the number of blood units transfused and any of the postoperative infections. Because of the low number of endocarditis (1 case, 0.031%), meningitis (1 case, 0.031%), central venous line infection (1 case, 0.031%), and sepsis (14 cases, 0.43%), we abstained from multivariable analysis. ConclusionsConscious of the limitations of this retrospective study, our data suggest an increased risk of surgical site infection, urinary tract infection, and overall postoperative infections, but not pneumonia, after exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery. These findings should be taken into account when considering blood transfusion and developing transfusion policies for patients undergoing lumbar spine procedures.

Healthcare-associated bloodstream infections in critically ill patients: descriptive cross-sectional database study evaluating concordance with clinical site isolates.

BackgroundHealthcare-associated bloodstream infections are related to both increased antibiotic use and risk of adverse outcomes. An in-depth understanding of their epidemiology is essential to reduce occurrence and to improve outcomes by targeted prevention strategies. The objectives of the study were to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates.MethodsWe conducted a descriptive cross-sectional study in critically ill adults admitted to a tertiary semi-closed intensive care unit in England to determine the epidemiology, source and concordance of healthcare-associated bloodstream infections with clinical site isolates. All nosocomial positive blood cultures over a 4-year study period were identified. Pathogens detected and concordances with clinical site are reported as proportions.ResultsContaminant pathogens accounted for half of the isolates. The most common non-contaminant pathogens cultured were Pseudomonas spp. (8.0%), Enterococcus spp. (7.3%) and Escherichia coli (5.6%). Central venous catheter-linked bloodstream infections represent only 6.0% of the positive blood cultures. Excluding contaminants and central venous line infections, in only 39.5% of the bloodstream infections could a concordant clinical site source be identified, the respiratory and urinary tracts being the most common.ConclusionsClinical practice should focus on a) improving blood culture techniques to reduce detection of contaminant pathogens and b) ensuring paired clinical site cultures are performed alongside all blood cultures to better understand the epidemiology and potential implications of primary and secondary discordant health-care associated bloodstream infections.

Update on surgical therapies for intestinal failure.

Parenteral nutrition enables long-term survival in patients with intestinal failure; however, it is associated with life-threatening complications necessitating alternative techniques of management to enable weaning parenteral nutrition and minimizing parenteral nutrition-associated comorbidities. This review aims at discussing the indications and techniques most commonly utilized for surgical management in a short gut. Surgical therapy for short gut has evolved and undergone refinement in the past 30-40 years with the older procedures being largely abandoned and replaced by newer and refined techniques. Lengthening surgeries (longitudinal intestinal lengthening and tapering and serial transverse enteroplasty) are the most commonly applied procedures in a dilated bowel with intestinal transplantation option reserved as a last resort for recurrent life-threatening central venous line infections, progressive loss of central venous access, and development of progressive liver disease. Management of intestinal failure requires a multidisciplinary approach to optimize intestinal rehabilitation and overall patient outcome. Although intestinal transplantation remains an excellent option for patients with severe life-threatening complications, autologous intestinal reconstruction appears to remain the better overall option.

Source, pattern and antibiotic resistance of blood stream infections in hematopoietic stem cell transplant recipients

Mucositis developing as a result of myelo-ablative high dose therapy administered prior to hematopoietic stem cell transplantation (HSCT) is associated with the risk of bacteremia. The aim of the present study was to detect the pattern of bacteremia coinciding with the present practice of HSCT, to study the contribution of health-care associated infection (HAI) to the pattern of infection, in the context of the problem of antibiotic resistance in HSCT recipients. Patients and methodsThis is a retrospective, single center study including patients who developed febrile neutropenia (FN) among HSCT recipients in one year duration. ResultsNinety FN episodes were recorded in 50 patients. Out of 39 positive blood cultures, Gram negative rods (GNR) were the predominant pathogens, constituting 67% (n=26) of isolated organisms, while 33% of infections were caused by gram positive cocci (GPC) (n=13). Bacteremia was significantly associated with central venous line (CVL) infections and gastroenteritis (diarrhea and vomiting) with a p-value 0.024, 0.20 and 0.0001, respectively. Multi-drug resistant organisms (MDROs) were identified in 27 (69%) of the 39 positive blood cultures. ConclusionIn one year duration, gram negative pathogens were the predominant causes of infection in HSCT recipients with high rates of MDROs in our institution. Gastroenteritis and central venous line infections are the main sources of bacteremia.

Abstract 18457: Outpatient Milrinone Therapy as a Bridge to Pediatric Heart Transplantation: A Large Single Center Experience

Objective: Milrinone infusion as treatment of end stage heart failure in children is well established. Previous reports of outpatient milrinone therapy (tx) are limited by small numbers. Our objective was to evaluate the safety of outpatient milrinone tx as a bridge to heart transplant (HT). Methods: We retrospectively reviewed the records of all patients (pt) at our institution that have received outpatient milrinone tx between February 2000 and June 2013. Results: A total of 53 pt received outpatient milrinone tx, all had failed milrinone weaning, all began milrinone as an inpatient, and all had an indication of bridge to HT. The median age was 9.7 years [IQR 2-16] and 27 (51%) were male. The diagnosis prior to HT was congenital heart disease (15), cardiomyopathy (21; 16 dilated and 5 restrictive), and graft failure (17). Successful HT was performed in 52 and 1 pt is alive waiting. The median length of stay (LOS) for initiation of milrinone was 7 days (d) [IQR 2-16]. There were 2737 d of outpatient milrinone tx without a death and the median duration of tx was 28 d [IQR 15-62; range1-377]. The mean dose was 0.5 ± 0.02 mcg/kg/min. Arrhythmias occurred in 2 pt (atrial flutter and 3 beats of non-sustained ventricular tachycardia). There were 27 rehospitalizations in 16 pt for a total 97 inpatient days with a median LOS of 2d [IQR 1-3]. Indications for rehospitalization were atrial flutter (1pt, 3d),worsening heart failure (4pt, 26d, median LOS=3d [IQR 1-11]), central venous line (CVL) malfunction (10 pt, 23d, median LOS = 1d [IQR 1-2], CVL infection (2 pt, 5d, mean LOS = 2.5d +/- 0.71, and other (16pt,10 admissions, 40d, median LOS=2d [IQR 1-6]. One pt with worsening heart failure was admitted for additional inotropic support with dopamine and remained an inpatient until HT. Conclusion: There was no mortality in patients on milrinone awaiting HT. Arrhythmias were rare and catheter related complications were infrequent. The outpatient use of milrinone in children is safe and effective when initiated in the inpatient setting and it may reduce costs and improve quality of life in children awaiting HT.

An audit of intravenous meropenem in inpatients at Alder Hey Children's NHS Foundation Trust

ObjectivesTo determine the indications for which meropenem was being used and to assess whether these indications adhered to Trust guidelines and national recommendations. This was prompted by the emergence and...

Cardiothoracic Surgeon Management of Postoperative Cardiac Critical Care

To determine whether postoperative cardiac care by cardiothoracic surgeons in a semiclosed intensive care unit model could be distinguished from that given by intensivists who are not board certified in cardiothoracic surgery. From January 2007 to February 2009, we retrospectively examined data on patients after cardiac operations from 2 consecutive periods during which full-time management of intensive care was changed from noncardiothoracic intensivists (period 1, 168 patients) to cardiothoracic surgeons (period 2, 272 patients). Variables measured included Society of Thoracic Surgeons observed and expected mortality, central venous line infections, ventilator-acquired pneumonia, red blood cell exposure, adherence to blood glucose level target at 6 am on the first and second postoperative days, length of stay, and intensive care unit pharmacy costs. Results were compared using a 2-sample t test or 2-tailed Fisher exact test. In similar populations, as witnessed by equivalent Society of Thoracic Surgeons operative risk, cardiothoracic surgeons providing postoperative critical care led to a mean (SD) decrease in hospital length of stay from 13.4(0.9) to 11.2 (0.4) days (P=.01) and decreased drug costs from $4300(1000) to $1800(200) (P<.001). These improvements occurred without losing benefits in other quality measures. By virtue of their cardiac-specific operative and nonoperative training, cardiothoracic surgeons may be uniquely qualified to provide postoperative cardiac critical care. In a semiclosed unit where care of the patient is codirected, the improvements noted may have been facilitated by the commonalities between surgeons and intensivists associated with similar training and experiences.

Single center experience of a vancomycin resistant enterococcal endocarditis cohort

Vancomycin resistant enterococcus (VRE) infective endocarditis (IE) is an increasing nosocomial problem. We describe the clinical management and outcomes of a cohort of patients with VRE IE at a tertiary endocarditis referral center. Retrospective review of all proven cases of VRE IE, from July 2000 through January 2008 was performed. Demographics, comorbidities and therapeutic details were collected and analyzed to assess for risk factors and clinical outcomes. Fifty cases of VRE IE were identified: 26 (52%) were Enterococcus faecium and 24 were Enterococcus faecalis. Vancomycin resistant E. faecalis IE was associated with the presence of a central venous line, liver transplantation, and mitral valve infection while VR E. faecium IE was significantly associated with tricuspid valve infection (p=0.03). The median duration of bacteremia was 14 days for E. faecium and 4 days for E. faecalis, respectively (p=0.002). Factors associated with mortality on bivariate analysis were hemodialysis via a catheter with VR E. faecium (OR=11.7. CI 1.1-122, p=0.02) and liver transplantation with both species. Combination antimicrobial therapy (OR=0.5 CI=0.06-3.2, p=0.1) and valve surgery (OR 1.3 CI 0.8-20, p=0.02) trended toward improved survival with E. faecalis on bivariate analysis. On multivariate analysis, none of the associations were significant. Hemodialysis and liver transplantation were factors associated with acquisition of VRE IE. There was a higher mortality and prolonged bacteremia with VR E. faecium IE than VR E. faecalis IE. Although not significant, combination antimicrobial therapy and surgical intervention trended toward improved survival.

A case of infection-associated antiproteinase-3-negative cytoplasmic antineutrophil cytoplasmic antibody pauci-immune focal necrotizing glomerulonephritis

We present the case of a man with Gram-negative sepsis and exposure to oral silica who developed pauci-immune focal necrotizing glomerulonephritis (PI-FNGN) in the setting of a subacute polymicrobial central venous line (CVL) infection. He developed a cytoplasmic antineutrophil cytoplasmic autoantibody (C-ANCA) that was antiproteinase-3 (PR-3) and antimyeloperoxidase (MPO) antibody negative. We believe this is the first reported case of Gram-negative sepsis-associated PI-FNGN. Chronic silica exposure is a leading environmental risk factor in the development of ANCA vasculitis. Oral silica is a common pharmaceutical additive and its bioavailability is being recognized. Oral silica, therefore, may also be a risk for development of autoreactivity. The PI-FNGN resolved with antibiotic therapy alone. The C-ANCA titer declined as the PI-FNGN resolved. The case supports experimental and observational research that environmental exposures act as adjuvants for an immune response and also provide epigenetic triggers for autoreactivity. The C-ANCA was negative for PR-3, its major antigen. C-ANCA antigen specificity may depend on the pathogenesis of the underlying disease, potentially elicited by a cross-reaction of an antibody to foreign and self target antigen sequence homology or alternatively elicited by antigenic epitope spread.