CVC-related Bloodstream Infections Research Articles

Chlorhexidine gluconate-coated gel pad dressings for prevention of central venous catheter-related bloodstream infections in patients with hematologic diseases or autologous stem cell transplantation: A registry-based matched-pair analysis.

Chlorhexidine gluconate (CHG)-coated gel pad dressings for central venous catheter (CVC) may prevent CVC-related bloodstream infections (CRBSI). However, real-world data showing beneficial effects in patients with hematologic malignancies are scarce. In a matched-pair analysis with data from a multicenter CVC registry, non-tunneled jugular and subclavian vein CVC in adults with hematologic malignancies or germ cell tumors (including patients receiving autologous hematopoietic stem cell transplantation [ASCT]) with CHG were compared with non-CHG dressings. The primary endpoint was definite CRBSI rate within 14 days (dCRBSI14) of CVC insertion; secondary endpoints were combined rate of definite or probable CRBSI within 14 days (dpCRBSI14), overall (dpCRBSI), and CRBSI incidences of all estimates. In total, 2070 CVCs were assessed. There was no statistically significant difference in dCRBSI14 (2.3% vs. 3.5%) between patients with and without CHG gel dressings. Likewise, with regards to dpCRBSI14 (6.2% vs. 6.3%) and the overall dpCRBSI rate (9.2% vs. 10.5%), no significant difference was detected. Furthermore, dCRBSI14 incidence (2.0 vs. 3.2/1000 CVC days), dpCRBSI14 incidence (5.4 vs. 5.6/1000 CVC days), and overall CRBSI incidence (5.5 vs. 6.0/1000 CVC days) showed no significant differences. CRBSI rates were not reduced by the use of CHG gel dressings in patients with hematologic malignancies and/or ASCT.

Impact of the insertion site of central venous catheters on central venous catheter-related bloodstream infections in patients with cancer: results from a large prospective registry.

Overall, insertion of central venous catheter (CVC) into femoral veins (FV) has been shown to be associated with a higher risk of infection compared with subclavian and internal jugular (IJV/SCV) CVC, but no data are available on the impact of the FV insertion site on the CVC-related bloodstream infections (CRBSI) risk in patients with cancer. The objective of the study is to compare CRBSI rates and incidences of FV with those of internal jugular and subclavian vein (IJV/SCV CVC) as observed in the prospective SECRECY registry. SECRECY is an ongoing observational, prospective, clinical CRBSI registry active in six departments of hematology/oncology in Germany. Each case of FV CVC was matched at a ratio of 1:1 to a case with IJV/SCV CVC. The propensity score was estimated using a multivariable logistic regression model adjusting for age, sex, cancer type, and duration of indwelling catheter. Of 4268 CVCs included in this analysis, 52 (1.2%) were inserted into the FV and 4216 (98.8%) into the IJV/SCV. 52 cases of FV CVC were matched with 52 IJV/SCV CVC. There was no significant difference in the CRBSI rate (3.8% vs. 9.6%), the CRBSI incidence (5.7 vs. 14.2/1000 CVC days), and the median CVC time (5.5 vs. 5days) between the FV and the IJV/SCV group. Based on this data, inserting FV CVCs in patients with cancer does, at least in the short-term, not appear to be associated with an increased risk of CRBSI as compared to IJV/SCV CVC.

Ten Years of KPC-Kp Bloodstream Infections Experience: Impact of Early Appropriate Empirical Therapy on Mortality.

In K. pneumoniae KPC (KPC-Kp) bloodstream infections (BSI), INCREMENT CPE score >7, Charlson Comorbidity Index (CCI) ≥3 and septic shock are recognized predictors of mortality, with a possible beneficial effect of combination therapy in seriously ill patients. We conducted a ten-year retrospective study including all KPC-Kp BSI in patients ≥18 years of age with the aim to evaluate the characteristics and impact of appropriate empirical therapy, either monotherapy or combination therapy, and targeted therapy on mortality. Appropriate therapy was defined as at least one active antimicrobial agent with in vitro activity against KPC-kp demonstrated by susceptibility testing, administered within 48 h from blood culture collection. The median age of the 435 analyzed patients was 66.09 years (IQR 54.87-73.98). The median CCI was 4. KPC-Kp colonization was present in 324 patients (74.48%). The probable origin of the KPC-Kp BSI was not identified in 136 patients (31.26%), whereas in 120 (27.59%) patients, it was CVC-related, and in 118 (27.13%), it was respiratory. Source control was achieved in 87 patients (72.5%) with CVC-related KPC-Kp BSI. The twenty-eight-day survival was 70.45% for empirical monotherapy, 63.88% for empirical combination therapy and 57.05% for targeted therapy (p = 0.0399). A probable source of KPC-Kp BSI other than urinary, CVC or abdominal [aHR 1.64 (IC 1.15-2.34) p = 0.006] and deferred targeted therapy [HR 1.67 (IC 1.12-2.51), p= 0.013] emerged as predictors of mortality, whereas source control [HR 0.62 (IC 0.44-0.86), p = 0.005] and ceftazidime/avibactam administration in empirical therapy [aHR 0.37 (IC 0.20-0.68) p = 0.002] appeared as protective factors. These data underline the importance of source control together with timing appropriateness in the early start of empirical therapy over the choice of monotherapy or combination therapy and the use of ceftazidime/avibactam against KPC-Kp BSI.

Scheduled removal of central venous catheters (CVC) to prevent CVC-related bloodstream infections in patients with hematological disease or autologous stem cell transplantation: a registry-based randomized simulation-study

Although not generally recommended, scheduled central venous catheter (CVC) removal is sometimes carried out in order to reduce the CVC-related bloodstream infection (CRBSI) incidence. We conducted a simulation for scheduled CVC removal within the multicenter CRBSI registry (SECRECY). Non-tunneled jugular and subclavian CVC in patients with hematological disease or with germ cell tumors (including patients receiving autologous stem cell transplantation [SCT]) were included. Cases were randomized in a 1:1:1:1 ratio to either a simulated, scheduled CVC removal after 7, 14, and 21 days, or to non-simulated, unscheduled CVC removal (control group). The primary endpoint was definitive CRBSI incidence for a scheduled CVC removal after 14 days (dCRBSI-D14rmv). Among other, secondary endpoints were definite CRBSI incidence for a scheduled removal after 7 days (dCRBSI-D7rmv) and 21 days (dCRBSI-D21rmv). Data on 2984 CVC were included. Patients’ median age was 59 (range 16–95) years, 58.8% being male. The vast majority (98.4%) were patients with hematological malignancies. Jugular veins were the main insertion site (93.2%). dCRBSI-D14rmv was 3.10/1000 CVC days as compared to 4.15/1000 CVC days in the control group (p = 0.23). There was a significant difference between dCRBSI-D7rmv (0.86/1000 CVC days) and controls (p < 0.001), but not between dCRBSI-D21rmv (4.10/1000 CVC days) and controls (p = 0.96). Our data suggest that in patients with hematological diseases or autologous SCT recipients scheduled CVC removal after 14 days does not result in a lower CRBSI incidence compared to unscheduled removal.Trial registration: DRKS00006551, 2014/09/29, retrospectively registered.

Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults.

Intermittent locking of central venous catheters (CVCs) is undertaken to help maintain their patency and performance. There are systematic variations in care: some practitioners use heparin (at different concentrations), whilst others use 0.9% sodium chloride (normal saline). This review looks at the effectiveness and safety of intermittent locking with heparin compared to normal saline, to see if the evidence establishes whether one is better than the other. This is an update of an earlier Cochrane Review. To evaluate the benefits and harms of intermittent locking of CVCs with heparin versus normal saline in adults to prevent occlusion. We used standard, extensive Cochrane search methods. The latest search date was 20 October 2021. We included randomised controlled trials in adults ≥ 18 years of age with a CVC that compared intermittent locking with heparin at any concentration versus normal saline. We excluded studies on infants and children from this review. We used standard Cochrane methods. Our primary outcomes were occlusion of CVCs and duration of catheter patency. Our secondary outcomes were CVC-related bloodstream infections and CVC-related colonisation, mortality, haemorrhage, heparin-induced thrombocytopaenia, CVC-related thrombosis, number of additional CVC insertions, abnormality of coagulation profile and allergic reactions to heparin. We used GRADE to assess the certainty of evidence for each outcome. We identified one new RCT with 30 participants for this update. We included a total of 12 RCTs with 2422 participants. Data for meta-analysis were available from all RCTs. We noted differences in methods used by the included studies and variation in heparin concentrations (10 to 5000 IU/mL), time to follow-up (1 to 251.8 days), and the unit of analysis used (participant, catheter, line access). Five studies included ICU (intensive care unit) patients, two studies included oncology patients, and the remaining studies included miscellaneous patients (chronic kidney disease, haemodialysis, home care patients, etc.). Primary outcomes Overall, combined results may show fewer occlusions with heparin compared to normal saline but this is uncertain (risk ratio (RR) 0.70, 95% confidence interval (CI) 0.51 to 0.95; 10 studies; 1672 participants; low-certainty evidence). We pooled studies that used participant or catheter as the unit of analysis. We carried out subgroup analysis by unit of analysis. No clear differences were detected after testing for subgroup differences (P = 0.23). We found no clear evidence of a difference in the duration of catheter patency with heparin compared to normal saline (mean difference (MD) 0.44 days, 95% CI -0.10 to 0.99; 6 studies; 1788 participants; low-certainty evidence). Secondary outcomes We found no clear evidence of a difference in the following outcomes: CVC-related bloodstream infections (RR 0.66, 95% CI 0.08 to 5.80; 3 studies; 1127 participants; very low-certainty evidence); mortality (RR 0.76, 95% CI 0.44 to 1.31; 3 studies; 1100 participants; very low-certainty evidence); haemorrhage (RR 1.54, 95% CI 0.41 to 5.74; 3 studies; 1197 participants; very low-certainty evidence); or heparin-induced thrombocytopaenia (RR 0.21, 95% CI 0.01 to 4.27; 3 studies; 443 participants; very low-certainty evidence). The main reasons for downgrading the certainty of evidence for the primary and secondary outcomes were unclear allocation concealment, suspicion of publication bias, imprecision and inconsistency. Given the low-certainty evidence, we are uncertain whether intermittent locking with heparin results in fewer central venous catheter occlusions than intermittent locking with normal saline in adults. Low-certainty evidence suggests that heparin may have little or no effect on catheter patency duration. Although we found no evidence of differences in safety (CVC-related bloodstream infections, mortality, or haemorrhage), the combined studies were not powered to detect rare adverse events such as heparin-induced thrombocytopaenia. Further research conducted over longer periods would reduce the current uncertainties.

Metastatic spondylodiscitis in central venous catheter related bloodstream infections in hemodialysis patients: Risk factors and prognosis.

Infection is one of the most common causes of death in hemodialysis patients. Catheter infections are among the most common infections in this patient group. Spondylodiscitis which has a high incidence in ESRD is more commonly encountered in patients with CVCs compared to AVF. In this study, we aimed to evaluate the frequency and risk factors of spondylodiscitis in catheter-related bloodstream infections in hemodialysis patients. In total, 1620 patients were screened and 42 male and 35 female patients with central catheter infection with a mean age of 65.8 ± 14.9 years were included in this study. Patients with metastatic infections secondary to CVC related bloodstream infections were determined. The diagnosis of spondylodiscitis was based on clinical information, computed tomography (CT) and magnetic resonance imaging (MRI), and vertebral cultures. Metastatic infection due to catheter infection was observed in 15 patients (19.5%). In the regression analysis, CRP level and RRT time were found to be significantly correlated with the development of metastatic infection. Spondylodiscitis was the most common subtype of metastatic infections (8/15). The presence of lumbar hernia was associated with increased risk of metastatic spondylodiscitis in case of catheter infection in hemodialysis patients. The only factor associated with resistance to medical treatment was the time from admission to diagnosis. Patients with long RRT time and high blood CRP levels on admission should be closely monitored for metastatic infection in patients with CVC related bloodstream infections. Screening for spondylodiscitis with CT or MRI should be performed in patients with symptoms, since early diagnosis may prevent the development of possible neurological deficits and treatment resistance.

Klebsiella pneumoniae Infections in Intensive Care Unit and Risk Factors for Carbapenem Resistance

Objective: Klebsiella pneumoniae infections have been a problem in intensive care units (ICU) in recent years due to multi-drug resistance. In this study, it was aimed to analyze K. pneumoniae infections in ICU, determine distribution of carbapenem resistance rates and risk factors. Methods: Nosocomial infections (NI) with K. pneumoniae between January 2017-January 2020 were evaluated retrospectively. In cases with recurrent K. pneumoniae infection, only the first episode was included. Results: K. pneumoniae infections were developed in a total of 78 patients. Bloodstream infections (BSI) were the most common (51.3%), followed by pneumonia (41%) and urinary tract infections (7.7%). Among BSI cases, 52.5% were associated with central venous catheter (CVC) and 81.2% of pneumonia cases were ventilator-associated pneumonia (VIP). It was observed that while the proportion of BSI was gradually decreasing in years, pneumonia rates have increased. Among BSI, it was observed that the rate of CVC-related BSI was increased from 33.3% in 2017 to 62.5% in 2019. Carbapenem resistance was 52.6% and colistin resistance was 17.9% in K. pneumoniae isolates and both increased over 3 years. When carbapenem-resistant K. pneumoniae infections were compared with carbapenem-sensitive K. pneumoniae infections, the independent risk factors associated with carbapenem resistance were found to be carbapenem use (p=0.008, OR: 8.45, 95% CI: 1.76-40.64), prior NI developing with different microorganism (p=0.005, OR: 8.70, 95% CI: 1.91-39.65) and total parenteral nutrition (TPN) use (p=0.04, OR: 4.2, 95% CI: 1.06-16.67). Conclusions: Carbapenem-resistant K. pneumoniae infections are gradually increasing in ICUs, and colistin resistance has started to be observed recently. Our study showed that carbapenems are independent risk factors in carbapenem resistance and suggested that carbapenem use should be restricted in our unit. It is important for each center to reveal its own data of frequency and resistance, in order to decrease infection rates with the infection control measures and determine the antibiotic using policies.

Catheter-related Blood Stream Infections among Children on Hemodialysis over 7 Years

Patients with end-stage kidney disease frequently require hemodialysis (HD) through central venous catheters (CVCs) as a bridge to renal transplantation. However, longevity of CVCs is affected by the occurrence of CVC-related bloodstream infections (CVC-RBI). This retrospective study evaluated the outcomes of CVCs inserted for HD, with specific attention to rates and etiology of CVC-RBI. Over 7 years between January 2010 and December 2016, 39 patients, aged 2–15 years, were admitted for HD for ESRD in the Department of Pediatric Nephrology, Sheikh Khalifa Medical City, Abu Dhabi, UAE. The most etiology for ESRD was renal dysplasia (28.2%). Tunneled cuffed CVC was inserted most commonly in the right internal jugular vein (40.2%). The most common reason for change of CVC was CVC-RBI (28.9%). The estimated rate of CVC-RBIs was 1.72/000 CVC days. Staphylococcus aureus was the most common (28.6%) etiology. CVC longevity was significantly influenced by the occurrence of CVC-RBI (P &lt; 0.001), and the rates of CVC-RBI were significantly different between patients with less or more than 200 CVC days (P = 0.002). Most patients either continued on HD (48.7%) or underwent kidney transplantation (28.2%). This study highlights that rates of CVC-RBI were low but were associated with prolonged CVC use.

Use of a gentamicin-citrate lock leads to lower catheter-related bloodstream infection rates and reduced cost of care in hemodialysis patients.

Central venous catheters (CVC) are a major contributor to infections in hemodialysis (HD) patients, leading to high morbidity and mortality. Gentamicin-citrate (GC) lock is used as standard of care at centers belonging to a mid-size dialysis organization. Four outpatient HD centers acquired by the organization continued to use heparin for catheter locks for a period of time before converting to the provider's standard of using GC lock. In this retrospective observational study, we included patients receiving HD by CVC at these four centers. We report rates of CVC-related bloodstream infections (CVC-BSI) during the heparin lock and the GC lock periods; crude rate ratios and adjusted rate ratios using Cox survival analyses adjusting for potential confounders; microbiology patterns; safety signals (gentamicin resistance, hospitalizations and deaths); and financial impact on payer. A total of 220 and 281 patients used tunneled CVCs, accounting for 25,245 and 44,550 catheter days in the heparin and the GC lock periods, respectively. CVC-BSI event rates were 66% lower in the GC lock period (CVC-BSI event rate: 0.20 per 1000 catheter-days) than the heparin lock period (rate: 0.59 per 1000 catheter days); rate ratio 0.34 (95% confidence interval (CI) 0.15-0.78, P = 0.01). In the fully adjusted multivariable Cox model, use of GC lock was associated with 70% reduction in CVC-BSI events (HR 0.30, 95% CI 0.12-0.72, P = 0.01). No increased risk of gentamicin resistance, hospitalizations, or death associated with use of GC lock were observed. Use of GC lock was associated with an estimated saving of $1533 (95% CI: $259-$4882) per patient per year. Use of GC lock led to significant reductions in CVC-BSIs with no signal for harm, and is associated with significant cost savings in dialysis care.

Incidence and Outcome of Bacterial Blood Stream Infections in Allotransplanted Patients: Rethinking the Role of Fluoroquinolone Prophylaxis

Introduction. Blood stream infections (BSIs) represent a common event during allogeneic hematopoietic stem cell transplantation (allo-SCT) and are associated with high rate of mortality. Prophylaxis with fluoroquinolones is commonly adopted to prevent severe infection during the neutropenic phase. The emerging bacterial strains resistant to these antimicrobial agents could lead to change this type of approach.Patients and methods. We retrospectively analyzed positive blood cultures (BCs) from patients allotransplanted from January 2010 to December 2015 within our transplant program. Antimicrobial prophylaxis was conducted with a quinolone during the neutropenic period, acyclovir and fluconazole starting from the day prior to reinfusion until the withdrawn of immunosuppressive therapy and sulfametoxazole/trimethoprim starting from the hematological recovery. GVHD prophylaxis consisted on cyclosporine and methotrexate in all cases, with the addition of ATG in patients transplanted from matched unrelated donor (MUD) or with cord-blood (CB) units. Post-transplant cyclophosphamide was used in the setting of haploidentical donors. At fever onset, BCs were collected from peripheral blood (PB-BCs) and central venous catheter (CVC-BCs). A CVC related infection was defined when a positive CVC-BC proceeded by 2 hours the positivity of PB-BCs. CVC contamination was defined by the presence of positive CVC-BCs and negative PB-BCs. Empirical broad-spectrum antimicrobial therapy was usually conduct with a third or fourth generation cephalosporin with the addiction of a glycopeptide agent, if mucositis occurred.Results. One hundred-sixty-two patients underwent allo-SCT of whom 88 (54%) had acute leukemia (AL); 70 (43%) were transplanted in first CR or up-front; 71 (44%) received a myeloablative conditioning (MAC). The stem cell source was bone marrow (BM) in 33 (20%), peripheral blood stem cells (PBSC) in 122 (75%) and CB in 7 (5%) cases. Donors were matched related donor (MRD) in 58 (36%), MUD in 86 (53%) and alternative (haploidentical or CB) in 18 (11%) cases. The median time to positive BCs since allo-SCT was 13 days (range -4 - +1482). Eighty patients (49%) had a positive BCs, for a total of 119 samples. No difference in the clinical characteristics of patients with or without BSI was detected (Table 1). The median follow up was 399 days (range 21-2039) for the BSI positive group and 437 (range 12-2157) for the BSI negative (p=0.52). In 43 out of 80 patients with BSI (53%) we observed a correlation between the BCs and an organ involvement (mainly the lung in 34% of the cases). Seventy-seven (65%) and 42 (35%) out of 119 BCs were sustained by a Gram positive and a Gram negative agent, respectively. The distribution and the antimicrobial sensitivity of the different species is reported in Table 2. Briefly, S. epidermidis and E. coli were the most frequently isolated Gram positive and Gram negative bacteria, respectively (35% and 20%). 67% of E. coli were ESBL positive and 92% were resistant to fluoroquinolones. Moreover 40% and 90% of P. aeruginosa were resistant to carbapenems and to fluoroquinolones, respectively. Sixty (50%) and 59 (50%) out of 119 BCs were CVC-BCs and PB-BCs, respectively. Regarding positive CVC-BCs, 28 (24%) were CVC related BSIs; CVC contamination was observed in 21 cases (18%). The most common isolate from CVC-BCs was S. epidermidis, with 25 cases (21%). Forty -seven out of 80 patients (59%) in the BSI positive group and 35 out of 82 (43%) in the BSI negative group died (p=0.04). Overall, the infection-related mortality was 19% (15 cases). Species with the higher mortality rate were: P. aeruginosa (50%) and E. faecium (67%).Conclusions: Prophylaxis with fluoroquinolones predominantly selects Gram positive infections the majority of which were CVC related. Infections by Gram negative strains are frequently characterized by multi-antimicrobial agent resistance. These results urge to reconsider the antimicrobial prophylaxis strategy. Prospective surveillance of BSIs is a mainstay in the management of patients addressed to allo-SCT. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Clinical effects of bundle intervention strategy on the prevention of CVC-related bloodstream infections

Objective To study the clinical effects of bundle intervention strategy on the prevention of CVC-related bloodstream infections. Methods A total of 847 patients were enrolled, of whom 411 cases received central venous catheterization (CVC) from June 2008 to June 2010 were allocated to control group with 5760 catheter days and traditional central venous catheter care. While a total of 436 cases from September 2010 to September 2012 were allocated to observation group with 6110 catheter days and performed bundle intervention strategy. The site and duration of CVC, and incidence of CVC-related bloodstream infections between two groups were compared. Results The length of catheter indwelling in the observation group was (8±3)d which was shorter than (13±7)d in the control group (t=2.672, P=0.008). A total of 436 patients of observation group had total 6 110 d catheter indwelling time, in whom14 cases happened CRBSI with incidence rate 2.3 per one thousand catheter day; 411 patients of the control group had 5 760 d catheter indwelling time, in whom 38 cases occurred CRBSI with incidence rate 6.6 per one thousand catheter day; the difference of CRBSI rate in two groups had statistical significance (χ2=12.60, P=0.002). Conclusions The implementation of bundle intervention strategy can effectively minimize the incidence of CVC-related bloodstream infections. Key words: Central venous catheter; Intensive Care Unit; Bundle intervention; Catheter-related bloodstream infection

Antibiotic Prophylaxis Revisited: The Impact of Fluoroquinolones on Epidemiology and on the Emergence of Resistant Strains in Acute Leukemia Patients. Results of a Prospective Study By the Rete Ematologia Lombarda (REL)

▪Introduction. Multiresistant (multiR) bacteria are emerging pathogens in hematologic cancer patients (pts) and may negatively impact on the outcome of bloodstream infections (BSI). The antibiotic pressure, including fluoroquinolones (Fq) prophylaxis, may be one of the factors responsible for this phenomenon. In order to better define the very recent epidemiology and outcome of BSI in a real-life setting, we planned a prospective study collecting all consecutive febrile/infectious episodes occurring in acute leukemia (AL) pts admitted to 9 hematological institutions participating to REL, representing about 75% of the entire AL population treated in Lombardy.Patients and Methods. From Dec-2012 to Jul-2014, all febrile/infectious episodes were recorded. The following data concerning BSI were analysed: age, gender, type and phase of leukemia, neutropenia, Fq prophylaxis, presence of central venous catheter (CVC), concomitant pulmonary infiltrates, antibiotic resistance.Results. In 218 AL pts (M/F 131/87; median age 54y, range 17-80; AML/ALL 181/37), 314 BSI were diagnosed. In 180 (57.3%) BSI occurred in pts on Fq prophylaxis. In 71 (22.6%) pneumonia was also present. Gram-positive cocci (GPC) were isolated in 145/314 BSI (46.2%); Gram-negative rods (GNR) in 117 (37.3%), polymicrobial (PMB) aetiology in 48 (15.3%) and fungi (F) in 4 (1.3%). Coagulase-negative staphylococci (CoNS) were the most frequent GPC (105/314, 33.4%); S. aureus, S. viridans and enterococci were observed in 7 (2.2%), 17 (5.4%) and 37 (11.8%) cases, respectively. Methicillin-resistant strains accounted for 75.9% of all staphylococci and vancomycin-resistant strains for 2.7% of enterococci. CVC-related BSI, which accounted for 31.4% of BSI occurring in pts with CVC, was independently correlated with GPC aetiology (OR 1.9, CI 1.1-3.1, p=0.01). Considering GNR, Enterobacteriaceae were isolated in 113/314 BSI (36%) and P. aeruginosa in 31 (9.9%). GNR occurred more frequently during consolidation cycles (45.8% vs 31.1%) and in pts not on Fq prophylaxis (44.2% vs 32.2%). Both conditions were independent risk factors at multivariate analysis (p=0.002 and p=0.02, respectively). Frequency of Enterobacteriaceae BSI was also higher during consolidation cycles in comparison with other AL phases (48.1% vs 27.3%, p=0.0005), but Fq prophylaxis was no longer a protective factor (35% vs, 37.3%). Fq resistance was observed in 63/113 (55.7%) of Enterobacteriaceae; in 84.1% of cases were detected during Fq prophylaxis. ESBL+ strains, which accounted for 24.8% of Enterobacteriaceae, were also associated with Fq prophylaxis (OR 2.8, CI 1.1-7.1, p=0.02) at multivariate analysis. Carbapenemase producing (CP) strains occurred in 8.8% of Enterobacteriaceae. Among P. aeruginosa strains, 19.4% were multiR. Thirty-day mortality was 7.6% (24/314); it was lower for GPC (5.5%) in comparison with GNR (9.4%) and PMB BSI (11.6 %). CP Enterobacteriaceae or multiR P. aeruginosa BSI (30d mortality: 33.3%; OR 21.3, CI 4.4-102.4, p=0.0001) but not ESBL+ strains were independent predictors of death. Furthermore, having relapsed/resistant AL (18.2%; OR 9, CI 2.7-30.7, p=0.0004), and the presence of concomitant pulmonary infiltrates (26.8%; OR 15, CI 4.8-46.8, p<0.001) significantly correlated with the risk of death at multivariate analysis.Conclusions. The proportion of multiresistant GNR is becoming a major problem in our real-life prospective study. Fq prophylaxis reduced the proportion of GNR BSI as a whole, but not those incurred by Enterobacteriaceae, mainly observed during consolidation phases. Moreover, Fq exposure was associated with ESBL+ aetiology, which also occurred during consolidation cycles. While ESBL+ did not impact on survival, both multiR- and CP-bacteria correlated with a higher risk of death. Interestingly, also a concomitant diagnosis of pneumonia during BSI was a strong predictor of a poorer outcome. The usefulness of Fq prophylaxis has to be reanalysed in this new epidemiologic scenario. DisclosuresNo relevant conflicts of interest to declare.

CVC-related bloodstream infections costly

CVC-related bloodstream infections costly

A Crossover Randomized Prospective Pilot Study Evaluating a Central Venous Catheter Team in Reducing Catheter-Related Bloodstream Infections in Pediatric Oncology Patients

Treatment for most children with cancer includes the use of a central venous catheter (CVC). CVCs provide reliable venous access for delivery of chemotherapy and supportive care. This advantage is mitigated by an increased risk of bloodstream infections (BSIs). Despite the ubiquitous use of CVCs, few prospective studies have been conducted to address infection prevention strategies in pediatric oncology patients. Prospective, crossover pilot study of a CVC team intervention versus standard care. Two inpatient oncology units in a metropolitan children's hospital. A total of 41 patients/135 admissions for the experimental unit (EU) and 41/129 admissions for the control unit (CU). Patients received a CVC blood draw bundle procedure by a CVC registered nurse (RN) team member (experimental intervention: EU) for 6 months and by the assigned bedside RN (standard care: CU) for 6 months. Feasibility of implementing a CVC RN team; a significant difference in CVC-related BSIs between the team intervention versus standard care and risk factors associated in the development of CVC-related BSIs were determined. There were 7 CVC-related BSIs/1238 catheter days in the EU group (5.7/1000 catheter days) versus 3 CVC-related BSIs/1419 catheter days in the CU group (2.1/1000 catheter days; P = .97). Selected risk factors were not significantly associated with the development of a CVC-related BSI. A CVC team in the care of pediatric oncology patients is feasible; however, a larger cohort will be required to adequately determine the effectiveness of the team reducing CVC-related BSIs.

FACTORS ASSOCIATED WITH MORTALITY AMONG PATIENTS WITH CENTRAL VENOUS CATHETER-RELATED BLOODSTREAM INFECTION IN AN INTENSIVE CARE UNIT

Central venous catheterization is a common practice in the management of critically ill patients and i s associated with various complications, such as Bloo dstream Infections (BSI), which are major determina nts of increased morbidity, mortality and healthcare ex penses. Few studies have addressed factors that pre dict mortality in patients with this complication. The a im of this study was to investigate factors associa ted with mortality in patients with Central Venous Catheter (CVC)-related BSI in an intensive care unit of a te rtiary care hospital in the Federal District, Brazil. This was a retrospective and observational study, in wh ich all CVC-related BSI that occurred between January 2008 and December 2010 were reviewed. We obtained demographic, clinical, biochemical and microbiologi cal data from medical records and investigated its association with mortality during ICU stay. There w ere 4,504 ICU admissions during the study period and 68 were complicated by CVC-related BSI (4.09 per 1000 catheter-days), most due to gram-negative organisms (45.6%). Overall mortality was 59.7%. Death risk was significantly associated with mechanical ventilat ion (OR 27.8, 95% CI 3.28-250, p<0.001), the mean number of invasive devices other than the CVC (1.44 Vs 2 .37 in controls Vs cases, p<0.001) and increased serum levels of urea (mean value of 44.2 mg dL -1 in survivors vs. 73.9 mg dL -1 in non-survivors, p = 0.001). Mortality was not as sociated with other clinical or biochemical features, neither with microbiological variables, a lthough lethality was high among patients with gram-positive infections (77% Vs 58.33% for fungi and 54.83% for gram-negative). CVC-related BSI was associated with high absolute mortality, which was predicted by mec hanical ventilation and a higher number of invasive devices other than the CVC. Knowledge of local factors predictive of mortality is critical for plannin g strategies to reduce death risk associated with thi s complication.

“Targeting to Zero” in Pediatric Oncology

Reducing or eliminating hospital acquired infections is a national quality of care priority. The majority of the 12,400 children diagnosed with cancer each year require long-term intravenous access to receive intensive and complex therapies. These children are at high risk for infection by nature of their disease and treatment, which often involves use of a central venous catheter (CVC). Throughout the nation, nurses assume frontline responsibility for safe, quality CVC care to minimize the risk of potentially life-threatening infections. Substantial financial and human costs are associated with CVC-related bloodstream infections, including prolonged hospital lengths of stay and increased care required to treat these infections. The purpose of this review of the literature is to summarize existing adult and pediatric data on CVC-related bloodstream infections and explore nursing models of CVC care that may improve pediatric oncology patient outcomes.

What features of educational interventions lead to competence in aseptic insertion and maintenance of CV catheters in acute care? BEME Guide No. 15

Background: Up to 6000 patients per year in England acquire a central venous catheter (CVC)-related bloodstream infection (Shapey et al. ). Implementation of Department of Health guidelines through educational interventions has resulted in significant and sustained reductions in CVC-related blood stream infections (Pronovost et al. 2002), and cost (Hu et al. ).Aim: This review aimed to determine the features of structured educational interventions that impact on competence in aseptic insertion technique and maintenance of CV catheters by healthcare workers.Methods: We looked at changes in infection control behaviour of healthcare workers, and considered changes in service delivery and the clinical welfare of patients involved, provided they were related directly to the delivery method of the educational intervention.Results: A total of 9968 articles were reviewed, of which 47 articles met the inclusion criteria.Conclusions: Findings suggest implications for practice: First, educational interventions appear to have the most prolonged and profound effect when used in conjunction with audit, feedback, and availability of new clinical supplies consistent with the content of the education provided. Second, educational interventions will have a greater impact if baseline compliance to best practice is low. Third, repeated sessions, fed into daily practice, using practical participation appear to have a small, additional effect on practice change when compared to education alone. Active involvement from healthcare staff, in conjunction with the provision of formal responsibilities and motivation for change, may change healthcare worker practice.

Central venous catheter-related bloodstream infections: improving post-insertion catheter care

Patients with central venous catheters (CVCs) are at increased risk of bloodstream infections and sepsis-related death. CVC-related bloodstream infections (CRBSIs) are costly and account for a significant proportion of hospital-acquired infections. The aim of this audit was to assess current practice and staff knowledge of CVC post-insertion care and therefore identify aspects of CVC care with potential for improvement. We conducted a prospective audit over 28 consecutive days at a university teaching hospital investigating current practice of CVC post-insertion care in wards with high CVC usage. A multiple choice questionnaire on best practice of CVC insertion and care was distributed among clinical staff. Rates of breaches in catheter care and CRBSIs were calculated and statistical significance assumed when P<0.05. Data was recorded from 151 CVCs in 106 patients giving a total of 721 catheter days. In all, 323 breaches in care were identified giving a failure rate of 44.8%, with significant differences between intensive care unit (ICU) and non-ICU wards (P<0.001). Dressings (not intact) and caps and taps (incorrectly placed) were identified as the major lapses in CVC care with 158 and 156 breaches per 1000 catheter days, respectively. During the study period four CRBSIs were identified, producing a CRBSI rate of 5.5 per 1000 catheter days (95% confidence interval: 0.12-10.97). There are several opportunities to improve CVC post-insertion care. Future interventions to improve reliability of care should focus on implementing best practice rather than further education.

Central Venous Catheter (CVC) related infections: a local retrospective study

Background. Central venous catheter (CVC) related infection is associated with significant increases in morbidity, mortality, and health care cost.This local surveillance study was carry out to monitor the frequency of occurrence of CVC-related blood stream infections. Materials and methods. During the period January – December 2005, 226 CVC specimens were analyzed (quantitative method) and microrganism identification from positive samples was performed by Vitek II. In 53 patients it was possible to compare quantitative results with those obtained from blood cultures. Results. Positive CVC samples were 125 (55%) and 130 microrganisms were isolated: 109 Gram-positives (84%), 4 Gram-negatives (3%), and 17 mycetes (13%). Among pathogens collected simultaneously from CVC and blood samples, the most frequently isolated were Staphylococcus spp. (30% coagulase-negative staphylococci and 20%. S. aureus) and Candida spp. (45%). In the group of patients that presented positive CVC and negative blood samples the most frequently recovered microrganisms were staphylococci. Many isolates (33%) were polymicrobial. Conclusions. Catheter-related infections occurred in those patients who presented the same pathogen in both CVC and blood cultures. These infections were principally caused by staphylococci and Candida spp. On the contrary, a possible CVC contamination could be suspected when positive CVC and negative blood cultures were found.

Linezolid lock prophylaxis of central venous catheter infection

Central venous catheter (CVC)-related infections are a major problem for patients requiring long-term venous access and may result in frequent hospital admissions and difficulties in maintaining central venous access. CVC-related blood stream infections are associated with increased duration of inpatient stay and cost approximately Euro 13,585 per patient [Blot, S. I., Depuydt, P., Annemans, L., Benoit, D., Hoste, E., De Waele, J. J., Decruyenaere, J., Vogelaers, D., Colardyn, F. & Vandewoude, K. H. (2005). Clin Infect Dis 41, 1591-1598]. Antimicrobial lock therapy may prevent CVC-related blood stream infection, preserve central venous access and reduce hospital admissions. In this paper, the impact of linezolid lock prophylaxis in a patient with short bowel syndrome is described.