Early Central Venous Catheter Removal Research Articles

Early removal of drains and lines after liver transplantation to reduce the length of hospital stay and enhance recovery - A systematic review of the literature and expert panel recommendations.

The timing of removing abdominal drains, central venous catheters (CVC) and urinary catheters (UC) on post liver transplantation (LT) outcomes is not well elucidated. To provide International expert panel recommendations and guidelines on time of drain and catheter removal as a part of an ERAS protocol to reduce the length of hospital stay and enhance recovery. Systematic review following PRISMA guidelines and recommendations using the GRADE approach derived from an international expert panel. Papers considered were those reporting one or more outcome of interest related to drainage and line removal in the setting of LT. POSPERO Protocol ID: CRD42021238349 RESULTS: On analysing five relevant studies pertaining to drains in patients undergoing LT (4 retrospective and one prospective), the length of hospital and/or ICU stay was similar or shorter, and postoperative morbidity and mortality were lower in those without drains. No studies pertaining specifically to the time of removal of drains, CVC's, or UC's in LT were found. Studies in patients undergoing major abdominal surgery or hepatectomies recommend early removal of CVC and UC to reduce catheter associated infections. Based more on expert recommendation, we propose that abdominal drains, if placed during LT, should be removed by post-operative day 5 after LT, based on quantity and fluid characteristics (Quality of Evidence; Low to Moderate | Grade of Recommendation; Strong). Larger studies are needed to more reliably determine indications for early drain and line removal in an ERAS protocol setting. This article is protected by copyright. All rights reserved.

A longitudinal study of Candida bloodstream infections in a Japanese university hospital: species distribution, drug susceptibility, clinical features, and mortality predictors.

We aimed to detect possible changes in Candida species distribution over time and to know the antifungal susceptibility profile of isolates obtained from patients with bloodstream infection (BSI) due to this pathogen. Risk factors associated with 30-day mortality were also assessed. We conducted a retrospective cohort study of patients diagnosed with Candida BSI at a Japanese university hospital from 2013 to 2021. The change in the distribution pattern of the Candida spp. isolated was examined by considering three successive sub-periods of 3years each. Risk factors for 30-day mortality were determined using Cox regression analysis. In the entire study period, Candida albicans was the most frequent species (46.7%), followed by Candida glabrata (21.5%) and Candida parapsilosis (18.7%). There was no change in Candida species distribution comparing the three sub-periods analyzed. All isolates were susceptible to micafungin, and most were susceptible to fluconazole, except for C. glabrata. No isolates were resistant to amphotericin B or voriconazole. The overall 30-day mortality was 40.2%. Univariate analysis revealed an association between 30-day mortality and central venous catheter (CVC) removal at any time, high Pitt bacteremia score (PBS), and high Charlson comorbidity index (CCI). Multivariate Cox analysis found that high PBS was the only independent predictor of 30-day mortality; subsequent multivariate Cox regression demonstrated that early CVC removal significantly reduced 30-day mortality. Candida species distribution and antifungal susceptibility profile in our hospital remained similar from 2013 to 2021. Early CVC removal may improve candidemia outcomes.

Early removal of central venous catheter may not impact the in-hospital mortality in patients with acute leukemia.

Central venous catheters (CVCs) are generally required for chemotherapy in patients with acute leukemia, but catheter-related infection is one of the common causes of neutropenic fever. We investigated the in-hospital mortality according to early removal of CVCs and the factors influencing the mortality in patients with acute leukemia undergoing remission induction chemotherapy. This study retrospectively analyzed the hospital record data of 278 patients with acute leukemia treated with non-tunneled CVCs and remission induction chemotherapy in a single institution. Bloodstream infection was more common (p < 0.0001) and median peak C-reactive protein (CRP) levels after neutropenic fever were significantly higher (23.3 vs. 14.5mg/dl, p = 0.003) in the group with early removal than in the group with maintenance of the CVC. Multivariate analysis of the patients revealed a significant decrease in the mortality with female gender (odds ratio (OR): 0.19, 95% confidence interval (CI): 0.06-0.54, p = 0.002) and a significant increase in the mortality according to the peak CRP (OR 1.12, 95% CI: 1.07-1.17, p < 0.0001). By contrast, early removal of the CVC had no significant effect on the mortality (OR = 1.16, 95% CI: 0.54-2.47, p = 0.706) in univariate analysis. Furthermore, subsequent bloodstream infection after clinical decision for maintenance or early removal of the CVC was confirmed more frequently in the group with early removal (early removal, 22.6%; maintenance, 7.6%, p < 0.0001). Early removal of the CVC had no benefit regarding the mortality and prophylaxis of bloodstream infection in patients with acute leukemia undergoing remission induction chemotherapy. Therefore, maintaining a CVC for as long as possible may be considered, if catheter-related bloodstream infection is not strongly suspected.

Risk of pulmonary emboli after removal of an upper extremity central catheter associated with a deep vein thrombosis

AbstractStandard treatment of catheter-associated upper extremity deep vein thrombosis (UE-DVT) is anticoagulation, although catheters are often removed for this indication. The optimal time for catheter removal and whether the act and/or timing of catheter removal is associated with pulmonary embolism (PE) remain unknown. A retrospective cohort study was performed at 8 participating institutions through the Venous thromboEmbolism Network US. Patients with hematologic malignancies and central venous catheter (CVC)–associated UE-DVT were included from 1 January 2010 through 31 December 2016. The primary outcome was objectively confirmed PE within 7 days of UE-DVT diagnosis in anticoagulated patients comparing early (≤48 hours) vs delayed (>48 hours) catheter removal. A total of 626 patients were included, among whom 480 were treated with anticoagulation. Among anticoagulated patients, 255 underwent early CVC removal, while 225 had delayed or no CVC removal; 146 patients received no anticoagulation, among whom 116 underwent CVC removal alone. PE within 7 days occurred in 2 patients (0.78%) with early removal compared with 1 patient (0.44%) with delayed or no CVC removal (P > .9). PE or any cause of death within 7 days occurred in 3 patients in both the early removal (1.18%) and delayed/no removal (1.33%) groups (P > .9). In patients treated with CVC removal only (no anticoagulation), there were no PEs but 3 deaths within 7 days. In patients with hematological malignancy and CVC-associated UE-DVT, early removal of CVCs was not associated with an increased risk of PE compared with delayed or no removal.

Management of enterococcal central line-associated bloodstream infections in patients with cancer

ObjectiveEnterococcus species are the third most common organisms causing central line-associated bloodstream infections (CLABSIs). The management of enterococcal CLABSI, including the need for and timing of catheter removal, is not well defined. We therefore conducted this study to determine the optimal management of enterococcal CLABSI in cancer patients.MethodsWe reviewed data for 542 patients diagnosed with Enterococcus bacteremia between September 2011 to December 2018. After excluding patients without an indwelling central venous catheter (CVC), polymicrobial bacteremia or with CVC placement less than 48 h from bacteremia onset we classified the remaining 397 patients into 3 groups: Group 1 (G1) consisted of patients with CLABSI with mucosal barrier injury (MBI), Group 2 (G2) included patients with either catheter-related bloodstream infection (CRBSI) as defined in 2009 Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection by the Infectious Diseases Society of America (IDSA) or CLABSI without MBI, and Group 3 (G3) consisted of patients who did not meet the CDC criteria for CLABSI. The impact of early (< 3 days after bacteremia onset) and late (3–7 days) CVC removal was compared. The composite primary outcome included absence of microbiologic recurrence, 90-day infection-related mortality, and 90-day infection-related complications.ResultsAmong patients in G2, CVC removal within 3 days of bacteremia onset was associated with a trend towards a better overall outcome than those whose CVCs were removed later between days 3 to 7 (success rate 88% vs 63%). However, those who had CVCs retained beyond 7 days had a similar successful outcome than those who had CVC removal < 3 days (92% vs. 88%). In G1, catheter retention (removal > 7 days) was associated with a better success rates than catheter removal between 3 and 7 days (93% vs. 67%, p = 0.003). In non-CLABSI cases (G3), CVC retention (withdrawal > 7 days) was significantly associated with a higher success rates compared to early CVC removal (< 3 days) (90% vs. 64%, p = 0.006).ConclusionCatheter management in patients with enterococcal bacteremia is challenging. When CVC removal is clinically indicated in patients with enterococcal CLABSI, earlier removal in less than 3 days may be associated with better outcomes.Based on our data, we cannot make firm conclusions about whether earlier removal (< 3 days) could be associated with better outcomes in patients with Enterococcal CLABSI whose CVC withdrawal is clinically indicated. In contrast, it seemed that catheter retention was associated to higher success outcome rates. Therefore, future studies are needed to clearly assess this aspect.

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

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

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.

Clinical impacts of delayed central venous catheter removal according to the severity of comorbidities in patients with candidaemia

The effects of early central venous catheter (CVC) removal on the clinical outcomes of patients with candidaemia remain controversial. This study evaluated the impact of delayed CVC removal on mortality according to the severity of comorbidities in patients with candidaemia. Patients with candidaemia in a tertiary care hospital between January 2010 and December 2017 were included retrospectively. The severity of comorbidities was classified as low [Charlson Comorbidity Index (CCI) score ≤3] or high (CCI score ≥4). Cases with removal of CVC >2 days after the onset of candidaemia or without CVC removal were classified as having delayed CVC removal. In total, 239 patients with candidaemia were included, excluding 18 who died within 2 days of onset of candidaemia. Of these, 149 had low CCI scores and 90 had high CCI scores. Septic shock [adjusted odds ratio (aOR)=9.5] and delayed CVC removal (aOR=4.7) were significantly associated with increased 30-day mortality, whereas Candida parapsilosis infection (aOR=0.2) and cerebrovascular disease (aOR=0.3) were associated with decreased 30-day mortality, in patients with low CCI scores. Septic shock (aOR=13.0) was the only risk factor for 30-day mortality in those with high CCI scores. Delayed CVC removal was associated with increased 30-day mortality in patients with low CCI scores (50.0% vs 20.3%; P=0.001), but not in those with high CCI scores (50.0% vs 47.9%; P=0.87). Early CVC removal may improve the survival of patients with candidaemia and low CCI scores, but no such protective effect was evident in those with high CCI scores.

Clinical impact of delayed catheter removal for patients with central-venous-catheter-related Gram-negative bacteraemia

Gram-negative bacteria are increasingly the cause of catheter-related bloodstream infection (CRBSI), and the prevalence of multi-drug-resistant strains is rising rapidly. This study evaluated the impact of delayed central venous catheter (CVC) removal on clinical outcomes in patients with Gram-negative CRBSI. Between January 2007 and December 2016, patients with Gram-negative bacteraemia and CVC placement, from two tertiary care hospitals, were included retrospectively. Cases with CVC removal more than three days after onset of bacteraemia or without CVC removal were classified as having delayed CVC removal. In total, 112 patients were included. Of these, 78 had CRBSI (43 definite and 35 probable) and 34 had Gram-negative bacteraemia from another source (non-CRBSI). Enterobacteriaceae were less common pathogens in patients with CRBSI than in patients with non-CRBSI (11.5% vs 41.3%; P<0.001). Delayed CVC removal was associated with increased 30-day mortality (40.5% vs 11.8%; P=0.01) in patients with Gram-negative CRBSI; this was not seen in patients with non-CRBSI (25.0% vs 14.3%; P>0.99). Delayed CVC removal [odds ratio (OR) 6.8], multi-drug-resistant (MDR) Gram-negative bacteraemia (OR 6.3) and chronic renal failure (OR 11.1) were associated with 30-day mortality in patients with CRBSI. The protective effect of early CVC removal on mortality was evident in the MDR group (48.3% vs 18.2%; P=0.03), but not in the non-MDR group (11.1% vs 0%; P=0.43). CVCs should be removed early to improve clinical outcomes in patients with Gram-negative CRBSI, especially in settings where MDR isolates are prevalent.

Impact of inappropriate antifungal therapy according to current susceptibility breakpoints on Candida bloodstream infection mortality, a retrospective analysis

BackgroundThe mortality of Candida Bloodstream Infection (CBSI) remains high. Antifungal susceptibility breakpoints were recently updated for Candida species, the impact remains unknown. In this study we evaluated the impact of inappropriate antifungal treatment according to recent breakpoints on 30-day mortality of CBSI.MethodsFrom June 2008 to July 2014, data on CBSI episodes from two tertiary-care centers, treated > 72 h were analyzed. Antifungal therapy and 30-day mortality were registered. Inappropriate antifungal treatment according to current Clinical & Laboratory Standards Institute (CLSI) breakpoints was adjusted with 30-day mortality-related co-variates.ResultsOne hundred forty-nine episodes of CBSI were analyzed. The most frequent species were: C. albicans (40%), C. tropicalis (23%) and C. glabrata complex (20%). According to the 2012 CLSI, 10.7% received inappropriate treatment. The 30-day mortality was 38%; severe sepsis [Odds ratio (OR) 3.4; 95% CI 1.3–8.4], cirrhosis (OR 36; 95% CI 12.2–605), early central venous catheter removal (OR 0.23; 95% CI 0.08–0.66) and previous antifungal therapy (OR 0.15; 95%CI 0.03–0.62), were associated with 30-day mortality by multivariate analysis. Inappropriate antifungal treatment was not (OR 0.19; 95% CI 0.03–1.2).ConclusionsAppropriate antifungal therapy according to CLSI 2012 did not have an impact on mortality. Mortality of CBSI remains high due to disease severity and comorbidities; early antifungal therapy and catheter removal may reduce it.

A3 for Central Line-Associated Blood Stream Infections

SESSION TITLE: Quality Improvement 1 SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: An estimated 30,000 central line associated blood stream infections (CLABSIs) occur in U.S. Intensive Care Units (ICUs) each year. Patient mortality rates associated with CLABSI range from 12-25% and the cost of CLABSIs ranges from $3,700 to $36,000 per episode of care. To address this issue, we collaborated with hospital management to create a multidisciplinary team to enhance the care of patients with central venous catheters (CVCs) by using A3. A3 is a problem solving and continuous improvement approach first employed by Toyota and based on Edward Denning’s PDSA (Plan-Do-Study-Act).We implemented an A3 problem solving methodology in order to systematically reduce CLABSI among the medical and surgical ICUs. METHODS: A review of CLABSI related events across the various adult ICUs was performed. Initial and target states were established. The goal was to achieve a zero CLABSI rate by standardizing workflow for insertion, implementing strict guidelines for maintenance, and emphasizing early removal of CVCs. Gap analysis was used to identify multiple areas for improvement, which fell into five major categories: workflow, education, documentation, assessment and visual management. During subsequent monthly meetings, multiple small experiments were developed and implemented. Some of the products of these experiments include the creation of standardized central line insertion and maintenance checklists, a CVC insertion and maintenance audit tool, and a decision algorithm for line insertion and maintenance. RESULTS: We reviewed a total of 14,960 ICU patient days. Mean patient-days per month was 298 (range 210-379). Following the implementation of insertion and maintenance checklists in ICUs, we were able bring down our CLABSI Rate (CLABSI events /1000 patient days) from 2.25 to 0.00 to achieve our target goal of zero. CLABSI rates were reduced by 100% among adult ICU patients (p<0.001). Despite emphasis to reduce the use of central lines by early removal and consideration of alternative access, the device utilization ratio (defined as device utilization days divided by patient days) remained relatively constant (mean 0.30; range 0.23-0.39). These rates were sustained over the next nine months and checklists are permanently embedded in ICU work protocol. CONCLUSIONS: Our data demonstrates the effectiveness of the A3 approach for improving quality and safety among the different ICUs. Using this methodology, we were able to serially introduce several interventions that acted synergistically to eliminate CLABSI in the ICU. CLINICAL IMPLICATIONS: A3 provides an effective appraoch to problem solving and can be used in clinical setting to decrease and sustain lower CLABSI rates. DISCLOSURE: The following authors have nothing to disclose: Sikander Zulqarnain, Anton Dela Cruz, Gem Snagg, Raymonde Elysee, Jacqueline Syrus, Samir Fahmy No Product/Research Disclosure Information

Can Early Removal of Central Venous Catheter Influence Duration of Fever in Febrile Neutropenic Patients with Acute Myeloid Leukemia?

Background: Febrile neutropenia is considered a medical emergency and generally prompts immediate hospitalization. For this reason, many physicians and researchers have tried some attempts to reduce the duration of febrile neutropenia. Patients with hematologic disorders frequently require the insertion of medium or long-term central venous catheters (CVCs) for stem-cell transplantation, the administration of chemotherapy, or transfusion of blood products. We have already known that the CVC is a major source of bloodstream infections in the neutropenic patients, but, there have been no reports about the duration of febrile neutropenia in the cases with early removal of CVCs except for catheter-related blood stream infections (CRBSIs). In this study, we want to investigate the factors influencing the duration of febrile neutropenia including early removal of CVCs except for CRBSIs in the patients diagnosed with acute myeloid leukemia.Methods: A total of 161 central catheter insertion cases with febrile neutropenia except for CRBSIs in 102 patients were eligible for analysis. CRBSI was defined as the same microorganism grown from at least one percutaneous blood culture and from a culture of the catheter tip (>15 colony-forming units), or a growth of microbes from blood sample drawn from a catheter hub at least 2 hours before microbial growth was detected in a blood sample obtained from a peripheral vein. Patients with blood stream infection (BSI) were defined as those with clinical signs of infection and the microorganism grown from at least one percutaneous blood culture without detecting microorganism from a culture of the catheter tip or from blood sample drawn from a catheter hub. The early removal of CVCs was defined as the removal of CVCs before 21 days from the insertion date of CVC. Duration of fever was investigated according to age, gender, body mass index (BMI), type of chemotherapy, presence of baseline fever, presence of BSI and/or early removal of central catheter by the Kaplan-Meier method and the Log Rank method. Statistical analysis was performed using SPSS software version 13.0 (IBM, Armonk, NY, USA).Results: Baseline characteristics of total cases were described in Table 1. Univariate and multivariate analysis about duration of fever are summarized in Table 2 and Table 3. Age, type of chemotherapy, presence of baseline fever and early removal of central catheter were significant in the univariate analysis and age, type of chemotherapy and early removal of central catheter were also significant, but, baseline fever was not significant in the multivariate analysis. Furthermore, duration of fever in the remission induction chemotherapy was significantly longer than consolidation chemotherapy, on the other hand, not significantly longer than salvage chemotherapy.Conclusion : In this retrospective study, age, type of chemotherapy, presence of baseline fever and early removal of central catheter were significant in the univariate analysis. They were equally significant in the multivariate analysis, only except for the presence of baseline fever. It is noteworthy that the cases with early removal of CVCs except for CRBSIs had significant reduction of the duration of febrile neutropenia. We may need active consideration about the early removal of CVCs in the acute myeloid leukemia patients with febrile neutropenia for the purpose of reduction of the duration of febrile neutropenia. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Nosocomial Bloodstream Infection Due to Candida spp. in China: Species Distribution, Clinical Features, and Outcomes.

To investigate the distribution of Candida spp., predictors of mortality, and effects of therapeutic measures on outcomes of nosocomial bloodstream infection (BSI) due to Candida spp. This retrospective, population-based study enrolled adult patients with Candida nosocomial BSI from January 2010 to December 2014 in one tertiary care hospital. The demographics, comorbidities, species distribution, risk factors, and effects of antifungal treatment were assessed. In total, 190 episodes of Candida BSI were identified. The most prevalent species was C. albicans (38.9%), followed by C. parapsilosis (23.2%) and C. tropicalis (20.5%). In vitro susceptibility testing showed that 88.9% of Candida isolates were susceptible to fluconazole. The 30-day hospital mortality was 27.9%, while the early mortality (within 7days) was 16.3%. In a multivariate regression analysis, the Acute Physiology and Chronic Health Evaluation II score [odds ratio (OR) 1.23; 95% confidence interval (CI) 1.080-1.390; P=0.002] and severe sepsis or septic shock (OR 15.35; 95% CI 2.391-98.502; P=0.004) were independently correlated with early mortality. Severe sepsis or septic shock (OR 24.75; 95% CI 5.099-120.162; P<0.001) was an independent risk factor for 30-day mortality, while proven catheter-related candidemia (OR 0.16; 95% CI 0.031-0.810; P=0.027) was a positive factor for 30-day mortality. Early central venous catheter removal and adequate antifungal treatment were closely related to decreased mortality in patients with primary candidemia. The proportion of candidemia caused by C. albicans was lower than that caused by non-albicans species. The severity of illness influenced early mortality, and the origin of the central venous catheter remarkably affected 30-day mortality.

Central Venous Catheter Retention and Mortality in Children With Candidemia: A Retrospective Cohort Analysis.

Candidemia causes significant morbidity and mortality among children. Removal of a central venous catheter (CVC) is often recommended for adults with candidemia to reduce persistent and metastatic infection. Pediatric-specific data on the impact of CVC retention are limited. A retrospective cohort study of inpatients <19 years with candidemia at the Children's Hospital of Philadelphia between 2000 and 2012 was performed. The final cohort included patients that had a CVC in place at time of blood culture and retained their CVC at least 1 day beyond the blood culture being positive. A structured data collection instrument was used to retrieve patient data. A discrete time failure model, adjusting for age and the complexity of clinical care before onset of candidemia, was used to assess the association of CVC retention and 30-day all-cause mortality. Two hundred eighty-five patients with candidemia and a CVC in place at the time of blood culture were identified. Among these 285 patients, 30 (10%) died within 30 days. Central venous catheter retention was associated with a significant increased risk of death on a given day (odds ratio, 2.50; 95% confidence interval, 1.06-5.91). Retention of a CVC was associated with an increased risk of death after adjusting for age and complexity of care at candidemia onset. Although there is likely persistence of unmeasured confounding, given the strong association between catheter retention and death, our data suggest that early CVC removal should be strongly considered.

Candida tropicalis bloodstream infection: Incidence, risk factors and outcome in a population-based surveillance

To assess the current clinical features and determinants of outcome of Candida tropicalis bloodstream infection (BSI). A population-based surveillance on Candida BSI was conducted from May 2010 to April 2011 in 29 Spanish hospitals. Antifungal susceptibility testing (EUCAST methodology) was centrally performed. The characteristics and outcome of C. tropicalis BSI episodes were compared with those due to other species. Fifty-nine out of 752 episodes (7.8%) were due to C. tropicalis (annual incidence: 0.62 cases per 100,000 population). Resistance to fluconazole and voriconazole was found in 23.2% and 26.8% of isolates. Breakthrough BSI occurred in 10.5% of episodes. Risk factors for C. tropicalis BSI were age (odds ratio [OR]: 1.01; P-value = 0.05), underlying leukaemia (OR: 4.77; P-value = 0.001) and chronic lung disease (OR: 2.62; P-value = 0.002). There were no differences in clinical failure (persistent BSI for ≥72 h after initiation of therapy and/or 30-day all-cause mortality) between C. tropicalis (39.6%) and non-C. tropicalis groups (45.6%). The appropriateness of antifungal therapy or the fluconazole MIC values had no significant impact on outcome, whereas early central venous catheter removal exerted a protective effect. C. tropicalis BSI was associated with advanced age, haematological malignancy and respiratory comorbidity. We found no correlation between the unexpectedly high resistance rate to azoles observed and outcome.

Do clinicians know which of their patients have central venous catheters?: a multicenter observational study.

Complications associated with central venous catheters (CVCs) increase over time. Although early removal of unnecessary CVCs is important to prevent complications, the extent to which clinicians are aware that their patients have a CVC is unknown. To assess how often clinicians were unaware of the presence of triple-lumen catheters or peripherally inserted central catheters (PICCs) in hospitalized patients. Multicenter, cross-sectional study. 3 academic medical centers in the United States. Hospitalized medical patients in intensive care unit (ICU) and non-ICU settings. To ascertain awareness of CVCs, whether a PICC or triple-lumen catheter was present was determined; clinicians were then queried about device presence. Differences in device awareness among clinicians were assessed by chi-square tests. 990 patients were evaluated, and 1881 clinician assessments were done. The overall prevalence of CVCs was 21.1% (n=209), of which 60.3% (126 of 209) were PICCs. A total of 21.2% (90 of 425) of clinicians interviewed were unaware of the presence of a CVC. Unawareness was greatest among patients with PICCs, where 25.1% (60 of 239) of clinicians were unaware of PICC presence. Teaching attendings and hospitalists were more frequently unaware of the presence of CVCs than interns and residents (25.8% and 30.5%, respectively, vs. 16.4%). Critical care physicians were more likely to be aware of CVC presence than general medicine physicians (12.6% vs. 26.2%; P=0.003). Awareness was determined at 1 point in time and was not linked to outcomes. Patient length of stay and indication for CVC were not recorded. Clinicians are frequently unaware of the presence of PICCs and triple-lumen catheters in hospitalized patients. Further study of mechanisms that ensure that clinicians are aware of these devices so that they may assess their necessity seems warranted. None.

Initial Use of Echinocandins Does Not Negatively Influence Outcome in Candida parapsilosis Bloodstream Infection: A Propensity Score Analysis

Concerns have arisen regarding the optimal antifungal regimen for Candida parapsilosis bloodstream infection (BSI) in view of its reduced susceptibility to echinocandins. The Prospective Population Study on Candidemia in Spain (CANDIPOP) is a prospective multicenter, population-based surveillance program on Candida BSI conducted through a 12-month period in 29 Spanish hospitals. Clinical isolates were identified by DNA sequencing, and antifungal susceptibility testing was performed by the European Committee on Antimicrobial Susceptibility Testing methodology. Predictors for clinical failure (all-cause mortality between days 3 to 30, or persistent candidemia for ≥72 hours after initiation of therapy) in episodes of C. parapsilosis species complex BSI were assessed by logistic regression analysis. We further analyzed the impact of echinocandin-based regimen as the initial antifungal therapy (within the first 72 hours) by using a propensity score approach. Among 752 episodes of Candida BSI identified, 200 (26.6%) were due to C. parapsilosis species complex. We finally analyzed 194 episodes occurring in 190 patients. Clinical failure occurred in 58 of 177 (32.8%) of evaluable episodes. Orotracheal intubation (adjusted odds ratio [AOR], 2.81; P = .018) and septic shock (AOR, 2.91; P = .081) emerged as risk factors for clinical failure, whereas early central venous catheter removal was protective (AOR, 0.43; P = .040). Neither univariate nor multivariate analysis revealed that the initial use of an echinocandin-based regimen had any impact on the risk of clinical failure. Incorporation of the propensity score into the model did not change this finding. The initial use of an echinocandin-based regimen does not seem to negatively influence outcome in C. parapsilosis BSI.

Factors prompting early central venous catheter removal from cancer patients with candidaemia

We evaluated clinical factors associated with early central venous catheter (CVC) removal in cancer patients with candidaemia who survived >3 days after the index blood culture. This was a retrospective cohort study from a previous candidaemia database conducted between January 2001 and June 2005. Eligible patients were those whose catheters were removed. Those who died in the first 72 h were excluded. Early CVC removal was defined as withdrawal in the first 72 h. We enrolled 164 patients with a 10.4% mortality rate. Multivariate analysis showed temporary non-tunnelled catheter type (odds ratio 5.06; 95% confidence interval 2.16-11.83) as the only variable associated with early removal. Among the 84 episodes judged not catheter-related, 52 CVCs were removed due to the need for further cancer treatment. No differences in mortality were seen among patients with early or late catheter removal. Stratified analysis showed a survival benefit (p = 0.04) of early removal among patients with a Karnofsky performance status score >60. The study shows a propensity to immediately remove short-term catheters and a tendency for early removal in patients undergoing active cancer treatment. There was no benefit of early catheter removal with regard to overall mortality. The favourable impact of early over late removal on survival among patients without significant illness merits further investigation.

Early Removal of Central Venous Catheter in Patients with Candidemia Does Not Improve Outcome: Analysis of 842 Patients from 2 Randomized Clinical Trials

Patients with candidemia frequently have a central venous catheter (CVC) in place, and its early removal is considered the standard of care. We performed a subgroup analysis of 2 phase III, multicenter, double-blind, randomized, controlled trials of candidemia to examine the effects of early CVC removal (within 24 or 48 h after treatment initiation) on the outcomes of 842 patients with candidemia. Inclusion criteria were candidemia, age >16 years, CVC at diagnosis, and receipt of 1 dose of the study drug. Six outcomes were evaluated: treatment success, rates of persistent and recurrent candidemia, time to mycological eradication, and survival at 28 and 42 days. Univariate and multivariate analyses were performed, controlling for potential confounders. In univariate analysis, early CVC removal did not improve time to mycological eradication or rates of persistent or recurrent candidemia but was associated with better treatment success and survival. These benefits were lost in multivariate analysis, which failed to show any beneficial effect of early CVC removal on all 6 outcomes and identified Acute Physiology and Chronic Health Evaluation II score, older age, and persistent neutropenia as the most significant variables. Our findings were consistent across all outcomes and time points (removal within 24 or 48 h and survival at 28 and 42 days). The median time to eradication of candidemia was similar between the 2 study groups. In this cohort of 842 adults with candidemia followed up prospectively, early CVC removal was not associated with any clinical benefit. These findings suggest an evidence-based re-evaluation of current treatment recommendations.

Vancomycin resistant enterococci (VRE) infections in hematopoietic stem cell transplant (HSCT) recipients

7036 Background: VRE blood stream infections (BSI) pose significant hazards to HSCT patients. Risk factors predisposing patients for a relatively nonpathogenic organism to become bacteremic include immune suppression, neutropenia, renal failure, antibiotic exposure, indwelling catheters, and VRE colonization. Some studies suggest that a VRE BSI is simply a marker of primary disease severity or an indicator of poor outcome, while other data demonstrate VRE BSI as an independent predictor of mortality. Methods: We performed a retrospective chart analysis of HSCT patient data using the electronic medical record and written charts using a standard data collection tool from February 1994 to October 2008. Vancomycin susceptibility was determined using the Dade Berhing panel. Results: We noted 625 infections in 385 HSCT patients; 26 patients developed 27 VRE infections over the course of 15 years. All isolates were Enterococcus faecium and not polymicrobial. Host characteristics included mean age of 49.5 yrs, all had central venous catheters, and 26 received linezolid treatment. Persistent infection was identified in 11 patients with central access removal in 4. VRE colonization was identified in stool (18 patients) and urine (5 patients) and 4 patients had a prior VSE BSI. 16 patients received vancomycin within 30 days of developing VRE BSI. 21 patients were neutropenic (mean duration15 days). 8 patients were not receiving immunosuppressants during time of bacteremia. Gastrointestinal endoscopy was identified in 6 patients prior to BSI. 16 patients died during the hospitalization. Conclusions: VRE accounted directly or indirectly for 13 of 16 deaths during incident hospitalization. In this population, blood, urine, stool surveillance is warranted to prevent morbidity/mortality related to developing a VRE BSI. Prolonged neutropenia was associated with development of a VRE BSI prophylactic granulocyte transfusion might be useful to prevent BSI. In contrast to prior studies, many patients were not receiving immunosuppressants and did not undergo GI instrumentation. VRE BSI prevention should include identifying patients with urinary or stool colonization, appropriate isolation and early central venous catheter removal if a VRE BSI is identified. No significant financial relationships to disclose.