Episodes Of Catheter-related Bloodstream Infection Research Articles

Can vancomycin lock therapy extend the retention time of infected long-term catheters?

We assessed the success rate of vancomycin catheter lock therapy (VLT) in combination with systemic antimicrobials in patients with staphylococcal catheter-related bloodstream infection (C-RBSI). Over a 6-year period, we retrospectively collected clinical and microbiological data from patients with long-term central venous catheters and staphylococcal C-RBSI who were treated with systemic antimicrobials and VLT. We then assessed the success rate of VLT based on two criteria: 1) catheter retention time>3months and 2) catheter in place until end of use. We found 217 staphylococcal C-RBSI episodes, 115 (53.0%) of which were managed with conservative therapy. Of these, 76 (66.1%) were treated with VLT (85.5% coagulase-negative staphylococci and 14.5% Staphylococcus aureus). The success rate of VLT was 42.1% with criterion 1 and 71.1% with criterion 2. We did not find statistically significant differences between success and failure in the majority of the clinical data recorded. We only found differences for crude mortality in criterion 1 and for parenteral nutrition in criterion 2. The success of catheter retention using VLT was moderate, reaching slightly more than 70% when the catheter was kept in place until the end of use.

The hidden cost of catheter related blood stream infections in patients on parenteral nutrition

Parenteral nutrition (PN) is a valuable and life-saving treatment for patients with intestinal failure. While its use is increasing, it has been demonstrated to be a risk factor for intravenous catheter-related blood stream infection (CRBSI) - a significant, serious and potentially fatal complication of PN use. CRBSI can have serious secondary consequences for patients, though, there is a paucity of literature describing these. The aim of this study is to audit the incidence of, and evaluate the consequences of, complications associated with CRBSI. Medical records were examined for all parenterally fed patients diagnosed with a CRBSI from 01/01/16 to 31/12/17 in a UK tertiary referral centre for patients requiring intravenous nutritional support. Patients were identified prospectively; data relating to the infection and complications was collected retrospectively. 114 episodes of CRBSI were recorded in 80 patients. 57 occurred during an inpatient admission, 57 occurred in the community and resulted in admission. 21 different adverse events occurred as a result of the CRBSI. The complications identified were varied with the most common being acute kidney injury, deranged electrolytes and urinary tract infections. Other significant complications included DVT, pulmonary abscess and infective endocarditis. 35% of episodes resulted in delayed discharge and 12% required escalation to a critical care bed. The financial impact is estimated at over £800,000 per annum. The findings demonstrate a plethora of complications which can arise following CRBSI, which pose a significant health risk to parenterally fed patients who already have reduced physiological reserve. Moreover, these findings represent additional financial and resource burden to the health service. The adverse events resulting from CRBSIs should, therefore, be audited to improve outcomes: well-resourced specialist centres are best placed to provide this service.

Microbiology and prevalence of E2SKAPE-resistant strains in catheter-related bloodstream infections in patients with cancer

Central venous catheters (CVCs) are essential for treating cancer patients, but infection is a risk associated with their use, particularly by multidrug-resistant (MDR) bacteria. The aim of this study was to describe the microbiology of catheter-related bloodstream infections (CRBSIs) in cancer patients and to compare the prevalence of MDR ESKAPE microorganisms (Enterococcus faecium, Staphylococcus spp, Klebsiella spp, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp) plus Escherichia coli (E2SKAPE). Based on data from 2013 to 2015 from a prospective survey of CRBSIs by the intravenous therapy team, we describe the microbiology and compare the prevalence of MDR E2SKAPE strains between hospitalized patients and outpatients. A total of 469 episodes of CRBSI were diagnosed: 261 (62%) were in women; 87 (18.6%) occurred in hospitalized patients, and 382 (81.4%) in ambulatory patients; 27.5% of patients had a hematologic malignancy and 72.5% a solid tumor. The median time between CVC insertion and CRBSI was 116 days (interquartile range [IQR], 48-207). The most common bacteria isolated were Staphylococcus epidermidis (18.1%), S aureus (10.9%), E coli (7.7%), and Klebsiella spp (8.6%). E2SKAPE accounted for 35.6%. Methicillin-resistant Staphylococcus aureus (MRSA) (odds ratio [OR], 16.4; 95% confidence interval [CI], 1.6-114; P = .01), extended-spectrum beta-lactamase (ESBL) Klebsiella spp (OR, 26; 95% CI, 2-286; P = .007), and ESBL E coli (OR, 26; 95% CI, 2-286; P = .007) were significantly more frequently isolated from hospitalized vs ambulatory patients. MRSA, ESBL E. coli and ESBL Klebsiella spp were significantly more frequently isolated from hospitalized patients with CRBSI.

P1.53: Are Femoral Tunnelled Central Venous Catheters safe to use for HPN?

Background: Patients with Intestinal Failure (IF) require reliable intravenous access for provision of Parenteral Nutrition. Venous access for Home Parenteral Nutrition (HPN) patients with Type 3 IF can be compromised due to thrombosis of deep veins. Preferred choice of veins for central venous catheter are the supra cardiac veins. Femoral tunnelled CVC are avoided due to concerns of catheter related blood stream infection (CRBSI) and are considered as a last resort when all other thoracic CVC access is exhausted. We assess the outcomes of tunnelled femoral catheters in our cohort of HPN patients. Methods: We did a retrospective analysis of a prospectively collected data of all HPN patients and venous access from January 2013 to December 2018 managed at a National HPN Unit. The details of venous access, complications of CVC, sex and details of stoma extracted from database. Results: In a cohort of 9 HPN patients with tunnelled femoral CVC, 6 were females and 3 were males leading to a total of 8418 days. A total 3 episodes of CRBSI were recorded in 1 patient. All of the 3 episodes (methicillin – sensitive Staphylococcus aureus (MSSA), Escherichia Coli and CNS) were successfully salvaged. The average no of days for femoral CVC was 935 days. The rate of CRBSI was 0.35 per 1000 catheter days. 8 patients had stoma or open abdominal wound. There were no episodes of ipsilateral femoral DVT. The CVC was replaced for 2 patients due to fracture of CVC. Conclusion: Tunnelled femoral CVC CRBSI rate (0.35)is comparable to thoracic veins CVC CRBSI rate(0.31) in our unit. Furthermore femoral access could be considered as a reliable access to provide HPN. It may be considered as an option if more than 2 thoracic deep veins are occluded to prevent complete occlusion of SVC. We feel tunnelled femoral CVC is a safe option to consider for HPN

SAT-052 VIGILANCE, SURVEILLANCE AND EDUCATION REDUCES RATES OF TUNNELLED HAEMODIALYSIS CATHETER-RELATED BLOODSTREAM INFECTIONS

Tunnelled haemodialysis catheter-related bloodstream infections (CRBSI) are associated with significantly increased patient morbidity, mortality and health care costs. A policy-driven systematic approach to haemodialysis catheter care, vigilance and surveillance, and focussed education of staff, is a mandatory part of implementing best practice, optimising patient outcomes and minimising the health care burden. Infection rates of < 1 infection per 1000 catheter-days is considered an excellent benchmark to target (REF - Semin Dial. 2008; 21(6):528-38). International guidelines and studies address infection prevention procedures but day-to-day practices and procedures vary, and account for a range of infection rates between clinical centres. Our vigilance and surveillance program for infection rates noted an increase in CRBSI at our clinical centre. An evaluation and assessment of our catheter care techniques and a mandatory education program to standardise practices and procedures was implemented. Following implementation of an infection surveillance program, an increase in infection rates was noted (graph 1). A policy to implement in-centre standardised catheter care and staff education was introduced. Analysis of CRBSI was performed before and after the policy change. Senior haemodialysis nursing staff evaluated tunnelled haemodialysis catheter care techniques by piloting a competency assessment program. Standard practice included (a) the use of personal protective equipment and aseptic technique with connection and disconnection of tunnelled haemodialysis catheters (b) the application of dressings with topical antimicrobial preparations (chlorhexidine solution) applied to the insertion sites. The trial of a competency assessment ensured systematic and stringent practices that were standardised across our clinical centre. The mandatory use of an insertion site observation chart was also instituted. This chart acted as “trigger” for closer follow up, medical review, and microbiological cultures of the insertion site or blood cultures from the catheter lumen if infection was clinically suspected. The competency pilot was introduced through formal education sessions, mandated reminders at every nursing handover and regular electronic-mail reminders to all haemodialysis nurses. Rates of CRBSI decreased with the introduction of standardised tunnelled haemodialysis catheter care practices and procedures from 2.1 CRBSI episodes per 1000 catheter-days to 1.3 per 1000 catheter-days in the first six months of implementation. This demonstrates a fall in infection rates trending towards a desirable target of excellence (<1 infection per 1000 catheter-days). Our Quality Assurance program will maintain continued monitoring, evaluation and improved practice changes. Centre-wide systematic evaluation and education of haemodialysis tunnelled catheter-care techniques dramatically reduced the incidence rates of CRBSI. The implementation of a formalised policy and annual competency assessment of catheter care, vigilance and surveillance and education is an effective method of improving the rates of CRBSI, patient care and outcomes.

P4.39: Citrate-taurolidine lock solution: impact on the incidence of catheter related bloodstream infections in children with intestinal failure receiving home parenteral nutrition

Introduction: The use of central venous catheters (CVC) for parenteral nutrition (PN) administration has increased survival rates and allowed patients with short bowel syndrome who are dependent on long-term PN to be discharged for home care. However, catheter related bloodstream infection (CRBSI) remains as a major complication of long-term PN and is associated to increased morbidity, mortality, length of stay and hospital costs. Several lock solutions have been used to prevent CVC contamination. Among them, the citrate-taurolidine solution (composed of 2% taurolidine and 4% citrate), which is unique by reducing the biofilm formation of bacterial cells and avoiding bacterial adhesion and clotting in the catheter. We aimed to identify the rates of CRBSI before and after the use of the citrate-taurolidine solution in de-hospitalized children receiving home PN. Methods: This was a prospective cohort study in 11 children with intestinal failure (IF), mean age 35.4 months (12.7), receiving home PN and followed-up at a center for intestinal rehabilitation between July 2015 and November 2018. The rate of CRBSI was calculated for each patient by the incidence density ratio, defined as number of infections per 1,000 catheter-days. The citrate-taurolidine solution began to be used from March 2017 onward. The primary outcome was the variation in the rate of CRBSI before and after use of citrate-taurolidine lock solution. Results: The median time on PN was 26.4 months (interquartile range 15.2 - 32.9). The mean number of catheter days per patient before and after taurolidine were 178 (interquartile range 32 - 85.5) and 238 (interquartile range 203 - 386) days, respectively. There were 13 episodes of CRBSI before and only one episode after the use of citrate-taurolidine line locks. The incidence density of pre-taurolidine CRBSI was 5.7 and of post-taurolidine was 0.3 per 1000 catheter days. The main microorganism identified was Staphylococcus epidermidis. Conclusion: The rate of CRBSI was greatly reduced after the citrate-taurolidine use; this lock solution should be the first choice in reducing CRBSI in children with IF receiving home PN.

Epidemiology of Infectious and Noninfectious Catheter Complications in Patients Receiving Home Parenteral Nutrition: A Systematic Review and Meta-Analysis.

Patients receiving parenteral nutrition (PN) as their primary source of nutrition are at high risk for both infectious and noninfectious catheter complications (catheter-related infections, catheter occlusion, and venous thrombosis). The aim of this review was to synthesize and evaluate what is known about catheter complications and prevention strategies in the PN population. Three electronic databases (Medline, Embase, and CINAHL) were screened for studies published between January 2012 and February 2019 regarding infectious and noninfectious catheter complications in patients receiving PN. Rates of infectious and noninfectious catheter complications, prevalence of causative pathogens, potential risk factors, and prevention strategies via the use of antimicrobial lock therapy (ALT) were assessed. Fifty-three catheter complication studies and 12 ALT studies were included. Studies were grouped by definition of complication: catheter-related bloodstream infections (CRBSI) or central line-associated bloodstream infections (CLABSI). Random effects summary rates per 1000 catheter days were 0.85 CRBSI episodes (95% CI 0.27-2.64) and 1.65 CLABSI episodes (95% CI 1.09-2.48). Use of taurolidine or ethanol ALT was efficacious in reducing infectious catheter complications; however, several studies had concerns for adverse mechanical complications. Potential risk factors for catheter complications were highly varied and often contradictory between studies. The rates of catheter complications were higher among catheterized patients receiving PN compared with nationally reported rates of complications in all catheterized patients. Risk factors for catheter complications need to be better understood for targeted prophylactic use of ALT. Future studies are warranted; however, they should be conducted using more standardized definitions and criteria.

Low Concentration Trisodium Citrate as a Non-inferior Locking Agent for Non-tunneled Dialysis Catheters in the Asian Setting.

Introduction:Unfractionated heparin is the commonly used catheter lock solution in patients with temporary dialysis catheters as hemodialysis access. The effectiveness of trisodium citrate as an alternate catheter lock agent has not been studied in Asian population.Methods:In this prospective quasi-experimental study, which included 180 patients with central venous dialysis catheter, patients were randomly allotted to citrate 4.67% and heparin 5000 units/ml arms in the ratio of 2:1. Baseline demographic and dialysis related data, incidence of catheter-related bloodstream infections, and mean catheter days in both the study cohorts were collected and compared. Formal cost analysis for citrate 4.67% use as catheter lock was done.Results:The mean age of the total study population was 50.49 ± 14.87 years. Sixty-six females (36.7%) and 80 (44.4%) diabetic patients were included in the study. The overall incidence of catheter-related bloodstream infection (CRBSI) was 11.11%. The majority had nontunneled dialysis catheters (95%; n = 114). On analyzing the data of patients with nontunneled catheters, it was found that the total number of catheter days for the citrate and heparin groups were 4,795 and 2,419 days, respectively. The number of CRBSI episodes per 1,000 catheter days for the citrate and heparin groups were 2.711 and 2.89, respectively. Citrate catheter lock cost only 6% of that of heparin lock.Conclusions:The incidence of catheter related bloodstream infections was comparable between the heparin and citrate 4.67% lock cohorts. The use of low concentration citrate as catheter lock was cost-effective when compared with heparin.

Is antibiotic lock therapy effective for the implantable longterm catheter-related bloodstream infections in children?

Tural Kara T, Özdemir H, Erat T, Yahşi A, Aysev AD, Taçyıldız N, Ünal E, İleri T, İnce E, Haskoloğlu Ş, Çiftçi E, İnce E. Is antibiotic lock therapy effective for the implantable long-term catheter-related bloodstream infections in children? Turk J Pediatr 2019; 61: 895-904. Catheter-related bloodstream infections (CRBSIs) are an important problem in pediatric patients with central venous catheters. This study aimed to determine the incidence of CRBSIs, responsible pathogens and outcomes of antibiotic lock treatment (ALT) in pediatric patients. Between January 2010 and November 2015 all hospitalized pediatric hematology, oncology and immunology patients diagnosed with CRBSIs were retrospectively analyzed. Seventy-eight CRBSI episodes were detected in 60 pediatric patients. The incidence of CRBSIs was 4.20/1000 catheter days. The most frequently detected pathogen was methicillin-resistant coagulase-negative Staphylococcus. Pseudomonas aeruginosa, Klebsiella spp., and Escherichia coli were other commonly isolated microorganisms. ALT was administered in 42 patients. The success rate of ALT was 81% (34/42). Catheter was removed without ALT in 36 episodes. Common reasons for catheter removal were sepsis and causative microorganisms which had high probability of biofilm formation. CRBSIs are an important cause of morbidity and mortality in pediatric patients. ALT is safe and effective. It is possible to obtain satisfactory results when ALT is used with intravenous systemic antibiotics for CRBSIs, though in some cases catheter removal is necessary. ALT helps to prevent unnecessary catheter removal in pediatric patients.

Infectious complications in home parenteral nutrition: A long-term study with peripherally inserted central catheters, tunneled catheters, and ports.

Home parenteral nutrition (HPN) has become a common therapy, with tunneled central venous catheters (CVCs) being the preferred route of administration. Peripherally inserted central catheters (PICCs) have been used increasingly, but whether they should be preferred over other types of CVCs is still controversial. The aim of this study was to evaluate catheter-related complications of CVC in patients receiving HPN. All patients treated at our center for HPN from 2007 to 2017 were prospectively included. A specialized intravenous therapy team took care of these patients. Catheter-related bloodstream infections (CRBSI) were confirmed with positive, simultaneous, differential blood cultures drawn through the CVC and peripheral vein and then semiquantitative or quantitative culture of the catheter tip. In all, 151 patients received HPN during the 11-y study period. Of these patients, 95 were women (63%) and 55 were men (37%), with a mean age of 58 ±13 y. Twenty-six were non-cancer patients (17%) and the remaining 125 patients had an underlying malignancy (83%). Regarding the CVC, 116 were PICCs, 18 Hickman, and 36 ports. Confirmed CRBSI per catheter-days showed 0.15 episodes per 1000 catheter-days for PICCs, 0.72 for Hickman, and 2.02 for ports. PICCs had less-confirmed CRBSIs per 1000 catheter-days than ports (φ = 0.54, P = 0.005), but no difference between PICCs and Hickman was found (φ = 0.32, P = 0.110). Confirmed episodes of CRBSI (2 versus 13%, χ2 = 6.625, P = 0.036) were more frequent with multilumen catheters. In our setting, single-lumen PICC and Hickman catheters showed low infectious complications.

Assessment of Intestinal Failure Associated Liver Disease according to different diagnostic criteria

Intestinal failure associated liver disease (IFALD) has been defined using numerous criteria; however the clinical relevance of these criteria has never been compared. We therefore aimed to evaluate the prevalence, incidence, evolution of IFALD diagnosed by different criteria and to assess any clinical features that may be associated with its occurrence. A cross sectional (CS) and retrospective study were carried out on adults on home parenteral nutrition (HPN) for chronic intestinal failure (CIF) managed at a single center. Inclusion criteria at CS: age ≥18 years, benign disease. Collected data included: patient demographics, CIF and HPN characteristics, episodes of central venous catheter related bloodstream infection (CRBSI). IFALD was diagnosed by 9 criteria based on liver function tests and liver ultrasound (US) imaging. IFALD diagnoses were categorized as steatosis (2 criteria), cholestasis (3 criteria) or fibrosis (2 criteria) and unclassified (2 criteria). Prevalence was assessed at CS and at starting HPN (baseline, BS). Evolution was assessed as change of IFALD between BS and CS. Incidence was calculated as patients who developed IFALD from BS to CS. A total of 113 patients were included. At CS, IFALD prevalence range in each diagnostic categories was: cholestasis 5-15%; steatosis 17-43%; fibrosis 10-20%; unclassified 7-38%. A 28.5% of patients did not have IFALD according to any criteria. Two cholestasis criteria and one fibrosis criterion were significantly (P<0.05) associated with a short bowel syndrome as the pathophysiological mechanism of CIF, HPN requirement and the number of CRBSI episodes. At BS, IFALD prevalence range was: cholestasis 13-40%; steatosis 27-90%; fibrosis 2-5%; unclassified 8-75%. The incidence range of IFALD was: cholestasis 0-7%; steatosis 0-39%; fibrosis 7-18%; unclassified 4-9%. IFALD steatosis diagnosed by US was the most frequent diagnosis at both CS prevalence and incidence assessments. Notably, IFALD criteria normalized in various percentages (2-70%), depending on the diagnostic categories, between BS and CS. This is the first study to systematically demonstrate that the frequency of IFALD varies greatly depending on diagnostic criteria used, confirming the need for a consensus definition to be used between different national and international IF units. IFALD can be present at HPN initiation but may resolve thereafter; further work is required to evaluate the factors associated with improvement.

Parenteral therapy and complications in patients with intestinal failure in a regional unit

Objective: To describe a cohort of patients with intestinal failure (IF) and tunnelled catheters in a regional IF unit, treatment and catheter-related complication rates, and to compare the quality of care with previously published results from specialised IF centres in Denmark.Methods: A retrospective chart review of an adult IF patient cohort receiving parenteral therapy through tunnelled catheters in a regional IF unit from 2005 to 2014. Demographics, indication, type and frequency of parenteral therapy, dwell time, cause of removal and complications were recorded.Results: Parenteral therapy was provided to 78 patients with a median age of 64 (25–86) years. Numbers increased from seven patients in 2005 to 40 in 2014. The cause of IF was surgical complications (33%), cancer (28%), inflammatory bowel disease (IBD, 15%) and other causes (24%). The median duration of parenteral therapy was 453 days (range: 16–3651 days). One hundred and forty-two tunnelled catheters were inserted. The incidence of catheter-related blood stream infection (CRBSI) was 1.51/1000 days (95% CI: 1.20–1.90) and the incidence of thrombosis was 0.10/1000 days (0.04–0.25). Seventy-two episodes of CRBSI occurred with 89 microorganisms cultured, the most common being coagulase-negative Staphylococcus (n = 25, 28%).Conclusion: The rate of CRBSI did not differ from larger centres in Denmark but the rate of thrombotic events was higher than expected. Parenteral therapy can safely and effectively be offered to patients with IF in smaller centres.

Short-course daptomycin lock and systemic therapy for catheter-related bloodstream infections: a retrospective cohort study in cancer patients with surgically implanted devices

Purpose: Few in vivo studies have been reported describing efficacy and duration of antibiotic lock therapy (ALT) with daptomycin (DPT) for long-term catheter-related bloodstream infections (CRBSI) due to coagulase-negative staphylococci (CoNS). We retrospectively analysed the efficacy of short-course ALT with DPT in combination with systemic treatment (ST) for CoNS-associated CRBSI in our hospital.Methods: Patients admitted for CoNS-associated CRBSI and treated with DPT as ALT and ST were retrospectively analysed. Success was defined as preservation of the catheter device 30 days after ending treatment. Catheter removal within 30 days of discontinuing treatment, for either microbiological documentation of CRBSI relapse or re-occurrence of unexplained fever, was considered as failure.Results: Among 7610 patients admitted to the Departments of Internal Medicine/Infectious Diseases and Pneumology in Cannes from January 2013 to November 2015, we identified 28 episodes of CoNS-associated CRBSI. Seven patients died of cancer during follow-up. Thus, 21 episodes were analysed among 20 patients (median age 67 years, 12 males, all treated for neoplasia and carrying a port-a-cath® device). Staphylococcus epidermidis was the main agent responsible for CRBSI. Median duration of systemic and ALT DPT was 3 days, in combination with rifampin for 4 days and then generally followed by a switch to oral drugs, most frequently cotrimoxazole or linezolid, to achieve 14 median days of treatment. Clinical success and failure rates were 76% and 24%, respectively.Conclusions: Short-course DPT as ALT, combined with 14 days of ST, allowed conservative management of CoNS-associated CRBSI in surgically implanted-catheters in three-fourth of cases.

Ethanol combined with heparin as a locking solution for the prevention of catheter related blood stream infections in hemodialysis patients: A prospective randomized study.

Ethanol lock solution has been mainly administered in paediatric and home parenteral nutrition patients in order to prevent catheter related blood stream infections (CRBSI). Its utility in hemodialysis (HD) patients with non-tunneled-uncuffed catheter (NTC) has been poorly explored. We conducted a prospective randomized study in chronic HD patients requiring a newly inserted NTC-while awaiting for the maturation of an already established arteriovenous fistula (AVF) or arteriovenous graft (AVG) or tunneled-cuffed catheter insertion. Patients were randomized in two groups: Group A, where the lock solution was ethanol 70% + unfractionated heparin 2000 U/mL and group B, that received only unfractionated heparin 2000 U/mL. Primary end point was CRBSIs whereas exit site infections, thrombotic and bleeding episodes were the secondary end points. One hundred three HD patients were enrolled in the study (group A, n = 52; group B, n = 51). The median number of catheter days was 32 for group A (range: 23-39) and 34 (range: 27-40) for group B with no statistically significant difference between the two groups. Group A (ethanol + heparin) demonstrated 4/52 episodes (7.69%) of CRBSI whereas Group B (heparin) 11/51 episodes (21.57%) (P = 0.04). CRBSI rates per 1000 catheter days were 2.53/1000 catheter days for group A and 6.7/1000 catheter days for group B (P = 0.04). Mean cumulative infection-free catheter survival in the ethanol group did not differ significantly compared to the heparin group (log-rank test = 2.99, P = 0.08). Thrombotic episodes did not differ between the two groups. Locking of NTCs in HD patients with ethanol 70% + unfractionated heparin reduces CRBSI rates without increasing the thrombotic episodes.

Risk factors for persistent bacteremia in infants with catheter-related bloodstream infection due to coagulase-negative Staphylococcus in the neonatal intensive care unit.

Coagulase-negative Staphylococcus (CoNS) is the predominant cause of catheter-related bloodstream infections (CRBSI). Infants in neonatal intensive care units (NICU) often suffer from CoNS CRBSI, which are often refractory to treatment. We sought to evaluate risk factors for developing persistent bacteremia due to CoNS CRBSI in infants, in order to identify those who require early aggressive management. We conducted a retrospective case-control study of infants in the NICU who developed CRBSI due to CoNS. Patient demographics, condition and management of CRBSI were compared between those with persistent and non-persistent bacteremia. Furthermore, prognosis of infants in the NICU after CoNS CRBSI was evaluated. Seventy six episodes of CRBSI, including 17 persistent bacteremia and 59 non-persistent bacteremia, were analyzed. In univariate analyses, persistent bacteremia was significantly associated with corrected age equivalent to gestational age of 22-28weeksat onset of CRBSI [Odds ratio (OR)=4.33; P=0.04], platelet count <100,000/μL (OR=11.5; P<0.001), use of vasopressor (OR=5.38; P=0.003), and delayed CVC removal (OR=6.25; P=0.003). In multivariate analysis, persistent bacteremia was significantly associated with platelet count <100,000/μL (OR=7.80; P=0.007), and delayed CVC removal (OR=5.07; P=0.03). Infants with persistent bacteremia tended to have a lower survival rate after CoNS CRBSI, however this was not statistically significant (P=0.21). Early CVC removal should be considered for the treatment of CRBSI due to CoNS in infants with platelet counts of less than 100,000/μL.

Vascular catheter colonization: surveillance based on culture of needleless connectors.

BackgroundSuperficial culture has a high negative predictive value in the assessment of catheter tip colonization (CC) and catheter-related bloodstream infection (C-RBSI). However, the process of hub culture requires the hubs to be swabbed, and this carries a risk of dislodging the biofilm. At present, most catheter hubs are closed by needleless connectors (NCs) that are periodically replaced. Our objective was to compare the yield of SC (skin + hub culture) with that of skin + NC culture in the assessment of CC and C-RBSI.MethodsDuring 5 months, we included the patients on the Major Heart Surgery ICU when a central venous catheter (CVC) remained in place ≥7 days after insertion. SCs were taken simultaneously when the NC was withdrawn and processed by the semi-quantitative method, even when the catheter was not removed. All catheter tips were cultured. All NCs belonging to a single catheter lumen were individually flushed with 100 μl of brain-heart infusion (BHI) broth. We considered the lumen to be colonized when ≥1 NC culture from the lumen flush was positive. We collected a total of 60 catheters.ResultsThe overall CC rate was 15.0 %, and we confirmed two episodes of C-RBSI. The validity values after the comparison of SCs with skin + NC culture for prediction of CC were the following: sensitivity 66.7 % vs. 77.8 %, and negative predictive value 93.6 % vs. 93.1 %. The sensitivity and negative predictive value for prediction of C-RBSI was 100 % for both SC and skin + NC culture.ConclusionThe combination of skin and flushed NC culture can be an alternative to conventional SC for ruling out CC and C-RBSI.

Evaluation of the usefulness of a quantitative blood culture in the diagnosis of catheter-related bloodstream infection: Comparative analysis of two periods (2002 and 2012)

IntroductionA retrospective study was conducted to investigate the usefulness of systematic quantitative blood culture (QBC) in the diagnosis of catheter-related bloodstream infection (CRBSI) during two 1-year periods (2002 and 2012). MethodsThe study included all QBC requests sent to the microbiology laboratory for suspected CRBSI in adults (≥18 years) with any type of intravascular catheter (IVC). Based on a ratio of ≥4:1CFU/mL of the same microorganism between IVC blood culture from any lumen and peripheral blood culture, 5 diagnostic groups were defined: confirmed or probable CRBSI, primary BSI, other focus of infection, and colonization. ResultsIn total, 4521 QBCs were evaluated; 24% positive in 2002 and 16% in 2012 (P<0.0001). There were 243 episodes of suspected CRBSI (101 in 2002 and 142 in 2012). Confirmed CRBSI episodes were higher in 2002 than 2012 (56% vs 34%) (P<0.0001), whereas colonization episodes were lower (18% vs 38%) (P=0.0006). Gram-positive cocci decrease in 2012 relative to 2002 (56% vs 79.7%) (P=0.022). Almost one-third (32%) of confirmed CRBSI would have been missed if blood from all catheter lumens had not been cultured. ConclusionsQBC is a useful method for diagnosing CRBSI. Blood samples from all catheter lumens must be cultured to avoid missing around one-third of CRBSI diagnoses.

In situ diagnostic methods for catheter related bloodstream infection in burns patients: A pilot study

BackgroundOne of the most common and potentially fatal complications in critically ill burns patients is catheter related bloodstream infection (CR-BSI). Lack of in situ diagnostic techniques requires device removal if CR-BSI is suspected with 75–85% of catheters withdrawn unnecessarily. AimsTo assess the sensitivity, specificity and accuracy of two in situ diagnostic methods for CR-BSI in an adult ICU burns population: Differential Time to Positivity (DTP) and Semi-Quantitative Superficial Cultures (SQSC). MethodsBoth arterial (AC) and central venous (CVC) catheters were studied. On clinicians’ suspicion of CR-BSI, the CVC and AC were removed. Superficial semi-quantitative cultures were taken by removing the dressings and swabbing within a 3cm radius of the CVC and AC insertion sites, as well as inside each hub of the CVC and AC. Peripheral blood was taken for qualitative culture and the catheter tip sent for semi-quantitative culture. DTP was considered positive if culture of lumen blood became positive at least 120min before peripheral blood with an identical pathogen. Superficial and tip cultures were identified as positive if ≥15 CFUs were grown. CR-BSI was confirmed when both catheter tip culture and peripheral blood culture were positive with the same micro-organism. ResultsSixteen patients (88% male) with an APACHE II score of 22.0 (7.3) were enrolled. The mean age was 45.7 (16.9) years with mean total burn surface area 32.9 (19.4)%. Fifty percent had airway burns. ICU stay was 19.9 (11.1) days. All 16 survived ICU discharge with a hospital survival of 93%. There were 20 episodes of CR-BSI in these 16 patients. For these 20 episodes the exposure time (line days) was 113.15. The CR-BSI rate was 15.6 per 1000 catheter days (95% CI 1.9–56.4). For diagnosis of CR-BSI in either AC and CVC, SQSC had a sensitivity of 50% [95% CI 3–97], specificity 83.3% [95% CI 67–93], PPV 14.3 [95% CI 1–58], NPV 96.8 [95% CI 81–100], accuracy of 81.6% [95%CI 65–92] and diagnostic odds ratio 5.0 [95% CI 0.3–91.5]. To diagnose tip colonisation (>15CFU), sensitivity of SQSC was 75% [95% CI 22–99], specificity 88.2% [95%CI 72–96], PPV 42.7 [95% CI 12–80], NPV96.8% [95% CI 81–100], accuracy 86.8% [95% CI 71–95] and diagnostic odds ratio 22.5 [95% CI 1.9–271.9]. For combined DTP blood cultures, sensitivity for CR-BSI was 50% [95% CI 3–97], with specificity 97% [95% CI 82–100], PPV 50% [5% CI 3–97%], NPV 97% [95% CI 82–100], accuracy 94.3% 95% CI 79–99] and diagnostic odds ratio 32 [95% CI 1.1–970.8]. ConclusionBoth DTP and SQSC displayed high specificity, NPV and accuracy in a population of adult burns patients. These features may make these tests useful for ruling out CR-BSI in this patient group. This study was limited by a low number of events and further research is required.

Use of Antibiotic Lock for Salvage of Tunneled Central Venous Catheters with Catheter Colonisation and Catheter Related Blood Stream Infection in a Tertiary Care Hematopoietic Stem Cell Transplantation Unit- a Strategy Revisited

Background: Catheter Related Blood Stream Infection (CRBSI ) and catheter colonization (CC) represent a significant problem encountered in hematopoietic stem cell transplantation (HSCT) setting adding to the morbidity, mortality and cost of healthcare in such patients. Unlike non-tunneled central venous catheters (CVCs), the higher complication rates and added cost associated with reinsertion of a tunneled CVC makes it important to devise effective strategies for catheter salvage.We report the incidence of CRBSI and CC of tunneled CVCs in our patients and use of antibiotic locks to salvage these catheters.Materials and Methods:All patients who underwent HSCT between September 2008 and December 2013 in our centre were included in this study. These patients underwent tunneled CVC (Hickman) insertion through internal jugular vein by Seldinger technique. Wherever possible, triple lumen Hickman catheters were used for patients undergoing allogeneic transplant, whereas double lumen catheters were used for those undergoing autologous transplant. Post insertion, surveillance blood cultures from all lumina of the catheter were taken. Catheter colonization (CC) was defined as growth of an organism from any lumen of the catheter without any evidence of fever as part of surveillance strategy. CRBSI was defined as growth of a recognized pathogen from catheter without growth from peripheral vein or growth from catheter with similar growth from peripheral vein with 2 hours lesser incubation for catheter in the presence of fever (>38o C), chills or hypotension. Antibiotic lock was used in all patients with CC according to the suceptibility patterns of the isolates, which included a third generation cephalosporin- β-lactamase inhibitor combination, aminoglycoside or carbapenem for gram negative bacteria; vancomycin, teicoplanin or linezolid for gram positive organism and amphotericin B or voriconazole for candida species. These patients did not receive systemic antibiotics. Systemic antibiotics were used in all cases of CRBSI. Catheters were removed in cases with persistent fever ( >72h), hemodynamic instability and repeated culture positivity. Antibiotic lock was continued for a total of 14 days with repeat cultures taken on 4th, 5th, 6th, 7th and 14th day of lock.Results: Two hundred and twenty four patients (95 allogeneic and 129 autologous) underwent HSCT. The incidence of CC was 9.8 % (22/224) while CRBSI was seen in 10.7 % (24/224). Coagulase Negative Staphylococcus (CONS) and gram negative organisms (Pseudomonas aeruginosa-3, E.Coli-2, Acinetobacter baumanni-2, Klebsiella pneumonia-2 and Sphingobacterium thalpophilum-1) were seen in 10 each (45%) of CC. One case of Candida tropicalis causing CC was noted. Antibiotic lock was used in 21 of 22 CC cases. Catheter salvage was successful in 95% (20 / 21) cases. One case of CC progressed to CRBSI and required systemic antibiotics. Amongst CRBSI, gram negative bacteria accounted for 83% (20 / 24) of the cases ( Pseudomonas aeruginosa-6, Acinetobacter baumanni-4, E coli-4, Klebsiella pneumonia-3, Ralstonia picketti-3, Stenothrophomonas maltilophila-2, Sphingomonas paucimobilis-1 and Ochrobactrum anthropi-1). Forty-five percent of E. coli & Klebsiella pneumonia confirmed to be Extended Spectrum β-Lactamase (ESBL) producers. Vancomycin resistant enterococci (VRE) and Candida parapsilosis related CRBSI were seen in 1 patient each. Antibiotic lock was used for 15 of the 24 cases of CRBSI. Catheter salvage was successful in 86% (13 / 15) patients. Two patients had a second episode of CRBSI, after an interval of 50 and 10 days respectively from last documented negative culture. The organisms in both these cases were gram negative bacteria.Conclusion: More than 80% of patients with catheter colonization and CRBSI could be salvaged with appropriate antibiotic locks in our setting. The use of antibiotic lock for tunneled CVCs is an effective strategy for catheter salvage in HSCT patients with CC and CRBSI. DisclosuresNo relevant conflicts of interest to declare.

Assessment of central venous catheter colonization using surveillance culture of withdrawn connectors and insertion site skin.

BackgroundCulture of catheter hubs and skin surrounding the catheter entry site has a negative predictive value for catheter tip colonization. However, manipulation of the hub for culture requires the hubs to be swabbed, introducing potential dislodging of biofilm and subsequent migration of microorganisms. Hubs are usually closed with needleless connectors (NCs), which are replaced regularly. Our objective was to evaluate whether culture of flushed withdrawn NCs is an alternative to hub culture when investigating central venous catheter colonization.MethodsThe study population comprised 49 intensive care unit patients whose central venous catheters had been in place for at least 7 days. Cultures of NCs and skin were obtained weekly.ResultsWe included 82 catheters with more than 7 days’ indwelling time. The catheter tip colonization rate was 18.3 % (15/82). Analysis of skin and NC cultures revealed a 92.5 % negative predictive value for catheter colonization. Three episodes of catheter-related bloodstream infection (C-RBSI) occurred in patients with colonized catheters.ConclusionSurveillance of NC and skin cultures could help to identify patients at risk for C-RBSI.