Incidence Of Catheter-related Bacteremia Research Articles

Catheter-Related Infections in Hemodialysis Patients: A Retrospective Study

Background: Catheter-related infection (CRI) is a serious complication among hemodialysis patients, associated with significant morbidity and mortality. This study investigated the incidence, predictors, presentation, and complications of CRI. Methods: This single-center, retrospective, observational study enrolled all eligible chronic hemodialysis patients with tunneled central venous catheters inserted between June 2016 and June 2019. Results: Over 3 years, 63 patients (59% men) with a total of 27,395 catheter days were included of these patients. The median age was 68 years (interquartile range [IQR]: 58,76), and median hemodialysis duration was 62 months (IQR: 16,101). A total of 30 episodes of clinical CRI occurred, resulting in an overall incidence rate of 1.1 per 1,000 catheter days. CRI was significantly associated with baseline anemia (adjusted hazard ratio [AHR]=3.29; 95% confidence interval [CI], 1.42–7.64; P=0.006) and the use of the femoral vein as opposed to internal jugular vein (AHR=3.23; 95% CI, 1.29–8.06; P=0.012). The incidence of catheter-related bacteremia was 0.91 per 1,000 catheter days, and the most commonly isolated organism was Staphylococcus aureus (26%). Recurrent infection developed in 9/27 (33.3%) episodes and was lower among catheter salvage with antibiotic lock and catheter removal compared to catheter salvage alone. Conclusions: Anemia and the use of the femoral instead of the internal jugular vein are associated with a higher incidence of CRI. Catheter-related blood stream infection was associated with increased mortality, recurrence rate, and resource utilization. Along with systemic antibiotics, catheter management such as catheter removal or antibiotic lock use may help reduce the recurrence rate.

#4588 EFFECT OF TRISODIUM CITRATE 30% VERSUS HEPARIN AS A CATHETER LOCK SOLUTION ON INFLAMMATORY RESPONSE AND DIALYSIS ADEQUACY IN HEMODIALYSIS PATIENTS

Abstract Background and Aims In hemodialysis (HD) patients, the majority of bloodstream infections are caused by infection of vascular access catheters. Commonly, Central venous catheters (CVCs) are the only option when HD is needed for patients without definitive vascular access. However, in addition to infection, CVCs are associated with other complications, such as thrombosis, and dysfunction, leading to higher mortality and expenditures. In Egypt, recent data show that 6.6% of HD patients use catheters as a vascular access, of which short term catheters represent 59.6% and 40.4% with long-term catheters. Many data show that the use of HD catheter-locking solutions could contribute to reduction of catheter-related complications, especially infections. Aim; to assess the possible effect of using Trisodium citrate 30% (TSC 30%) in comparison to unfractionated heparin, as a lock solution for HD catheters, on inflammatory status, incidence of catheter related Bacteremia (CRB) and dialysis adequacy in HD patients. Method This was a randomized controlled clinical trial, conducted on 70 prevalent HD patients on regular dialysis using HD catheters as a vascular access, recruited from hemodialysis unit in Nasser Institute Hospital in Cairo government at the time of catheter insertion. Patients were divided into two groups: Citrate Group; 35 patients received trisodium citrate 30% as a catheter lock after HD session, Heparin Group; 35 patients received unfractionated heparin (5000i.u) as a catheter lock solution after HD session. Both groups were followed up for 3 months period and monitored for signs of CRB. Also, Urea reduction ratio (URR) were measured monthly. Highly sensitive CRP were measured at baseline and 3 months after start using the lock solutions. Blood cultures were withdrawn in patients who developed signs of CRB. Results In our study, the catheter-related bacteremia (CRB) episodes were significantly lower in the Citrate group when compared to Heparin group. Only 2 patients (5.7%) in Citrate group had CRB, whereas in Heparin group, 8 patients (22.9%) had CRB (P = 0.04) (Fig. 1). Also, Bacteremia-free time was longer in the Citrate group. The mean bacteremia free time in Citrate group was 10.97 ± 2.36 weeks, while in Heparin group it was 9.43 ± 3.91 weeks (P = 0.032) (Fig. 2). At base line, there was no significant difference between both groups regarding hsCRP (P = 0.596) and WBCs (P = 0.528). While after 3 months of using TSC 30% as a lock solution, there was a significant difference as regards levels of hsCRP (P = 0.030) (Fig. 3) and WBCs (P = 0.036), with the higher levels of inflammatory markers showed in Heparin group. There was no difference between the two studied groups regarding thrombosis events. However, dialysis adequacy and catheter performance, assessed by URR, were higher in citrate group compared to heparin group after 3 months (P = 0.005) compared to baseline (P = 0.108) (Fig. 4). Conclusion we may conclude that, using Trisodium citrate 30% as lock solution for HD catheters was associated with reduction in the inflammatory markers and CRB incidence compared to the standard heparin lock. Also, its use was associated with better catheter performance and dialysis adequacy. We therefore believe that TSC 30% may be a potential alternative to standard heparin as a catheter lock solution for HD patients.

Hand hygiene and catheter related bacteraemia rates in ICU patients in Latvia during five years, before and after interventions

Implementation of a procedure of evidence-based measures resulted in reduced incidence of catheter related bacteraemia from 13.3 to 2.1 cases per 1000 bed days. This improved the results of patient treatment, and shortened the length of hospitalisation. Correct personnel hand hygiene is one of the infection control measures. The results obtained during the study showed that at the beginning hand hygiene compliance indicators were very low (8%), but after implementing targeted measures, these results improved.

Hand hygiene and catheter related bacteraemia rates in ICU patients in Latvia during five years, before and after interventions

Implementation of a procedure of evidence-based measures resulted in reduced incidence of catheter related bacteraemia from 13.3 to 2.1 cases per 1000 bed days. This improved the results of patient treatment, and shortened the length of hospitalisation. Correct personnel hand hygiene is one of the infection control measures. The results obtained during the study showed that at the beginning hand hygiene compliance indicators were very low (8%), but after implementing targeted measures, these results improved.

Anticoagulants and antiplatelet agents for preventing central venous haemodialysis catheter malfunction in patients with end-stage kidney disease.

Catheter malfunction, including thrombosis, is associated with reduced dialysis adequacy, as well as an increased risk of catheter-related bacteraemia and mortality. The role of anticoagulants in the prevention of catheter malfunction remains uncertain. This review aimed to compare the prophylactic effect of different anticoagulant agents, preparations, doses and administration on the incidence of central venous haemodialysis catheter-related malfunction and sepsis in patients with end-stage kidney disease (ESKD). We searched the Cochrane Renal Group's Specialised Register to 7 January 2016 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We included all randomised controlled trials (RCT) assessing anticoagulants compared with conventional care for the prevention of catheter malfunction in adult patients receiving haemodialysis for ESKD. The primary outcome was catheter malfunction defined as a catheter blood flow of 200 mL/min or less, or as defined by study authors. Secondary outcomes were catheter-related bacteraemia, all-cause mortality and bleeding events. Relative risks (RR) with 95% confidence intervals (CI) for individual studies were pooled using random effects models within treatment classes. Analyses were conducted by class, with subgroup analyses performed of individual agents within classes. We included 27 studies (3003 participants) that were followed up for a median of six months. Study interventions included alternative anticoagulant locking solutions (19 studies, 2216 patients), systemic agents (6 studies, 664 patients) and low or no dose heparin (2 studies, 123 patients). The most common comparison treatment was a locking solution of heparin 5000 IU/mL, used in 17 studies. No significant effect on catheter malfunction was observed for alternative anticoagulant locking solutions (RR 0.96, 95% CI 0.74 to 1.26), systemic agents (RR 0.59, 95% CI 0.28 to 1.23), or low or no dose heparin (RR 0.90, 95% CI 0.10 to 8.31). A significant reduction on incidence of catheter-related bacteraemia was observed for alternative anticoagulant locking solutions (RR 0.46, 95% CI 0.32 to 0.66) but not systemic agents (RR 2.41, 95% CI 0.89 to 6.55), and could not be assessed in reports of low or no dose heparin studies. No significant effect on all-cause mortality was observed for alternative anticoagulant locking solutions (RR 0.88, 95% CI 0.54 to 1.43) or systemic agents (RR 0.78, 95% CI 0.37 to 1.65), and was not reported in studies of low or no dose heparin. Bleeding events were only reported in eight studies, including only 2/5 studies of systemic warfarin, with no clear effect demonstrated (RR 1.43, 95% CI 0.86 to 2.39). For individual agents, recombinant tissue plasminogen (rt-PA) was the only locking solution shown to reduce catheter malfunction (RR 0.58, 95% CI 0.37 to 0.91) based on the results of a single study. No significant on catheter malfunction was observed for other individual classes of alternative anticoagulant locking solutions (citrate: RR 1.14, 95% CI 0.76 to 1.69; antibiotic: RR 1.48, 95% CI 0.79 to 2.77; ethanol: RR 0.88, 95% CI 0.21 to 3.67). On the other hand, all individual classes of alternative anticoagulant locking solutions, except ethanol, reduced catheter-related bacteraemia (citrate: RR 0.49, 95% CI 0.36 to 0.68; antibiotic: RR 0.27, 95% CI 0.11 to 0.70; rt-PA: RR 0.35, 95% CI 0.13 to 0.93; ethanol: RR 0.33, 95% CI 0.03 to 4.05). No significant effect on all-cause mortality was observed for any individual agent within the class of alternative locking solutions. Studies were mainly of low quality and underpowered with an average participant number of 75 and study duration of six months. The interpretation of the study evidence was further limited by the variation in tested interventions and outcome reporting. The relative net benefit of anticoagulant therapies for prevention of catheter malfunction remains uncertain. Multiple agents appear to reduce catheter-related bacteraemia although the lack of clear assessment of harms and the limitations of study quality mean these results should be interpreted with caution. Methodological approaches can be used to avoid methods of reporting unduly affecting on the results of meta-analyses incorporating studies employed mixed reporting methods. Further high quality randomised studies, including safety outcomes, are needed.

PP242-SUN: Impact of the Implementation of a Multidisciplinary Prevention Strategy in the Incidence of Catheter-Related Bacteremia due to Parenteral Nutrition (BRC-NP) in the HOSPITAL

PP242-SUN: Impact of the Implementation of a Multidisciplinary Prevention Strategy in the Incidence of Catheter-Related Bacteremia due to Parenteral Nutrition (BRC-NP) in the HOSPITAL

Does Bisphosphonate-Induced Osteonecrosis of the Jaw (BONJ) Preclude Intensive Chemotherapy? Oral and Infectious Toxicities Associated with Autotransplantation In Patients with BONJ.

AbstractAbstract 1314 Background:Bisphosphonate-induced osteonecrosis of the jaw (BONJ) is a recently recognized adverse reaction associated with intravenous bisphosphonate use. The incidence of BONJ is estimated to be between 5–15% of patients with multiple myeloma (MM) treated with biphosphonates. Relevant to this complication, areas of osteonecrosis can harbor bacteria with the potential to cause infection and bacteremia during prolonged periods of myelosuppression. Furthermore, it is unclear if BONJ can worsen mucositis associated with cytotoxic therapy or if intensive chemotherapy can impair the healing of osteonecrosis. Since autologous peripheral blood stem cell transplantation (APBSCT) is an integral part of the treatment of MM, it is important to determine toxicities associated with APBSCT in patients with BONJ. Study Purpose:To determine the oral and infectious toxicities associated with APBSCT in patients with multiple myeloma and BONJ. Method:This is a retrospective analysis of patients with MM and BONJ who underwent APBSCT between January 2005 and June 2010. All the patients were evaluated for dental clearance by local dentists prior to referral to our institution. Before transplantation, all the patients underwent another oral evaluation by our institution's dentist who specializes in oral and maxillofacial pathology and is experienced in the evaluation and care of transplant patients. Results:During the study period, 176 patients underwent APBSCT for MM at our institution. Ten male patients, or 6% of all patients, were diagnosed with BONJ prior to transplantation. The median age of patients with BONJ was 60 years (range, 39–70). BONJ developed a median of 444 days (range, 187–2194) after the initiation of treatment with bisphosphonates. Patients with BONJ received a median of 15 infusions of biphosphonates (range, 6–60) before the diagnosis of BONJ was established. Six patients received zoledronate, 3 received pamidronate and one received both. Eight of the 10 patients with BONJ were diagnosed by our dentist. Five patients received dental care by local dentists a median of 5 months (range 1–7) before they were seen at our facility where they were examined by our dentist. Two of the five patients had received extractions placing them at risk of developing BONJ. None of the patients received radiation to the jaw or had lytic lesions in the jaw area.The transplant conditioning regimen was similar for all patients: melphalan 100 mg/m2 daily for 2 days. Six patients developed neutropenic fever for a median of 4 days (range, 1–9). Bacteremia was diagnosed in 3 patients and 1 met criteria for catheter-related bacteremia (CRB) as defined by the Centers for Disease Control of the United States. The incidence of CRB in patients with BONJ appears similar to the 13% CRB observed at our institution during the study period. The organisms isolated from the blood were Pseudomonas aeruginosa, Corynebacterium species, Sphingomonas paucimobilis and Coagulase-negative staphylococcus, the last 2 were cultured from one patient. None of these organisms are predominantly found in the oral cavity but have been well described as pathogens in immunosuppressed hosts. Seven patients with BONJ developed mucositis posttransplantation but only one patient experienced grade 3 mucositis as defined by the Common Toxicity Criteria version 3. Of the remaining patients, 3 developed grade 1 and 3 developed grade 2 mucositis posttransplantation. Patients without BONJ had a similar frequency of mucositis: 31% of patients did not experience any mucositis, another 31% developed grade 1, 30% developed grade 2 and only 7% developed grade 3 mucositis. There was no treatment-related mortality within one year posttransplantation. So far, only 1 patient has died of progressive disease 13 months after APBSCT. Of interest, BONJ healed in nine patients posttransplantation with conservative management and 3 patients had bisphosphonates reintroduced with no recurrence of BONJ. Conclusion:Autologous stem cell transplantation can be performed safely in patients with BONJ. The incidence of oral and infectious toxicities observed in patients with BONJ appears similar to the incidence observed in patients without BONJ transplanted during the same period of time. BONJ was not recognized by most practitioners who referred patients for transplantation. Finally, BONJ healed in most patients after the transplant with conservative management. Disclosures:No relevant conflicts of interest to declare.

Catheter-related bacteremia in a jugular site with tracheostomy and in a femoral site

In previous guidelines of the Centers for Disease Control and Prevention (CDC) [1] and in the recently published Guidelines of the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America (SHEA/IDSA) [2] it is recommended to avoid the femoral access to reduce the risk of catheter-related bacteremia (CRB). However, in these guidelines there are no recommendations for the catheter site regarding the presence of tracheostomy, and we have not found data about the incidence of CRB comparing a central jugular site with tracheostomy and a femoral site. The objective of this study was to determine whether a jugular site with tracheostomy may have a higher risk of CRB than a femoral site.

Prophylaxis of catheter-related bacteremia using tissue plasminogen activator–tobramycin locks

This retrospective study was designed to investigate the effectiveness of tissue plasminogen activator-tobramycin antibiotic lock solutions (TPA/tobra ABLs) for prophylaxis of catheter-related bacteremia (CRB) in high-risk children on long-term hemodialysis. During the first 6 months (Era 1), the high-risk group was defined. These patients received TPA/tobra ABL prophylaxis after every hemodialysis treatment for the next 6 months (Era 2). The prophylaxis regimen was applied once a week for the third 6-months period (Era 3). Primary endpoints were CRB and infection-free catheter survival. There were 16,412 catheter days, and 95 cases of CRB in 43 children. The incidence of CRB was 5.8/1,000 catheter days. Significant decrease in the incidence of CRB was observed when prophylactic TPA/tobra ABL was used in the high-risk group (P = 0.0201). There was a tendency for less CRB when prophylactic ABL was applied after every hemodialysis session compared with once a week (P = 0.0947). The catheters in the high-risk group had shorter survival times than those in the average-risk group in Era 1 (P < 0.0001). However, both the overall and infection-free survival of the catheters in the high-risk group significantly improved while the patients were receiving TPA/tobra ABL prophylaxis, becoming similar to the outcomes of the catheters in the average-risk group and exhibiting statistically non-significant differences (P = 0.5571 and P = 0.9711, respectively). In conclusion, the TPA/tobra ABLs may effectively reduce the rate of CRB, and this may prolong both the overall and infection-free survival times of the catheters in the high-risk group.

Controlling exit site infections: Does it decrease the incidence of catheter‐related bacteremia in children on chronic hemodialysis?

The aim of this retrospective study was to investigate whether the application of a chlorhexidine-impregnated dressing (Biopatch) at the exit site of tunneled-cuffed hemodialysis catheters has any effect on the incidence and etiology of catheter-related bacteremia (CRB). This study was carried out over a 5-year period in a single center, where, in the first 2(1/2) years, the exit sites were cleansed with betadine at every hemodialysis session and then covered with a transparent dressing (pre-Biopatch Era). During the next 2(1/2) years, Biopatch was applied to the exit site once a week after cleansing with betadine, and then covered with a transparent dressing (Biopatch Era). The application of Biopatch significantly decreased the incidence of exit site infections (ESI) (P<0.05). However, there was no difference in the incidence of CRBs or their microbiological distribution. The improved ESI rate had no effect on the overall catheter survival time. The antimicrobial sensitivities of the Gram-positive microorganisms were statistically different for the 2 different types of infections (P<0.05). In conclusion, even though Biopatch is effective in decreasing the incidence of ESI, it has no effect on the incidence of CRB, the etiology of CRB, or the overall catheter survival time. The distinct difference between the antimicrobial sensitivities of the ESI and CRB suggests that they are not a spectrum of the same pathogenesis. These preliminary data support the intraluminal pathogenesis of CRB, rather than the exit site as a possible entry point for the extraluminal route.

The Effectiveness of Antibiotic-Lock Therapy for the Prevention of Catheter-Related Bacteremia in Patients on Chronic Hemodialysis: Case Controlled Study in a Veteran Population

Central venous catheters (CVCs) are frequently used in patients with chronic renal failure who require long-term hemodialysis. CVCs are also known to be a major source of bloodstream infections. Though antibiotic-lock therapy (ALT) has previously been used to prevent and treat catheter-related infections, the use of ALT remains controversial due to the lack of large prospective randomized controlled trials. The purpose of this study was to evaluate the effectiveness of ALT in the prevention of catheter-related bacteremia (CRB) in a veteran population who required chronic hemodialysis. This was a retrospective, case-controlled study. All patients who underwent hemodialysis using a tunneled central catheter (TCC) from January 1, 2006 to October 8, 2008 were examined. Eleven patients who received ALT were compared with 15 case control subjects. The effectiveness of ALT for prevention of CRB was determined by the incidence of CRBs during the study period and catheter removal secondary to a CRB. A total of 10,961 catheter-days were calculated from 47 TCCs among 26 patients. The two groups had similar demographics and risk factors for CRBs. There were a total of 17 incidences of CRBs with a rate of 1.55 incidences/1,000 catheter-days. The rate of CRB was significantly lower in the ALT group (0.69 incidences/1,000 catheter-days) than the control group (2.54 incidences/1,000 catheter-days), p=0.041. The rate of catheters removal due to a CRB was also significantly less in the ALT group (0.5 catheter removed/1,000 catheter-days) than the control group (2.41 catheter removed/1,000 catheter-days), p=0.041. Seven out of 9 patients died in the control group secondary to CRBs. Three patients died in the ALT group; however none of these deaths were associated with CRB. Our study results revealed that ALT is an effective way to prevent catheter related bacteremia among veterans with central venous catheter for chronic hemodialysis.

The Use of Rifampicin‐Miconazole–Impregnated Catheters Reduces the Incidence of Femoral and Jugular Catheter‐Related Bacteremia

The guidelines of the Centers for Disease Control and Prevention do not recommend the use of an antimicrobial- or antiseptic-impregnated catheter for short-term use. In previous studies, we have found a higher incidence of central venous catheter-related bacteremia among patients with femoral and central jugular accesses than among patients with other venous accesses. The objective of our study was to determine the incidence of central venous catheter-related bacteremia associated with rifampicin-miconazole-impregnated catheters and standard catheters in patients with femoral and central jugular venous accesses. This was a cohort study, conducted in the 24-bed polyvalent medical-surgical intensive care unit of a university hospital. We included patients who were admitted to the intensive care unit from 1 June 2006 through 30 September 2007 and who underwent femoral or central jugular venous catheterization. We inserted 184 femoral (73 rifampicin-miconazole-impregnated catheters and 111 standard catheters) and 241 central jugular venous catheters (114 rifampicin-miconazole-impregnated catheters and 127 standard catheters). We found a lower rate of central venous catheter-related bacteremia associated with rifampicin-miconazole-impregnated catheters than with standard catheters among patients with femoral access (0 vs. 8.62 cases per 1000 catheter-days; odds ratio, 0.13; 95% confidence interval, 0.00-0.86; P = .03) and among patients with central internal jugular access (0 vs. 4.93 cases per 1000 catheter-days; odds ratio, 0.13; 95% confidence interval, 0.00-0.93; P = .04). Rifampicin-minonazole-impregnated catheters are associated with a statistically significant reduction in the incidence of catheter-related bacteremia in patients with short-term catheter use at the central jugular and femoral sites.

Surface‐Treated Catheters—A Review

Almost 30% of prevalent hemodialysis patients use catheters for vascular access although outcomes are superior with the use of either an arteriovenous fistula or a synthetic graft. Catheter complications are a major cause of morbidity and mortality for hemodialysis patients and increase the burden on the health care system. Surface-treated catheters have been developed to combat the three most common causes of catheter failure: infection, fibrin sheath formation, and thrombus formation. Two types of catheter surface treatments are available: antimicrobial coatings and antithrombotic coatings. Surface treatment of central venous catheters with antimicrobial materials reduces both bacterial colonization and the incidence of catheter-related bacteremia in critical care patients by 30-50%. Antithrombotic coatings reduce platelet adhesion, inhibit the inflammatory response, and reduce thrombus formation on coronary stents, ventricular assist devices, central venous catheters, and vascular grafts. However, few reports on the use of surface-treated catheters in the chronic hemodialysis patient population exist. At the present time, it is difficult to justify the increased cost of surface-treated catheters for chronic hemodialysis in the absence of clinical data demonstrating that they reduce catheter-related complications in this patient population.

Catheter-related bacteremia from femoral and central internal jugular venous access

The objective of this prospective observational study was to determine the influence of femoral and central internal jugular venous catheters on the incidence of catheter-related bacteremia (CRB). We included patients admitted to a 12-bed polyvalent medico-surgical intensive care unit over 4 years who received one or more femoral or central internal jugular venous catheters. We diagnosed 16 cases of CRB in 208 femoral catheters and 22 in 515 central internal jugular venous catheters. We found a higher incidence of CRB with femoral (9.52 per 1,000 catheter days) than with central internal jugular venous access (4.83 per 1,000 catheter days; risk ratio = 1.93; 95% confidence interval: 1.03-3.73; P = 0.04). Central internal jugular venous access could be considered a safer route of venous access than femoral access in minimizing the risk of central venous catheter-related bacteremia.

Predictors and outcome of catheter-related bacteremia in children on chronic hemodialysis

Tunneled central venous catheters are often used in children on chronic hemodialysis. This study was done to evaluate the spectrum of catheter-related bacteremia (CRB) and to determine predictors of recurrent CRB in children on hemodialysis. Chart review was performed in 59 children from a pediatric dialysis unit with chronic, tunneled, cuffed hemodialysis catheters between January 1999 and December 2003. CRB was diagnosed in 48 of 59 (81%) patients. The incidence of CRB was 4.8/1,000 catheter days. Overall catheter survival (290+/-216 days) was significantly longer than infection-free catheter survival (210+/-167 days, p<0.05). Organisms isolated were gram-positive in 67%, gram-negative in 14%, and polymicrobial in 19%. Systemic antibiotics cleared CRB in 34% and an additional 23% cleared with the inclusion of antibiotic-heparin locks; 43% required catheter exchange. There was a significant likelihood of early catheter exchange with polymicrobial CRB (p<0.01). Catheter loss occurred from infection in 63%. Risk factors for CRB included young age (<10 years) and presence of human immunodeficiency virus (HIV) infection. Patients with >2 initial positive blood cultures (p<0.0001) had a significantly higher rate of recurrence after 6 weeks of initial treatment. In conclusion, CRB remains a major determinant of catheter loss. However, overall catheter survival is longer than infection-free catheter survival, suggesting that systemic antibiotics with antibiotic-heparin locks should be the initial step in the management of CRB and this approach may salvage some catheters.

Chlorhexidine and silver-sulfadiazine coated central venous catheters in haematological patients—a double-blind, randomised, prospective, controlled trial

Central venous catheters (CVCs) are essential for the intensive care of patients with haematological illness. Catheter-related infections (CRI) are an important problem in modern medicine, which may lead to life-threatening situations, to prolonged hospitalisation and increased cost. In immunocompromised patients suffering from haemato-oncological diseases, CRI is a significant factor for adverse outcome. Several clinical studies have shown that CVCs coated with antiseptics such as chlorhexidine and silver-sulfadiazine (CHSS) reduce the risk of catheter-related bacteraemia. Most studies, however, were performed on intensive care patients not suffering from chemotherapy-induced immunosuppression. A prospective double-blind, randomised, controlled trial was performed to investigate the effectiveness of CHSS-coated catheters in haemato-oncological patients. A total number of 184 catheters (median duration of placement, 11 days) were inserted into 184 patients (male 115, female 69), of which 90 were antiseptically coated. After removal, all catheters were investigated for bacterial growth. Catheters coated with CHSS were effective in reducing the rate of significant bacterial growth on either the tip or subcutaneous segment (26%) compared to control catheters (49%). The incidence of catheter colonisation was also significantly reduced (12% coated vs 33% uncoated). Data obtained show a significant reduction of catheter colonisation in CHSS catheters. There was no significant difference in the incidence of catheter-related bacteraemia (3% coated vs 7% uncoated). However, due to the overall low rate of CRI, we could not observe a significant reduction in the incidence of catheter-related bacteraemia. Our data show that the use of CHSS catheters in patients with haematological malignancy reduces the overall risk of catheter colonisation and CRI, although the incidence of catheter-related bacteremia was similar in both groups.

Do not go with the flow, remember indwelling catheters.

PURPOSE: To determine the precise clinical and economic effect of catheter- related bladder infection. To enhance understanding of the importance of preventing catheter-related infection. BACKGROUND: Indwelling bladder catheters are frequently used in patients admitted to acute care hospitals. Approximately 15% to 25% of hospitalized patients have an indwelling catheter placed at some point during their stay. 1 The risk of developing bacteruria, urinary tract infection (UTI), and bacteremia is directly related to the duration of catheterization. 2 Approximately 40% of nosocomial infections are due to UTI, and 80% of these are secondary to an indwelling catheter. 1,3 Continuation of catheter use is frequently not reviewed, and indwelling catheters may be left in place inappropriately, leading to development of complications. These include fever, symptomatic UTI, acute pyelonephritis, bacteremia, sepsis, and death. The incidence of developing catheter-related bacteruria has been estimated to be between 3% and 10% per day. 1,2,4 The growing emphasis on improving hospital care and decreasing hospital errors supports revisiting the morbidity, mortality, and economic effect of indwelling bladder catheters in hospitalized patients. DATA SOURCES: The studies in this quantitative review were identified through a Medline search of English language articles published between 1966 and 1998 using specific Medical Subject Headings (MeSH) and selected authorities in catheter-related infection. The term nosocomial infection was not used in the MeSH heading search but could be an appropriate inclusion. Additional studies were obtained through review of cited references. Peer-reviewed publications, published theses, and abstracts were considered, but not every possible report was located and reviewed. STUDY SELECTION CRITERIA: No specific selection criteria are documented. Ten prospective studies, natural history evaluations or randomized trials that compared various ways of preventing bacteruria, were used to estimate cumulative incidence of bacteruria. The patients assessed were those with standard, noncoated indwelling bladder catheters with closed drainage systems in place for 2 to 10 days who were not receiving systemic antimicrobials or other interventions to prevent bacteruria. Only the consequences of short-term catheterization (<30 days) were examined. DATA EXTRACTION: In determining the incidence of bacteruria, data were extracted from 10 studies that included participants from urology, surgery, and medicine services. The definition of bacteruria in these studies was not consistent. The proportion of patients with bacteruria who develop symptomatic UTI was determined by pooling data from two prospective studies. The definition of UTI in both studies was similar: temperature greater than 100.0°F for more than 12 hours in the absence of other sites of infection or presence of symptoms referable to the urinary system (bladder discomfort, dysuria). Bacteremia was defined as isolating the same organism from both the urine and the blood. The incidence of catheter-related bacteremia was determined from five studies, two of which were large-scale studies participating in the National Nosocomial Infections Survey System.

Bacteraemia in a paediatric oncology unit in South Africa.

To identify the morbidity and mortality due to infections in a South African paediatric oncology unit, and to identify risk factors associated with first bacteraemic episodes in this unit. A retrospective cohort study was done in a large regional referral paediatric cancer centre from 1991-1995, of all consecutive patients with culture proven bacteraemia. Eighty-three oncology patients were studied (median age 4.0 years) in whom a total of 200 episodes of bacteraemia were recorded, of which 83 first bacteraemic episodes. Of the 200 episodes 70% were caused by Gram-positive organisms, 20% by Gram- negative organisms and 10% by fungal organisms. Organisms associated with high mortality were Gram-negative organisms (Acinetobacter spp., Pseudomonas aeruginosa, Klebsiella species), and fungal organisms, (Candida parapsilosis). Seventeen out of 200 episodes ended in death of the patient. In 59% of patients Hickman catheters were in situ. The mean incidence of catheter related bacteraemia's was 3.3 episodes per 1000 catheter days. Seventy percent of first bacteraemic episodes occurred within 50 days after placement of the catheter. The generalized estimation equations model revealed that more Gram-negative infections occurred in the presence of a Hickman catheter (odds ratio 2.2, 95% CI 1.0-5.0). The presence of neutropenia and the use of parenteral nutrition were not associated with specific bacteraemic patterns. Including all bacteraemic episodes in this cohort study a high incidence of fungal infections occurred of which 64% occurred with a Hickman catheter in situ. Candida parapsilosis had a higher incidence than reported in other centres. Secondly looking at first bacteraemic episodes a high incidence of Gram-negative infections was observed especially in the presence of a Hickman catheter.

Retention of antibacterial activity and bacterial colonization of antiseptic-bonded central venous catheters.

We determined how long antiseptic impregnation with silver sulphadiazine and chlorhexidine (SCC) on polyurethane central venous double- or triple-lumen catheters is retained in vivo. A total of 116 antiseptic catheters were tested for antibacterial activity in an in-vitro bioassay after various periods of iv catheterization. Segments from the subcutaneous (sc) and intravenous (iv) portions of the catheters were cultured. The results of test antiseptic catheters were compared with those from 117 noncoated control (c) catheters. Retention of antibacterial activity followed an exponential curve and lasted for up to 520 h after catheter insertion. Significant differences (P = 0.0001) between SSC and C catheters were noticed with regard to the quantitative level of bacterial colonization (SSC-sc 87 +/- 34 vs C-sc 584 +/- 122; SSC-iv 52 +/- 17 vs C-iv 286 +/- 57; all values are given as mean cfu +/- S.E.M.), and the frequency of bacterial colonization (SSC-sc 20.7% vs C-sc 38.5%, P = 0.0047; SSC-iv 18.1% vs C-iv 30.8%, P = 0.0361). There was no significant difference between the incidence of catheter-related bacteraemia in the test (n = 0) and control groups (n = 3) (P = 0.2573). Further prospective studies are required to delineate the role of antiseptic catheters in preventing catheter-related infections.

Infection related to intravascular pressure monitoring: Effects of flush and tubing changes

The optimal frequency for changing pressure monitoring tubing and flush solution that minimizes catheter-related infection and contains cost has not yet been established. We conducted a pilot study to examine the effects of three protocols on catheter-related infection: group I, change of flush solution and pressure monitoring tubing every 24 hours; group II, change of flush solution every 24 hours and change of pressure monitoring tubing every 48 hours; group III, change of flush solution and pressure monitoring tubing every 48 hours. Thirty critically ill patients were randomly assigned to one of the three protocols. Semiquantitative cultures of the solution from the flush bag and catheter tip were obtained. Intervening variables were documented: duration of cannulization, number of entries into the system, presence of other invasive devices, white cell count, patient's temperature, presence of preexisting infection, patient's age and diagnosis, use of steroids and antibiotics, and host risk factors for immunocompromise. All flush solution cultures were negative for growth. Incidence of catheter-related bacteremia was zero. The cultures of four catheter tips were positive for Staphylcoccus epidermidis; none in group I, three in group II, and one in group III. The results of this pilot study suggest that there is no difference in the incidence of catheter-related infection whether the change interval for flush solution and pressure monitoring solution is 24 or 48 hours. However, further study with a larger sample is needed.