Indwelling Central Venous Catheter Research Articles

Development and validation of machine learning-based models for predicting healthcare-associated bacterial/fungal infections among COVID-19 inpatients: a retrospective cohort study

BackgroundCOVID-19 and bacterial/fungal coinfections have posed significant challenges to human health. However, there is a lack of good tools for predicting coinfection risk to aid clinical work.ObjectiveWe aimed to investigate the risk factors for bacterial/fungal coinfection among COVID-19 patients and to develop machine learning models to estimate the risk of coinfection.MethodsIn this retrospective cohort study, we enrolled adult inpatients confirmed with COVID-19 in a tertiary hospital between January 1 and July 31, 2023, in China and collected baseline information at admission. All the data were randomly divided into a training set and a testing set at a ratio of 7:3. We developed the generalized linear and random forest models for coinfections in the training set and assessed the performance of the models in the testing set. Decision curve analysis was performed to evaluate the clinical applicability.ResultsA total of 1244 patients were included in the training cohort with 62 healthcare-associated bacterial/fungal infections, while 534 were included in the testing cohort with 22 infections. We found that patients with comorbidities (diabetes, neurological disease) were at greater risk for coinfections than were those without comorbidities (OR = 2.78, 95%CI = 1.61–4.86; OR = 1.93, 95%CI = 1.11–3.35). An indwelling central venous catheter or urinary catheter was also associated with an increased risk (OR = 2.53, 95%CI = 1.39–4.64; OR = 2.28, 95%CI = 1.24–4.27) of coinfections. Patients with PCT > 0.5 ng/ml were 2.03 times (95%CI = 1.41–3.82) more likely to be infected. Interestingly, the risk of coinfection was also greater in patients with an IL-6 concentration < 10 pg/ml (OR = 1.69, 95%CI = 0.97–2.94). Patients with low baseline creatinine levels had a decreased risk of bacterial/fungal coinfections(OR = 0.40, 95%CI = 0.22–0.71). The generalized linear and random forest models demonstrated favorable receiver operating characteristic curves (ROC = 0.87, 95%CI = 0.80–0.94; ROC = 0.88, 95%CI = 0.82–0.93) with high accuracy, sensitivity and specificity of 0.86vs0.75, 0.82vs0.86, 0.87vs0.74, respectively. The corresponding calibration evaluation P statistics were 0.883 and 0.769.ConclusionsOur machine learning models achieved strong predictive ability and may be effective clinical decision-support tools for identifying COVID-19 patients at risk for bacterial/fungal coinfection and guiding antibiotic administration. The levels of cytokines, such as IL-6, may affect the status of bacterial/fungal coinfection.

Stenotrophomonas maltophilia Infections in Haematological Malignancies and Hematopoietic Stem Cell Transplantation: A Case Series including Cefiderocol-Based Regimens.

Background and Objectives: Stenotrophomonas maltophilia is a ubiquitous, aerobic, Gram-negative bacillus causing increasing concern in patients affected by haematological malignancies. Materials and Methods: We report a case series from two centres in Northern Italy to describe the characteristics, outcome and microbiological response of S. maltophilia infections in patients with haematological malignancies and/or allogenic hematopoietic stem cell transplantation (aHSCT). Results: Ten patients were included. The median age was 67 years, and seven patients (70%) were males. The median Charlson Comorbidity Index was 6 (IQR: 4-8). The most frequent haematological comorbidities were acute myeloid leukaemia (AML; n = 3; 30%) and non-Hodgkin's lymphoma (n = 3; 30%). Three (30%) patients underwent aHSCT before infection, all for AML. All the patients had undergone a recent antibiotics course and had an indwelling central venous catheter before infection. The main clinical presentations were nosocomial pneumonia, with (2; 20%) or without (4; 40%) secondary bloodstream infection and CRBSI (3; 30%). Four patients were treated with cefiderocol in monotherapy or combinations therapy with cotrimoxazole. The rest of the patients were treated with cotrimoxazole or levofloxacin in monotherapy. Conclusions: Despite a high rate of clinical improvement (90%) after starting antimicrobial therapy, we faced high 30-day mortality (30%) and in-hospital mortality (50%) rates in a highly comorbid population.

#4562 OUTBREAK OF RALSTONIA SPP AND BURKHOLDERIA SPP CATHETER-RELATED BLOODSTREAM INFECTION IN A HAEMODIALYSIS UNIT

Abstract Background and Aims Ralstonia (RB) and Burkholderia (BB) species are environmental Gram-negative bacilli responsible for several nosocomial infections in immunocompromised or frail patients. RB and BB may contaminate medical devices because of their ability to survive in a biofilm and with low nutrient requests. Reports of infection outbreaks due to RB and BB are very few and only in sporadic cases, the source of contamination was identified. We describe here: i) how we managed an outbreak of bacteremia caused by RB and BB occurred in our dialysis unit, ii) what we have done to identify the source of infection and iii) the countermeasures we adopted to reduce the risk of new events. Method From 7 to 16 April 2021, 6 out of 39 (15.4%) hemodialyzed (HD) patients with a long-term indwelling central venous catheter (CVC) developed symptoms related to infection. Blood cultures revealed the presence of RB and BB. Thus, a prompt check of the blood cultures of all HD patients with CVC was performed. Blood samples were incubated in an automated microbial detection system (VIRTUO BIOMERIEUX) and subsequently, blood positive samples were inoculated in Chocolate and Columbia blood Agar plates. In addition, a microbiological analysis of disinfectants, drugs used in dialysis unit and samples collected from the reverse osmosis water unit (ROW) and from the ROW delivery line were performed. None of the samples obtained from the ROW and from the ROW delivery line resulted positive. Thus, a microbiological analysis of the biofilm attached on the loading pipes (LP) and on the loading plastic tubes (LPT) that connect the hemodialyzer consoles (HC) to the ROW delivery line were performed. Briefly, LTP were subjected to ultrasound sonication at 30-40 KHz (BactoSonic-Bandelin), to disrupt the bacterial biofilm. The material obtained from sonication was cultured. Bacteria was identified by an automated mass spectrometry (MALDI-TOF VITEK®MS, Biomerieux). Results Bacteremia due to RB and BB was confirmed in 7 out of 39 (17.9%) of the hemodialyzed patients with a long-term indwelling CVC. 1 out of 7 was asymptomatic. Baseline characteristics of the 6 symptomatic patients were: mean age 68±16 years; mean C-reactive protein 4.48±1.3 mg/dl; mean procalcitonin 13.27±11.07 ng/ml; mean body temperature 37.9±1.4°C. The antibiotic therapy was decided according to antibiogram and included meropenem and ciprofloxacin. CVC were removed in all infected patients between 6 to 11 days from the diagnosis. Concomitantly, a new one was placed. None of the HD patients with arterio-venous fistulae developed bacteremia. RB and BB were isolated in the biofilm of 11 out of 37 LPT. Thus, we modified the ROW delivery line in order to set up a scheduled chemical and physical disinfections of the ROW delivery line with the hemodialysis consoles connected avoiding the risk of new contamination of the LPT and loading pipes. Briefly, on alternate months the whole system that include ROW delivery line (PE-Xa Medical Device, Fresenius Medical Care), loading pipes, LPT and hemodialysis consoles are disinfected by hot water (90°C) produced by a water heater (AquaB plus HF, Fresenius Medical Care) and by chemical disinfectant, 5% peracetic acid according to the protocols made by the console fabricant. In addition, we added to the reverse osmosis system a filtration module of 0.01 μm (AquaUF, Fresenius Medical Care) prior to the ROW delivery line, Figure 1. Awaiting for the modification of the ROW delivery line, the patients with CVC were dialyzed using a portable water treatment unit. After more than 14 months from the modification of the whole system for production and delivery of ROW none of the hemodialyzed patients developed infection by RB and BB. Conclusion Our experience suggests that infection outbreak by unusual bacteria such as RB and BB could be successful treated using antibiotic therapy. Nevertheless, in dialysis unit the source of infection should be investigated in order to adopt the countermeasures necessary to reduce the risk of new infections.

An Unusual Case of Hematemesis

Question: A 68-year-old African-American man with history of end-stage renal disease with multiple previous indwelling central venous catheters and current left-side arteriovenous fistula, essential hypertension, and no known history of liver disease presented to the emergency department after an episode of large-volume hematemesis during his routine session of hemodialysis. His blood pressure on presentation was 81/52 with a heart rate of 106 beats per minute. Physical examination was notable for venous distention in the neck and anterior chest wall.

Infective Endocarditis in Pregnancy: A Contemporary Cohort.

Pregnancy-related infective endocarditis (IE) caries a high risk of morbidity and mortality. With increasing intravenous drug abuse (IVDA) amid the opioid epidemic, the risk factor profile may be shifting. In this case series, we aimed to describe risk factors and outcomes for peripartum IE in a contemporary cohort. We identified patients with IE diagnosed during pregnancy or up to 6 weeks' postpartum from 2015 through 2018 at a single tertiary care center. We abstracted detailed medical history and clinical outcome measures from the electronic medical record. The diagnosis of IE was supported by the modified Duke Criteria. Nine patients had peripartum IE: eight (89%) with a history of IVDA, one with an indwelling central venous catheter (11%), and one with prior IE (11%). None had preexisting congenital or valvular heart disease. Six (67%) had comorbid hepatitis C. Eight cases (89%) had gram-positive cocci with vegetations involving the tricuspid valve (56%) and both mitral and tricuspid valves (22%). Major complications included shock (33%), mechanical ventilation (44%), septic emboli (67%), and noncardiac abscesses (33%). Two patients underwent valve surgery, and there were two cases of postpartum maternal mortality (22%), one from septic shock and one from intracerebral hemorrhage. While four patients (44%) delivered preterm (average gestational age 35 weeks), most delivered vaginally (89%) with only one requiring an emergent caesarean section. There was no fetal mortality, although three newborns (43%) required admission to the neonatal intensive care unit. Two patients were initiated on medication-assisted treatment for opioid use disorder. Consultants included infectious disease, cardiology, cardiac surgery, maternal-fetal medicine, and psychiatry. These findings confirm that IVDA is a growing risk factor for pregnancy-related IE. Peripartum IE carries a high risk of complications, including maternal mortality, and warrants management with a multidisciplinary care team at a tertiary center. · Intravenous drug use was the most common risk factor for IE in pregnancy.. · IE in pregnancy carries a high morbidity and mortality with complications including septic emboli, septic shock, and need for mechanical ventilation.. · A multidisciplinary team approach can assure the best possible maternal and fetal outcomes..

Disseminated Mycobacterium avium infection in a young woman with sickle cell disease and iatrogenic iron overload

A 29-year-old woman with known sickle cell disease (SCD) and iatrogenic iron overload presented to the emergency department with a recurrent pain crisis and fever. Blood cultures obtained at a recent prior admission for the same complaints grew M avium. Bone marrow biopsy revealed non-caseating granulomas, but stains for mycobacteria and fungi were negative. Disseminated non-tuberculous mycobacterial infections (NTMIs) occur almost exclusively in immunosuppressed patients. SCD is not considered a risk factor for the development of disseminated NTMIs, making diagnosis challenging in this population. However, a number of case reports describing disseminated NTMIs in patients with SCD have been published. This case adds to the current literature, suggesting SCD with iatrogenic iron overload is a possible risk factor for disseminated NTMIs. Potential mechanisms for this increased risk include 1) functional asplenia, 2) iatrogenic iron overload, 3) chronic indwelling central venous catheters, and 4) hydroxyurea use. Further investigation is required to describe the strength and mechanism of the relationship between SCD and disseminated NTMIs.

Clinical efficacy of an enhanced recovery after surgery protocol in patients undergoing robotic-assisted laparoscopic prostatectomy.

ObjectiveTo evaluate the application of an enhanced recovery after surgery (ERAS) protocol in patients undergoing robot-assisted laparoscopic prostatectomy (RALP).MethodsWe conducted a retrospective cohort study of 136 patients who underwent RALP between August 2017 and June 2018 as the control group and a prospective analysis of 106 patients who underwent RALP between January 2019 and January 2020 as the ERAS group. ERAS focused on preoperative education, nutritional intervention, electrolyte solution intake, restrictive fluid infusion, body warming, no indwelling central venous catheter, use of nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and eating recovery.ResultsThe times from RALP to the first intake of clear liquid; first ambulation; first defecation; first fluid, semi-liquid, and general diet; drain removal; and length of hospital stay (LOS) were significantly shorter, and operative time, fluid infusion within 24 hours, postoperative day (POD) 1 albumin, POD 1 hemoglobin, and POD 2 drainage were significantly higher in the ERAS group. Five patients (3.8%) in the ERAS group developed postoperative complications (urine leakage, n = 4; intestinal obstruction, n = 1), while 1 patient (0.7%) in the control group developed intestinal obstruction.ConclusionsERAS effectively accelerated patient rehabilitation and reduced the LOS for patients undergoing RALP.

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.

Pediatric subcutaneous treprostinil site maintenance and pain control strategies from the Pediatric Pulmonary Hypertension Network.

Pulmonary arterial hypertension is a chronic, progressive, and life-threatening disease in children with diverse causes of pulmonary arterial hypertension. The most severe cases of pulmonary arterial hypertension require aggressive treatments with systemic administration of continuous prostacyclin therapy, including treprostinil and epoprostenol. The successful use of continuous subcutaneous treprostinil therapy eliminates the need for an indwelling central venous catheter and its associated risks. However, pain at the subcutaneous infusion site, an expected side effect of this therapy, is often a deterrent to its widespread use. Effective subcutaneous treprostinil site maintenance and pain management is essential to achieve success with this therapy, but strategies surrounding site maintenance and pain control vary significantly between pediatric pulmonary hypertension treatment centers. In an attempt to standardize practice, a survey on the use of subcutaneous treprostinil and site maintenance and pain management strategies, as well as its perceived effectiveness, was disseminated to 13 pediatric pulmonary hypertension centers of the Pediatric Pulmonary Hypertension Network. Responses to the survey were collected and analyzed and were developed into a set of formalized strategies to facilitate knowledge sharing and standardization of practice.

Presence of retained calcified fibrin sheath after central venous catheter removal: A systematic literature review.

Central venous catheters (CVC) are used in many clinical settings for a variety of indications. We performed a systematic literature review concerning case reports of retained calcified fibrin sheaths after dialysis CVC removal. The aim of our study was to systematize the knowledge regarding clinical management of this phenomenon, placing special emphasis on diagnostic radiological features in different imaging modalities, including chest radiography, echocardiography, computed tomography, and magnetic resonance imaging. We discuss the most common risk factors associated with this CVC complication. In our review, we found eight cases of hemodialysis patients. The most common risk factors associated with calcified fibrin sheath formation in the analyzed cases were pro-thrombotic and pro-calcification factors related to patient comorbidities, and prolonged catheter dwell time. Differentiating between a calcified fibrin sheath (present in about 6% of patients with long-term indwelling CVC as diagnosed by computed tomography) and a retained catheter tip can be challenging. The initial diagnosis based on imaging methods was incorrect in most of the analyzed cases. This suggests that some cases of retained fibrin sheaths may remain undetected or misinterpreted. This is important in patients with known pro-thrombotic and pro-calcification risk factors and prolonged catheter dwell time. Therefore, implementation of preventive strategies, familiarity with radiological findings of this phenomenon, comparison with previous imaging studies, and an overall comprehensive assessment with clinical data is imperative.

Epidemiology, prevalence and risk factors for infections in burn patients: results from a regional burn centre’s analysis

Burn patients are at high risk of infections due to severe impairment of immunity and loss of skin barrier function. We aimed to describe the epidemiology, incidence and risk factors for infection in a cohort of burns patients. Two hundred patients were retrospectively enrolled and subdivided into infected (N = 81) and uninfected groups (N = 119). The cumulative prevalence of infections was 27% on day 7 and 43.8% on day 28. Skin and soft tissue infections (32%) were the most frequent. Carbapenem-resistant Acinetobacter baumannii (28%), Pseudomonas aeruginosa (26%) and methicillin-resistant Staphylococcus aureus (25%) infections were most prevalent. An indwelling central venous catheter (CVC; sub-hazard ratio [SHR] 7.41, 95% confidence interval [CI] 3.78–14.62) and revised Baux score (RBS; SHR 2.08, 95% CI 0.98–4.42) were associated with higher incremental infection rate while surgical treatment resulted in a protective factor (SHR 0.45, 95% CI 0.29–0.75). RBS may be useful to stratify the infection risk: a strict collaboration between surgeons and infectious disease specialists is needed to implement source control and antimicrobial surveillance.

Superior Vena Cava Endocarditis in a Patient with Anterior Chest Wall Tunneled Catheter for Hemodialysis

Healthcare related bacterial endocarditis represents a significant portion of endocarditis seen today. Suspicion for these infections should be particularly high in patients with chronic indwelling central venous catheters, and most notably, in patients with hemodialysis catheters. These infections may have a predilection for the superior vena cava due to proximity of the catheters to the great veins of the neck. Transthoracic echocardiography and/or trans-esophageal echocardiography should be done promptly in patients in which there a high suspicion for such infections, in order to identify these lesions, and guide appropriate management with either antibiotics or surgical intervention. We present a 59-year-old female with multiple comorbidities including diabetes mellitus and end-stage renal disease requiring dialysis via an anterior chest wall catheter, who presented with fever, chills, and abdominal pain. She was found to have pus in and around her catheter. Further evaluation with trans-esophageal echocardiography revealed the presence of a superior vena cava vegetation extending into the right atrium. She received a 6 week course of appropriate antibiotics with repeat trans-esophageal echocardiography showing a significant reduction in the size of the vegetation. Patient remained afebrile, and without leukocytosis and negative blood cultures for the remainder of her hospital stay.

P708 Multimodality imaging of catheter-related right atrial thrombus: a case report

Abstract INTRODUCTION Catheter-related right atrial thrombosis (CRAT) is potentially life-threatening complication of long-term indwelling central venous catheters (CVC), which are used extensively in various patients. Reported incidence of CRAT is variable (2-62%) and probably underestimated due to predominantly asymptomatic course and lack of routine screening. Main pathogenic mechanisms that promote CRAT include mechanical and chemical injury of atrial endocardium by the catheter and infused drugs, stasis of blood and hypercoaguability. Differential diagnosis between thrombus and other intracardiac masses, especially myxoma, is sometimes very difficult and requires multimodality imaging studies. CASE PRESENTATION 62-years old patient after chemotherapy of lymphoma, in remission, with subcutaneous CVC inserted in right subclavian vein, which was used as chemotherapy port several years ago, was sent to emergency department because right atrial mass was found on elective outpatient transthoracic echocardiography (TTE). Urgent computed tomography (CT) was performed and showed well defined, 1.8 x 2.0 cm large, low attenuating mass with some calcifications. Several features were primarily suggestive of myxoma, however differentiation from thrombus was not possible. Patient was admitted to hospital, where transesophageal echocardiography (TEE) confirmed the presence of heterogenous mass attached to right atrial free wall with tumor-like movement. Mobile catheter tip was nearby and touching the mass irregularly. Although in addition to CT also some echocardiographic characteristics were more consistent with myxoma, there was still high clinical suspicion of CRAT due to multiple risk factors for thrombosis. Cardiac magnetic resonance imaging (MRI) using cine sequence was performed for further evaluation and revealed mobile, homogeneously low-signal intensity mass that remained hypointense on contrast-enhanced sequences (first pass perfusion and late gadolinium enhancement), which led to final diagnosis of thrombus. CONCLUSION CRAT should be suspected and anticipated in all, also asymptomatic patients with long-term indwelling CVC (e.g. for chemotherapy, parenteral nutrition, hemodialysis..), majority of whom have additional multiple risk factors for thrombosis. Routine screening for CRAT can provide early diagnosis and treatment and should be considered especially in high-risk patients in order to prevent potentially severe complications. Although echocardiography is the modality of choice for screening, further imaging modalities, e.g. CT and MRI are often required to differentiate thrombus from myxoma or other cardiac masses. Our case demonstrates difficult differential diagnosis of right atrial mass in an asymptomatic patient with a long-term indwelling chemotherapy port, in whom multimodality imaging studies were performed, but only MRI with contrast-enhanced sequences providing superior tissue characterization, could differentiate between CRAT and myxoma. Abstract P708 Figure. Multimodality imaging of atrial thrombus

Enteral Acetaminophen Bioavailability in Pediatric Intensive Care Patients Determined With an Oral Microtracer and Pharmacokinetic Modeling to Optimize Dosing.

Decreasing morbidity and mortality by rationalizing drug treatment in the critically ill is of paramount importance but challenging as the underlying clinical condition may lead to large variation in drug disposition and response. New microtracer methodology is now available to gain knowledge on drug disposition in the intensive care. On the basis of studies in healthy adults, physicians tend to assume that oral doses of acetaminophen will be completely absorbed and therefore prescribe the same dose per kilogram for oral and IV administration. As the oral bioavailability of acetaminophen in critically ill children is unknown, we designed a microtracer study to shed a light on this issue. An innovative microtracer study design with population pharmacokinetics. A tertiary referral PICU. Stable critically ill children, 0-6 years old, and already receiving IV acetaminophen. Concomitant administration of an oral C radiolabeled acetaminophen microtracer (3 ng/kg) with IV acetaminophen treatment (15 mg/kg every 6 hr). Blood was drawn from an indwelling arterial or central venous catheter up to 24 hours after C acetaminophen microtracer administration. Acetaminophen concentrations were measured by liquid chromatography-mass spectrometry and C concentrations by accelerated mass spectrometry. In 47 patients (median age of 6.1 mo; Q1-Q3, 1.8-20 mo) the mean enteral bioavailability was 72% (range, 11-91%). With a standard dose (15 mg/kg 4 times daily), therapeutic steady-state concentrations were 2.5 times more likely to be reached with IV than with oral administration. Microtracer studies present a new opportunity to gain knowledge on drug disposition in the intensive care. Using this modality in children in the pediatric intensive care, we showed that enteral administration of acetaminophen results in less predictable exposure and higher likelihood of subtherapeutic blood concentration than does IV administration. IV dosing may be preferable to ensure adequate pain relief.

The Risk Factors for Development of Sepsis in Newborns with a Central Venous Catheter and their Association with the Serum Zinc Levels

Introduction: Neonates with indwelling central venous catheters are at risk of developing the infection. Serum zinc plays a major role in mounting an immune response. Aim: To analyse the risk factors for development of sepsis in hitherto aseptic neonates with a centrally inserted venous catheter and to study their association with the serum zinc levels. Materials and Methods: After Institutional Ethics Committee Approval, 132 neonates were included who required Neonatal Intensive Care Unit (NICU) admission and had an indwelling central venous catheter and their serum zinc levels were measured. Only neonates who were proven aseptic at admission were included and were followed up for development of signs of sepsis using the Clinical Sepsis (CSEP) criteria, baseline septic screen parameters and blood culture, at admission and on the Day 5 along with catheter site culture. This was then correlated with their serum zinc levels and analysed by MannWhitney’s test using SPSS 17.0. Results: Out of 132 neonates, 19 had low and 113 neonates had normal zinc levels respectively (Zn 55µg/dL). A total of 25% neonates developed clinical sepsis by day 5 and 23.5% of neonates had positive catheter site culture. Neonates without clinical sepsis had slightly higher levels of zinc as compared to neonates who had clinical sepsis (147µg/dL and 141 µg/dL respectively). Neonates born to mothers without risk factors and neonates without perinatal asphyxia had higher zinc levels. Neonates with perinatal asphyxia showed statistically significant association with serum zinc levels (94.2 mcg/dL in asphyxiated newborns as compared to 131 mcg/dL in nonasphyxiated newborns). Neonates with significant bandneutrophil ratio on Day 5 had lower zinc levels than those with normal band-neutrophil ratio (107 µg/dL and 111 µg/dL). Conclusion: The risk factor for sepsis in neonates with indwelling catheters associated with zinc deficiency was perinatal asphyxia. Prematurity, low birth weight, maternal risk factors and clinically septic newborns had lower zinc levels,though statistically not significant.

The Incidence and Risk Factors of Venous Thromboembolism in Patients with Inflammatory Bowel Disease: A Prospective Multicenter Cohort Study

Background: Venous thromboembolism (VTE) has been shown to be more frequent in inflammatory bowel disease (IBD) than in the general population in Western studies. However, the actual state of VTE in Asian IBD remains poorly understood. Aims: To reveal the incidence of VTE in IBD patients in Japan. Methods: Eighty-five patients admitted to 3 gastroenterology centers were registered from 2013 to 2018. The incidence of VTE in patients with IBD (n = 42) was prospectively compared to that among patients with other digestive diseases (n = 43). The presence of VTE was surveyed using contrast-enhanced computed tomography and/or ultrasonography at admission and at 1–2 weeks after admission. The patient characteristics and laboratory data of IBD patients with or without VTE were compared to determine the risk factors for VTE. Results: The incidence of VTE with IBD was 16.7%, which was significantly more frequent than with other digestive diseases (2.3%; p = 0.0296). In IBD patients, VTE was detected in 6 of 22 patients with ulcerative colitis (27.2%) but in only 1 of 20 patients with Crohn’s disease (5.0%). VTE was diagnosed at admission in 4 IBD patients and 2 weeks after admission in 3 IBD patients. The risk factors of VTE in IBD were the presence of an indwelling central venous catheter, a low level of total protein, a low activated partial thromboplastin time, and a high level of fibrinogen degradation products. Conclusion: VTE was frequently detected in Japanese IBD patients both at and after admission. Adequate screening and prophylaxis for VTE is deemed necessary in IBD.

2322. Reduced Vancomycin Susceptibility Among Pediatric Staphylococcus aureus Bloodstream Infections

BackgroundReduced vancomycin susceptibility (RVS) is considered to be present when the minimum inhibitory concentration (MIC) is equal to 2 µg/mL. RVS Staphylococcus aureus (SA) bloodstream infections (BSI) have been associated with worse outcomes than non-RVS BSI in adults but not been well studied in children.MethodsWe reviewed the electronic medical records of infants and children admitted to Penn State Children’s Hospital with ≥1 blood culture positive for SA from 2005 to 2015. We abstracted demographic information, potential risk factors, laboratory results and clinical outcomes. We defined RVS as a vancomycin MIC = 2 µg/mL as determined by the clinical microbiology laboratory at the time of the infection. We used Chi square and Wilcoxon rank-sum tests to compare patient factors for RVS and non-RVS infections. Using a logistic regression adjusted for year and the presence of an infection-related complication, we calculated the odds of treatment failure for children with RVS and non-RVS BSI. For children with a central line in place at the time of the first positive culture, we also calculated the odds of treatment failure adjusted for year, presence of a complication and line removal. We defined treatment failure as death within 30 days of the first positive culture, recurrence of SA BSI within 30 days or a duration of bacteremia > 3 days.ResultsOf the 216 identified pediatric SA BSI, 139 (64%) had RVS: RVS was present in 63% of MSSA BSI and 65% of MRSA BSI, P = 0.835. There was no difference in age, sex, and racial distributions among children with RVS vs. non-RVS BSI. Similarly, hospitalization in the prior year, surgery within the prior 30 days, the presence of an underlying comorbidity or use of immunosuppressing medications were not more common for RVS vs. non-RVS BSI. RVS was not associated with an increased risk of treatment failure overall, odds ratio (OR)=1.34 (95% confidence interval: 0.71, 2.55), but did increase the odds of treatment failure if an indwelling central venous catheter was present and not removed, OR=3.14 (1.16, 8.54).ConclusionRVS is common among pediatric SA BSI. For central line associated SA BSI, RVS was associated with increased odds of treatment failure compared with non-RVS infections if the line was retained.Disclosures All authors: No reported disclosures.

206P - Incidence of catheter-related thrombosis in patients with long-term indwelling central venous catheter who received chemotherapies for unresectable advanced digestive cancers

206P - Incidence of catheter-related thrombosis in patients with long-term indwelling central venous catheter who received chemotherapies for unresectable advanced digestive cancers

Catheter-related infections in patients with acute type II intestinal failure admitted to a national centre: Incidence and outcomes

The management of intestinal failure (IF) requires safe and sustained delivery of parenteral nutrition (PN). The long-term maintenance of central venous catheter (CVC) access is therefore vital, with meticulous catheter care and salvage of infected CVCs being of prime importance. CVC-related infection and loss of intravenous access are important causes of morbidity and mortality in IF. Avoidance, prompt recognition and appropriate management of CVC-related infections are crucial components of IF care. However, there are few, if any, data on the occurrence of CVC-related infections in patients with acute, type 2, IF managed on a dedicated IF unit and no data on the salvage outcomes of infected CVCs in this group of patients. This is a retrospective observational study conducted between January 2011 and July 2017. All patients with acute, type 2 IF newly admitted to a national U.K. IF unit (IFU) during these dates were included. All patients admitted to the unit with a CVC in place underwent immediate 'screening' paired central and peripheral blood cultures on arrival before the CVC was used for any infusate. A prospectively maintained database was used to record all confirmed catheter-related blood stream infections (BSI)/colonisations, demographic and clinical data. Diagnosis of catheter-related BSI/colonisation was based on quantitative and qualitative analysis of paired central and peripheral blood cultures. A standardized 10-14-day catheter salvage treatment protocol involving antibiotic and urokinase CVC locks and systemic antibiotic administration was used to salvage any infected or colonised CVCs, as appropriate. The CVC was not used for PN until successful salvage had been confirmed by negative blood cultures drawn 48h after antibiotic completion. The development of a subsequent catheter-related BSI was recorded for all patients, both during the remaining in-patient stay on the IFU and after discharge home on PN. Of the 509 patients with type 2 IF admitted to the IFU during the study period, 341 (54% female; mean age 54.6 (range 16-86 years)) had an indwelling CVC that had been placed in the referring hospital. Surgical complications and mesenteric ischaemia were the most common underlying disease aetiologies. Sixty-five of 341 (19.1%) patients had an infected/colonised CVC on the initial screening set of blood cultures. A successful CVC salvage rate of 91% was achieved in this cohort after antibiotic therapy. The subsequent in-patient catheter-related BSI rate for those admitted with a CVC (n=341) on the IFU was 0.042 per 1000 catheter days, over a total of 23,548 in-patient catheter days. Two hundred and seventy nine of 341 patients were discharged on home PN (HPN); with a subsequent catheter-related BSI rate on HPN of 0.22 per 1000 catheter days (mean duration of HPN=778 catheter days (range:)) over a follow-up period of 216,944 out-patient catheter days. There was no increased risk of HPN-related catheter-related BSI (p=0.09) or mortality (p=0.4) in those admitted with an infected CVC. This is the first study to report catheter-related BSI/colonisation rates and salvage outcomes in patients with type 2 IF newly admitted to a dedicated IF Unit. We report that nearly one-fifth of all patients were referred with evidence of a catheter related BSI/colonisation; despite this, successful catheter salvage is possible and, with stringent CVC care, an extremely low subsequent catheter related BSI rates can be achieved and maintained during in-patient stay on a dedicated IF Unit and after discharge on HPN. These data provide novel evidence to support ESPEN recommendations that patients with type 2 IF are managed on a dedicated IF Unit.

Clinical and molecular characteristics, risk factors and outcomes of Carbapenem-resistant Klebsiella pneumoniae bloodstream infections in the intensive care unit

BackgroundTo analyze the clinical characteristics and outcomes of carbapenem-resistant Klebsiella pneumoniae (CRKp) and carbapenem-susceptible K. pneumoniae (CSKp) bloodstream infections (BSIs), and to study the risk factors for development of CRKp BSI and K. pneumoniae BSI-related mortality.MethodsA retrospective case control study of patients with K. pneumoniae BSI was conducted in the intensive care unit of the First Affiliated Hospital, Medical of College, Zhejiang University from January 2013 to December 2014. Carbapenem resistance was defined in accordance with the Clinical and Laboratory Standards Institute 2016 guidelines. Risk factors for the development of CRKp BSI and risk factors for mortality due to K. pneumoniae BSI were assessed. Virulence genes were detected by polymerase chain reaction assay.ResultsIn total, 48 patients were enrolled in the study, including 31 (65%) patients with CRKp BSI and 17 (35%) patients with CSKp BSI. CSKp infection was associated with more severe clinical symptoms, particularly a higher serum creatinine level (165.06 ± 127.01 in the CSKp group vs. 93.77 ± 84.35 μmol/L in the CRKp group, p = 0.039), but there was no significant difference in prognosis between the CSKp and CRKp groups. On multivariate analysis, indwelling central venous catheter (p = 0.045) was the only factor independently associated with CRKp bacteremia. However, the mortality of K. pneumoniae BSI patients was not correlated with carbapenem resistance. In addition, the isolates had diverse clonality and different origins. The frequency of detection of the allS and magA virulence genes was higher in the CSKp group than in the CRKp group (alls p = 0.04; magA p = 0.047).ConclusionsPatients in the CSKp group experienced more severe clinical symptoms, although mortality did not differ significantly between the CRKp and CSKp groups. An indwelling central venous catheter was the only factor independently associated with CRKp BSI. The mortality of patients with K. pneumoniae BSI was not associated with carbapenem resistance. The frequency of virulence genes was higher in the CSKp group than in the CRKp group.