Intravascular Infections Research Articles

Investigation of Chlorhexidine and Chitosan Gel-Based Coatings for the Prevention of Intravascular Catheter-Associated Infections Following Quality by Design Approach.

Intravascular catheter-associated infections pose a significant threat to the health of patients because of biofilm formation. Hence, it is imperative to exploit cost-effective approaches to improve patient compliance. With this aim, our present study reported the potential of an antimicrobial polymeric gel coating of chitosan (CS) and chlorhexidine (CHX) on the marketed urinary catheters to minimize the risk of biofilm formation. The study involved the implementation of the Quality by Design (QbD) approach by identifying the critical parameters that can affect the coating of the catheter's surface in any possible way. Later, design of experiments (DoE) analysis affirmed the lack of linearity in the model for the studied responses in a holistic manner. Moreover, in vitro studies were conducted for the evaluation of various parameters followed by the antibiofilm study. The coating exhibited promising release of CHX in the artificial urinary media together with retention of the coating on the catheter's surface. Therefore, this study aims to emphasize the importance of a systematic and quality-focused approach by contributing to the development of a safe, effective, and reliable catheter coating to enhance intravascular catheter safety.

Nationwide Analysis of Adult-Onset Still Disease With and Without Hemophagocytic Lymphohistiocytosis.

Adult-onset Still disease (AOSD) is a rare inflammatory condition with a monophasic, intermittent, or chronic clinical course, and a subset may experience life-threatening complications such as hemophagocytic lymphohistiocytosis (HLH). This study aims to characterize concurrent AOSD and HLH and identify variables independently associated with in-hospital death. We performed a medical records review of AOSD with and without HLH from the 2016-2019 National Inpatient Sample database. We performed a multivariable logistic regression analysis for in-hospital death. Results were reported as adjusted odds ratios (OR adj ). There were 5495 hospitalizations with AOSD, of which 340 (6.2%) had HLH. Thirty (9.0%) of the combined AOSD and HLH group died in the hospital compared with 75 (1.5%) of those without HLH. Multivariable analysis in AOSD inpatients showed that disseminated intravascular coagulation (OR adj 6.13), hepatic failure (OR adj 7.16), infection (OR adj 3.72), respiratory failure (OR adj 6.89), and thrombotic microangiopathy (OR adj 14.05) were associated with higher odds of death. However, HLH itself was not an independent predictor of mortality in AOSD population. HLH occurred in a small minority of inpatients with AOSD. HLH itself was not an independent risk factor for in-hospital death. Disseminated intravascular coagulation, hepatic failure, infection, respiratory failure, and thrombotic microangiopathy were associated with higher odds of in-hospital death in AOSD. Better awareness of these life-threatening complications may improve hospital outcomes.

Problems with the diagnosis of haemotropic mycoplasma - like infection in the European wisent (Bison bonasus)

A veterinarian treating wildlife must sometimes provide assistance to a sick animal based on incomplete data. Animals of special biological value are not the same as livestock. Some procedures routinely performed on domestic animals require pharmacological restraint in the veterinary service of large and dangerous wild animals. Therefore, such procedures are performed only in situations of absolute necessity. Such a situation took place in the Gdańsk zoo when a young European wisent (Bison bonasus) showed symptoms of haemotropic mycoplasma infection. Hemotropic mycoplasmas cause intravascular infection by attaching to red blood cells and triggering an immune response leading to elimination of the affected cells. This process can result in the development of hemolytic anemia. The case of suspected hemotropic mycoplasmosis in a European wisent described in this paper concerns an almost 2-year-old female, who lost her mother at the age of 11 months and from that time was the lowest in the hierarchy in the group of 10 wisents exposed at the zoo. The disease was manifested by emaciation, marked weakness, protrusion of the third eyelid and severe pallor of the mucous membranes. The sick animal was immobilized. Collected blood showed significant anemia (RBC 1.51 T/l, Ht 0.08 l/l), and microscopic imaging showed characteristic cells adjacent to erythrocytes suggestive of hemotropic mycoplasma infection. The animal was treated with a long-acting oxytetracycline administered three times a week, for 6 weeks. At the end of the 6-week treatment the wisent was immobilized and it was found that the nutritional status of the animal improved, the third eyelid returned to its physiological state and the pallor of the mucous membranes disappeared completely. Examination proved that the red blood cells and hematocrit reached a state that could be interpreted as physiological (RBC 4.89 T/l, Ht 0.26 l/l0, no microscopic changes of RBCs. Unfortunately, the available laboratory methods did not confirm the presence of mycoplasma genetic material. However, the efficacy of the used antibiotic therapy could be a confirmation that the disease was caused by hemotropic mycoplasmas.

Improved Genomic Prediction of Staphylococcus epidermidis Isolation Sources with a Novel Polygenic Score.

Staphylococcus epidermidis infections can be challenging to diagnose due to the species frequent contamination of clinical specimens and indolent course of infection. Nevertheless, S. epidermidis is the major cause of late-onset sepsis among premature infants and of intravascular infection in all age groups. Prior work has shown that bacterial virulence factors, antimicrobial resistances, and strains have up to 80% in-sample accuracy to distinguish hospital from community sources, but are unable to distinguish true bacteremia from blood culture contamination. Here, a phylogeny-informed genome-wide association study of 88 isolates was used to estimate effect sizes of particular genomic variants for isolation sources. A "polygenic score" was calculated for each isolate as the summed effect sizes of its repertoire of genomic variants. Predictive models of isolation sources based on polygenic scores were tested with in-samples and out-samples from prior studies of different patient populations. Polygenic scores from accessory genes (AGs) distinguished hospital from community sources with the highest accuracy to date, up to 98% for in-samples and 65% to 91% for various out-samples, whereas scores from single nucleotide polymorphisms (SNPs) had lower accuracy. Scores from AGs and SNPs achieved the highest in-sample accuracy to date, up to 76%, in distinguishing infection from contaminant sources within a hospital. Model training and testing data sets with more similar population structures resulted in more accurate predictions. This study reports the first use of a polygenic score for predicting a complex bacterial phenotype and shows the potential of this approach for enhancing S. epidermidis diagnosis.

1097A: THERAPEUTIC PLASMA EXCHANGE FOR THROMBOTIC MICROANGIOPATHY ASSOCIATED WITH PANCREATITIS IN A CHILD

Introduction: Thrombotic microangiopathy (TMA) is characterized by thrombocytopenia and microangiopathic hemolytic anemia (MAHA). These features reflect the presence of an active microvascular endotheliopathy. TMA has been reported as a rare complication of acute pancreatitis in adults, with good outcomes after therapeutic plasma exchange (TPE). Sparse pediatric literature addresses the association of TMA and pancreatitis, or the merit of TPE for this indication. Description: A 13-year-old obese male with no previous medical history was admitted to the pediatric intensive care unit for management of acute pancreatitis and kidney injury after two days of abdominal pain, nausea, emesis, and decreased urine output. After fluid resuscitation, his initial labs revealed a lipase of 8520U/L, AST 153U/L, ALT 150U/L, Hgb 14g/dL, WBC 23,000/uL, Platelets 58,000/uL, INR 1.3, BUN 37mg/dL and Cr 4.06mg/dL. A non-contrast CT scan confirmed radiographic evidence of acute pancreatitis. He was afebrile, with stable hemodynamics and a reassuring neurological exam. His hemoglobin decreased to 10.8g/dL 24 hours after admission with subsequent workup suggestive of hemolysis (haptoglobin < 30mg/dL, LDH 4898U/L, schistocytes on peripheral blood smear). A diagnosis of MAHA with thrombocytopenia was established and TPE was initiated. Common underlying conditions associated with TMA such as disseminated intravascular coagulation, infection, drug-induced, autoimmune disorders and malignancy were addressed and ruled out. Complement levels (C3 and C4) were normal, direct/indirect Coombs were negative and ADAMTS13 activity was normal (>60%). The patient received three days of TPE with improvement in platelet counts to 102,000/uL and decrease in LDH to 486U/L after the third session. Renal replacement therapy (RRT) was required for nine days after TPE with good recovery of renal function. He was discharged on hospital day 19 with downtrending Cr 0.78mg/dL and lipase 53U/L. He was tolerating a regular diet without volume restriction prior to discharge. Discussion: Thrombocytopenia and MAHA should raise a suspicion for TMA in children presenting with acute pancreatitis. Acute renal failure requiring RRT is a frequent comorbidity. TPE with RRT may be effective and lifesaving in these patients.

Infection Control in Intensive Care Units

Infections acquired in the hospitals, especially in the intensive care unit (ICU) settings, ranging between 15% and 20%, may further lead to complications in >40% in critically ill patients. The order of incidence may vary in different settings, but the most usual causes are ventilator-associated pneumonia, intravascular catheter-associated bloodstream infection, catheter-associated urinary tract infection, posttraumatic intra-abdominal infection, and surgical site infection. These can be prevented by adequate and appropriate application of preventive strategies, which can be implemented strictly at the bedside. The basic norms for surveillance strategies, general preventive measures such as standard and isolation precautions and monitoring of antibiotic use should be followed without fail. Specific practical measures for ICU-related infections should be in place, and the monitoring of activities should be documented regularly as “bundle-care” in view of standardizing the practice, irrespective of place or person. Adequate attention, unfortunately, has not been paid for infection control measures in India for years. It is now mandatory that the essential practices are prioritized and integrated fully into regular hospital administrative procedure as a continuous process for improving quality health care.

In-silico screening and identification of potential bioactive compounds of Trifolium repens against pathogenic bacterial target proteins

From medicinal plants, a number of bioactive substances have been discovered and reported in the past, including flavonoids, alkaloids, phenols, tannins, saponins, and sterols. To identify the most effective natural bioactive compounds against the target proteins of bacteria, the bioactive compounds from T. repens have been studied in the current work. Numerous infections like chronic sinusitis, otitis media, intravascular catheter infection, pacemaker infection, peritoneal dialysis, urinary infection, prosthetic joint infection, pulmonary infection, and keratitis are caused by biofilm-forming bacteria. The increased rate of biofilm formation has threatened life forms as they show resistance to most antibiotics. During in-silico analysis, among the nine bioactive compounds listed, two bioactive compounds namely Trifolin and Naringenin were selected as their biological activity has not been reported. The optimum binding affinities between ligand–protein were chosen after screening study of 22 target proteins from Staphylococcus aureus, Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus faecalis, and Klebsiella pneumoniae. The effects of trifolin and naringenin, two naturally occurring bioactive chemicals from T. repens, on several bacterial biofilm target proteins were investigated. An in-silico study was carried out to determine the interaction between the ligand and receptor (target proteins). The top docking poses showed multiple conventional hydrogen bond, which indicated a high binding affinity with the bacterial target biofilm proteins.

Prevalence of Contrast-Induced Acute Kidney Injury in Acute Ischemic Stroke Patients Undergoing Contrast-Enhanced CT Angiography at a Tertiary Care Centre

BACKGROUND&#x0D; Multimodal Computed Tomography (CT) imaging with contrast-enhanced CT angiography (CTA) is frequently being used to guide the management of acute ischemic stroke. The administration of contrast media (CM) may lead to nephrotoxicity. However, little has been reported about the safety of intravenous CM exposure in acute stroke patients. This study aims to evaluate whether there is a significant change in renal function following contrast agent administration, determine the proportion of patients developing contrast-induced acute kidney injury(CI-AKI), and analyze the risk factors associated with the same.&#x0D; METHODS&#x0D; We analysed 138 patients with acute ischemic stroke who underwent emergency CTA at our centre, followed up on the renal parameters and prospectively evaluated them for the development of CI-AKI. The patients who developed CI-AKI were analysed for specific risk factors and categorized into risk groups based on a pre-validated risk score. Univariate and multivariate logistic regression was done to identify independent predictors of CI-AKI.&#x0D; RESULTS&#x0D; CI-AKI occurred in 19 patients (13.7%). Significant (p&lt;0.001) changes in renal parameters were observed following contrast administration irrespective of whether it satisfied the criteria for CI-AKI. Most of the patients had a low-risk score for CI-AKI. The predicted risk of CI-AKI based on the Mehran Risk Score (MRS) was similar to that observed in our study population. No patient had to be on haemodialysis. Raised baseline S.creatinine(p-value&lt;0.03), Diabetes with microangiopathy(p-value&lt;0.001), and systemic hypertension(p-value&lt;0.001) were significant predictors for CI-AKI.&#x0D; CONCLUSIONS&#x0D; The development of renal sequelae is low in acute ischemic stroke patients undergoing contrast imaging. Prompt CTA, if indicated, need not be delayed in those with no history of renal impairment or without relevant risk factors. A practical reflection of this study is to be cognizant of the renal risks that an in-patient stroke population is exposed to as Intravascular depletion, infections(urinary tract infections, pneumonia), and nephrotoxic medications.

Peripheral intravascular catheter-associated bloodstream infection in the medical–surgical ICU

Background: Prompt removal of unnecessary central venous catheters (CVC) may reduce central-line–associated bloodstream infection (CLABSI). Primary non–central-line–associated hospital-acquired bloodstream infection (BSI), including peripheral intravascular (PIV) catheter-associated bloodstream infection (PIVABSI) remains a problem. Hospitals use CLABSI surveillance data to measure patient safety, yet this measure alone fails to describe the burden of total intravascular device-related infection. We described non-CLABSI primary BSI due to PIV in our medical–surgical ICU population. Methods: Hospital-wide surveillance for primary hospital-acquired BSI, including CLABSI, was conducted in accordance with NHSN protocol. We measured PIV catheter days and central-line days using a database including nursing device documentation and patient census data to count the number of patients with 1 or more devices in place in each location, counted at the same time each day. By substituting the role of the CVC with short or midline PIV in NHSN CLABSI surveillance protocols, we performed surveillance for PIVABSI. We defined PIVABSI as a patient without CVC and either a short or midline catheter in place for &gt;2 calendar days on the date of BSI. Patients with BSI and both CVC and PIV were counted as CLABSI. We compared CVC and PIV utilization and the incidence density of CLABSI and PIVABSI in 8 medical and surgical ICUs at our large teaching hospital. We used OpenEpi version 3.01 software to test the hypothesis that the incidence density of CLABSI would be significantly different from that of PIVABSI. Results: From January to September 2021, there were 16 CLABSIs and 12 primary non–central-line–associated hospital-acquired BSIs, all 12 were PIVABSIs. Of these 12, 8 had &gt;1 PIV in place and none were midlines. There were 13,418 central-line days, 10,897 short and midline peripheral IV days, and 22,415 patient days, resulting in device utilization ratios of 0.60 and 0.49, respectively. The incidence density of CLABSI was 1.2 per 1,000 central-line days, although the incidence density of PIVABSI was 1.1 per 1,000 peripheral IV days (P = .84). There was no difference in pathogens between the 2 groups. Conclusions: PIVABSI represented more than one-third of the total primary hospital-acquired BSIs in our medical and surgical ICUs. Total BSI surveillance is feasible. Efforts to reduce CLABSI should be part of a broader strategy to decrease total hospital-acquired BSI from all vascular access devices.Funding: NoneDisclosures: None

A precision medicine approach to hereditary hemorrhagic telangiectasia and complex vascular anomalies

Vascular anomalies represent a diverse group of disorders classified broadly as malformations or tumors and include the second most common hereditary bleeding disorder worldwide, hereditary hemorrhagic telangiectasia (HHT). Patients with HHT and other vascular anomalies suffer morbid consequences of these diseases, including bleeding, thrombosis, anemia, localized intravascular coagulation, tissue overgrowth, infections, and other complications. The International Society for the Study of Vascular Anomalies (ISSVA) has developed a standard classification of these disorders, creating a uniform approach to their diagnosis, and the treatments for vascular anomalies are rapidly evolving. Recent discoveries have elucidated the molecular basis of a number of common and uncommon vascular anomalies. HHT occurs due to mutations in the transforming growth factor beta (TGF‐β) pathway, resulting in vascular endothelial growth factor excess. Complex vascular anomalies including Klippel‐Trénaunay syndrome (KTS) and arteriovenous malformation (AVM) may occur due to mutations in the PI3K/AKT/mTOR and RAS/MAPK/MEK pathways. The discovery of the pathophysiologic mechanisms driving these diseases has led to improved phenotype–genotype correlation and the opportunity to target molecular pathways with medical therapies. Therefore, targeted agents have quickly become a standard of care in the treatment of vascular disorders (particularly HHT). Herein, we provide a case‐based approach to the use of antiangiogenic therapies including bevacizumab and pazopanib for the treatment of bleeding in HHT and the use of mammalian target of rapamycin (sirolimus), PIK3CA (alpelisib), and MEK (trametinib) inhibitors in the treatment of complex vascular anomalies.

Bacterial DNA load in Staphylococcus aureus bacteremia is significantly higher in intravascular infections.

ObjectivesDetermination of pathogen-specific bacterial DNA load (BDL) in blood has been shown to be directly correlated with severity of infection in patients with bacteremia. In the diagnostic work-up of patients with Staphylococcus aureus bacteremia (SAB), determination of the primary focus is imperative, because of implications for treatment duration, and ultimately prognosis. Here we investigate whether measurement of BDL in patients with SAB can distinguish between intravascular and extravascular foci of infection.MethodsIn a consecutive cohort of 43 patients with positive blood cultures with Staphylococcus aureus, we performed a quantitative PCR on whole blood to detect the bacterial DNA load. Infections were classified into 3 categories: i) soft tissue infections and phlebitis, ii) deep-seated infections and iii) endocarditis and other intravascular infections. Bacterial DNA loads and inflammatory parameters in the three categories were analyzed and compared.ResultsMedian BDL in patients with endocarditis and other intravascular infections was 1015 cfu/ml, significantly higher than BDL in the other two categories (28 and 31 cfu/ml respectively). In contrast, CRP and leukocytes were not significantly different between the three patient categories. BDL could be detected in all patients with intravascular causes and levels were generally 10–30 times higher than in the other infection categories. Median BDL in non-survivors was 85 cfu/ml, which was higher than in survivors with a median BDL of 29 cfu/ml, although not significant.ConclusionsIn Staphylococcus aureus bacteremia pathogen-specific BDL is distinctly higher in patients with intravascular infections compared to extravascular origins. As measurement of BDL by PCR can easily be implemented in routine diagnostics, it can improve the diagnostic work-up of SAB by rapidly identifying the subset of patients who need higher dosages of antibiotics and additional measures to improve outcome.

Identifying biofilm-forming strains of Staphylococcus epidermidis isolated from intravascular-catheterized patients by icaA and icaD genes

Abstract Staphylococcus epidermidis has gained a substantial importance in recent years because it is one of the main causative agents of nosocomial infections. It requires a predisposed host in order to switch from a normal inhabitant of the human skin to a pathogenic flora. This study aimed to use icaA/icaD genes as biomarkers in differentiating biofilm-forming S. epidermidis, obtained from patients with intravascular catheter (IVC) infections, from other saprophytic strains. Twenty isolates of S. epidermidis obtained from 100 cases of intravascular catheter infections were investigated for the presence of the intracellular adhesion icaA and icaD genes by polymerase chain reaction (PCR) and for phenotypic biofilm production by qualitative Congo red agar assay (CRA). Results: Nine (~45%) S. epidermidis isolates out of 20 isolates collected from IVC infections were positive for both CRA (produce black colonies) and icaA/icaD genes; while 11 (~55%) S. epidermidis isolates were negative for CRA and icaA/icaD genes. Detection of icaA/icaD gene is a reliable, efficient, and more rapid tool for characterizing biofilm-forming strains of S. epidermidis. Keywords: Staphylococcus epidermidis; icaA; icaD; biofilm

Diagnostic efficacy of WT1 expression in asymptomatic acute promyelocytic leukemia

We report a case of early asymptomatic acute promyelocytic leukemia (APL) with leukopenia as the only hematologic abnormality. A 55-year-old woman was referred to our hospital with leukopenia (white blood cell [WBC] count of 1,500/µl with 36% neutrophils), which was incidentally determined during an annual medical checkup. Two months before the presentation, her WBC was 3,400/µl with 60% neutrophils. A WBC count was 1,200/µl with 40% neutrophils. Immature myeloid cells were not observed. Her hemoglobin level and platelet count were normal. Moreover, no clinical or laboratory evidence was suggestive of disseminated intravascular coagulation or infection. The peripheral blood WT1 mRNA level was increased to 26,000 copies/µg RNA. The bone marrow aspirate smear revealed 40% myeloperoxidase-positive promyelocytes with occasional Auer rods and faggots; however, circulating leukemia cells were not revealed by cell morphology or flow cytometry analysis. Quantitative reverse-transcription polymerase chain reaction analysis revealed WT1 and PML-RARA fusion transcripts in both the peripheral blood and bone marrow samples. Thus, the determination of peripheral blood WT1 expression may be sufficiently sensitive for detecting a small number of circulating APL cells.

Practices and intravascular catheter infection during on- and off-hours in critically ill patients

BackgroundThe potential relationship between intravascular catheter infections with their insertion during weekend or night-time (i.e., off-hours or not regular business hours) remains an open issue. Our primary aim was to describe differences between patients and catheters inserted during on- versus off-hours. Our secondary aim was to investigate whether insertions during off-hours influenced the intravascular catheter infectious risks.MethodsWe performed a post hoc analysis using the databases from four large randomized-controlled trials. Adult patients were recruited in French ICUs as soon as they required central venous catheters or peripheral arterial (AC) catheter insertion. Off-hours started at 6 P.M. until 8:30 A.M. during the week; at weekend, we defined off-hours from 1 P.M. on Saturday to 8.30 A.M. on Monday. We performed multivariable marginal Cox models to estimate the effect of off-hours (versus on-hours) on major catheter-related infections (MCRI) and catheter-related bloodstream infections (CRBSIs).ResultsWe included 7241 patients in 25 different ICUs, and 15,208 catheters, including 7226 and 7982 catheters inserted during off- and on-hours, respectively. Catheters inserted during off-hours were removed after 4 days (IQR 2, 9) in median, whereas catheters inserted during on-hours remained in place for 6 days (IQR 3,10; p < 0.01) in median. Femoral insertion was more frequent during off-hours. Among central venous catheters and after adjusting for well-known risk factors for intravascular catheter infection, we found a similar risk between off- and on-hours for MCRI (HR 0.91, 95% CI 0.61–1.37, p = 0.65) and CRBSI (HR 1.05, 95% CI 0.65–1.68, p = 0.85). Among central venous catheters with a dwell-time > 4 or > 6 days, we found a similar risk for MCRI and CRBSI between off- and on-hours. Similar results were observed for ACs.ConclusionsOff-hours did not increase the risk of intravascular catheter infections compared to on-hours. Off-hours insertion is not a sufficient reason for early catheter removal, even if femoral route has been selected.

Thrombocytopenia in pregnant women.

Thrombocytopenia is one of the two most common hematological problems in pregnant women. It is defined as the platelet (PLT) count below 150 × 103/μL. Gestational incidental thrombocytopenia (GIT) represents about 75% of thrombocytopenia cases in pregnancy and it is believed that GIT is secondary to accelerated platelet destruction and increased plasma volume associated with pregnancy. The pregnancy complications such as preeclampsia and its most severe form - HELLP syndrome account for 20% cases of thrombocytopenia in pregnancy and primary immune thrombocytopenic purpura (ITP) - for 3-4 percent. During ITP, maternal antiplatelet antibodies can pass through the placenta and bind to fetal thrombocytes leading to the development of fetal thrombocytopenia which occurs in about 50% cases. Even if the maternal platelet count stabilizes, the estimated fetal and neonatal risk of thrombocytopenia in ITP is approximately 30%. Other types of thrombocytopenia in pregnant women constitute 1-2% of cases (disseminated intravascular coagulation, autoimmunological diseases, congenital, infection and drug-related, concomitant with blood neoplastic diseases). Although thrombocytopenia in pregnant women usually has a mild course, in case of a significant decrease in PLT count may lead to dangerous bleeding, especially when the platelet count falls below 20 × 103/μL. Since it is important to identify the cause of thrombocytopenia and to determine the risk for both the mother and the child, this paper presents the influence of maternal thrombocytopenia on the pregnancy course as well as its etiology and diagnostics. The treatment principles are discussed.

Late onset infection of covered and bare metal arterial stents.

The objective was to present the case of a late covered iliac stent late infection and report a comprehensive literature review on diagnosis and outcomes in this setting. A comprehensive review of the literature was performed through MedLine by two independent reviewers from 1990 to 2020 on reported cases of arterial stent late onset infection over arterial stents. The data about on the risk factors, clinical presentation, treatment and outcomes were collected. Twenty-two studies were selected as pertinent for the analysis, totalling 24 patients including the indexed case. Infection occurred at a median of 22months postoperatively (range 2-120months) over a bare metal stent in 66.7% (n 16) of cases versus 33.3% (n 8) over a covered stent. Clinical presentation included local symptoms (local pain, oedema, petechiae or skin rash) in 21 (87.5%) cases and non-specific systemic symptoms (fever, sepsis, chills and leucocytosis) in 8 cases (33.3%). In 4 cases (16.7%), patients presented with haemorrhagic shock upon arterial rupture. The bacteria most frequently encountered were S. aureus (54.2% of cases). Several factors were supposed to be responsible for the infection including among which procedure-related (non-aseptic technique, lack of prophylactic antibiotics and repetitive punctures at the access site) or related to pre-existing patient's clinical conditions (immunosuppression, diabetes and concurrent infection) have been considered responsible for the infection. Treatment consisted in antibiotics alone (2 patients, 8.3%) or in association with surgical explant, both with or and without revascularization (n 21, 87.5%). In one case, an endovascular coiling was performed. Complications occurred in 29.2% (n 7) of cases and included the need for amputation, bowel resection, endocarditis, pulmonary failure or pneumonia. Overall, three patients (12.5%) died from a septic shock or multi-organ failure. Intravascular stent infection is a rare but fearsome condition associated with high morbidity and mortality.

Short-Course Versus Long-Course Systemic Antibiotic Treatment for Uncomplicated Intravascular Catheter-Related Bloodstream Infections due to Gram-Negative Bacteria, Enterococci or Coagulase-Negative Staphylococci: A Systematic Review.

IntroductionThe optimal duration of systemic antimicrobial treatment for catheter-related bloodstream infections (CRBSI) is unknown. In this systematic review, we aimed to assess the efficacy of short-course treatment for CRBSI due to Gram-negative bacteria, coagulase-negative staphylococci and enterococci.MethodsWe systematically searched the electronic bibliographic databases MEDLINE, EMBASE and Cochrane Library for studies published before February 2021. All studies that investigated the duration of adequate systemic antibiotic treatment in adult patients with uncomplicated intravascular catheter infections due to Gram-negative bacteria, coagulase-negative staphylococci or enterococci were eligible for inclusion. Studies including concomitant treatment with antibiotic lock therapy were excluded. The primary outcomes were clinical failure/cure, mortality and microbiologic-confirmed relapse.ResultsSeven retrospective cohort studies and one case-cohort study met the inclusion criteria. No randomized controlled studies met inclusion criteria. The quality of the included studies was low (n = 7) to moderate (n = 1). No significant differences were observed regarding mortality and microbiological relapse between short-course and long-course systemic antibiotic treatment in patients with CRBSI due to coagulase-negative staphylococci or Gram-negative bacteria. No association was found between mortality and treatment duration in the two studies assessing enterococcal CRBSI.ConclusionThe limited data available suggests that shorter systemic antibiotic treatment duration may be sufficient for uncomplicated CRBSI. Further well-designed prospective studies are needed to confirm these findings.Trial Registration NumberCRD42021224946 (PROSPERO)Supplementary InformationThe online version contains supplementary material available at 10.1007/s40121-021-00464-0.

Diagnostic stewardship based on patient profiles: differential approaches in acute versus chronic infectious syndromes

ABSTRACT Introduction: New diagnostics may be useful in clinical practice, especially in contexts of high prevalence of multidrug-resistant organisms (MDRO). However, misuse of diagnostic tools may lead to increased costs and worse patient outcome. Conventional and new techniques should be appropriately positioned in diagnostic algorithms to guide an appropriate use of antimicrobial therapy. Areas covered: A panel of experts identified 4 main areas in which the implementation of diagnostic stewardship is needed. Among chronic infections, bone and prosthetic joint infections and subacute-chronic intravascular infections and endocarditis represent common challenges for clinicians. Among acute infections, bloodstream infections and community-acquired pneumonia may be associated with high mortality and require appropriate diagnostic approach. Expert opinion: Diagnostic stewardship aims to improve the appropriate use of microbiological diagnostics to guide therapeutic decisions through appropriate and timely diagnostic testing. Here, diagnostic algorithms based on different patient profiles are proposed for chronic and acute clinical syndromes. In each clinical scenario, combining conventional and new diagnostic techniques is crucial to make a rapid and accurate diagnosis and to guide the selection of antimicrobial therapy. Barriers related to the implementation of new rapid diagnostic tools, such as high initial costs, may be overcome through their rational and structured use.

Obesity and risk of catheter-related infections in the ICU. A post hoc analysis of four large randomized controlled trials.

Obesity increases the risk of nosocomial infection, but data regarding the role of body mass index (BMI) in catheter related infections are scarce. We used the data gathered from four randomized, controlled trials (RCTs) to investigate the association between body mass index (BMI) and intravascular catheter infections in critically ill obese patients. Adult obese patients who required short-term central venous, arterial or dialysis catheter insertion in the intensive care unit (ICU) were analyzed. The association between BMI and major catheter-related infection (MCRI), catheter-related bloodstream infection (CRBSI) and catheter tip colonization was estimated using univariate and multivariate marginal Cox models. Exploratory analysis using dressing disruptions was added. A total of 2282 obese patients and 4275 catheters from 32 centers were included in this post-hoc analysis. Overall, 66 (1.5%) MCRI, 43 (1%) CRBSI and 399 (9.3%) catheter colonizations were identified. The hazard ratio (HR) for MCRI, CRBSI and colonization increased with BMI. After adjustment for well-known infection risk factors, the BMI ≥ 40 group had an increased risk for MCRI (HR 1.88, 95% CI 1.13-3.12, p = 0.015), CRBSI (HR 2.19, 95% CI 1.19-4.04, p = 0.012) and colonization (HR 1.44, 95% CI 1.12-1.84, p = 0.0038) compared to the BMI < 40 group. The mean dressing disruption per catheter was increased in the BMI ≥ 40 group (2.03 versus 1.68 in the BMI < 40 group, p = 0.05). Using the largest dataset ever collected from large multicentric RCTs, we showed that patients with BMI ≥ 40 had an increased risk for intravascular catheter infections. Targeted prevention measures should focus on this population with a particular attention to catheter care and dressing disruption.

Salvage Treatment with Cefiderocol Regimens in Two Intravascular Foreign Body Infections by MDR Gram-Negative Pathogens, Involving Non-Removable Devices.

IntroductionThe objective of this study was to describe two challenging cases of intravascular foreign body infections caused by multidrug-resistant Gram-negative pathogens requiring complex antimicrobial regimens including cefiderocol and successfully treated without implant removal.MethodsClinical charts and microbiological reports of the clinical cases.ResultsCase 1 included a left ventricular assist device (HEARTMATE 3™Abbot®) infection due to Achromobacter xylosoxidans, while case 2 included a portal prosthesis infection due to Pseudomonas aeruginosa. As the pathogens were multidrug-resistant (MDR), both cases required antimicrobial regimens with cefiderocol; treatment was successful without implant removal. Importantly, case 1 presented a probable, drug-induced thrombocytopenia, a non-previously described side effect related to cefiderocol.ConclusionCefiderocol may be an additional, promising drug to the available arsenal, even for challenging foreign body infections caused by MDR Gram-negative pathogens.