Long-term Central Venous Catheters Research Articles

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

Effectiveness, safety and cost reduction of long-term tunneled central venous catheter insertion in outpatients performed by an interventional nephrologist.

Introduction:Invasive procedures performed by trained nephrologists can reduce delays in making a definitive vascular access, complications, number of procedures on the same patient, and costs for the Public Health System.Objective:to demonstrate that a long-term tunneled central venous catheter (LTCVC) implanted by a nephrologist is safe, effective, and associated with excellent results.Methods:A retrospective study analyzed 149 consecutively performed temporary-to-long-term tunneled central venous catheter conversions in the operating room (OR) from a dialysis facility from March 2014 to September 2017. The data collected consisted of the total procedures performed, demographic characteristics of the study population, rates of success, aborted procedure, failure, complications, and catheter survival, and costs.Results:the main causes of end stage renal disease (ESRD) were systemic arterial hypertension and diabetes mellitus, 37.9% each. Patients had a high number of previous arteriovenous fistula (1.72 ± 0.84) and temporary catheter (2.87 ± 1.9) attempts until a definitive vascular access was achieved, while the preferred vascular site was right internal jugular vein (80%). Success, abortion, and failure rates were 93.3%, 2.7% and 4%, respectively, with only 5.36% of complications (minors). Overall LTCVC survival rates over 1, 3, 6, and 12 months were 93.38, 71.81, 54.36, and 30.2%, respectively, with a mean of 298 ± 280 days (median 198 days). The procedure cost was around 496 dollars. Catheter dysfunction was the main reason for catheter removal (34%).Conclusion:Our analysis shows that placement of LTCVC by a nephrologist in an OR of a dialysis center is effective, safe, and results in substantial cost savings.

Practical anatomical landmark for optimal positioning of left-sided long-term central venous catheter (a pilot study).

Background:Long-term central venous catheter (CVC) insertion in dialysis patients is an accepted method of hemodialysis. The appropriate CVC tip placement may reduce both early and late complications related to catheter and increase patency rate. This study aimed to evaluate a new, simple, and feasible method based on surface anatomy for the proper placement of tunneled CVC in the left internal jugular vein for hemodialysis or chemotherapy.Materials and Methods:The study was carried out as a quasi-experimental model at Saint Al-Zahra Education Hospital in 2016. A total of forty patients with an indication of left-sided (upper) long-term CVC insertion were enrolled. The length of catheter to be inserted in the left internal jugular vein was considered as the sum of distance from the insertion point of the needle up to sternal notch plus the total distance between the left and right sternoclavicular joint and half-length of the sternum. The right atrium (RA) or superior vena cava-RA junction was the correct region for inserting the catheter tip. The collected data were analyzed using Fisher's exact test and t-test using SPSS (version 22).Results:The patients were 63.75 ± 17.96 years of age, weighed 67.33 ± 13.20 kg, and height of 166.92 ± 8.99 cm. Catheters were inserted successfully in 95% of patients (n = 38). No significant relationship was found between the success of new method and age, gender, height, weight, body mass index, and sternum half-length plus the distance between the right and left sternoclavicular joint.Conclusion:“The mid – sternal length plus sternoclavicular joints spacing” as a new formula (based on anatomical landmarks) was found practical and safe and could easily be used among adult patients who undergo tunneled CVC in the left internal jugular vein.

Infective endocarditis in children: A 10-year multicentric study

Congenital heart disease (CHD) represents a predisposing condition for the development of infective endocarditis (IE). In recent years, the reduction in the incidence of rheumatic heart disease, advances in cardiac surgery and the increased use of long-term central venous catheters (CVC) in subjects without CHD have changed significantly the epidemiology of the disease. We sought to evaluate the epidemiology of IE in children in the north of France. We retrospectively included all children < 18 years hospitalised for IE in 2008-2018 in 4 tertiary centres. Demographic, underlying conditions, echocardiography, microbiology and outcomes were collected. We identified 64 episodes of IE in 60 children. Incidence was 3,07/10 000 paediatric hospitalisations. Median age was 8 years [0–13] and distribution was bimodal with peaks in infancy and adolescence. An organism pathogen was isolated in 87% of cases. The most common was Staphylococcus aureus (34%) then streptococcus (25%). At echocardiography, anomalies were vegetations ( n = 32), new valvular regurgitations ( n = 10), peri valvular abscesses ( n = 2). Among cohort, 45 had a CHD (70%), 7 were pre-term birth (11%), 2 had long-term CVCs and 10 no predisposition. Non-CHD patients were significantly younger than CHD patients ( Table 1 ). Anomalies at echocardiography and identification of pathogen were more common in non-CHD patients. Among CHD patients, 38 (84%) had previous heart surgery and 10 presented an IE < 2 months after surgery. Pulmonary bioprosthetic valve were involved in 22 cases and mechanical valve in three. Cardiac surgery was needed in 26 cases (41%) including valve replacement in half of them. Complications of IE occurred in 35 (58%) including emboli, mycotic aneurysm, cerebral haemorrhage and myocardial abscess. IE mostly occurred in predisposed children. IE in CHD and non-CHD patients has different features, diagnosis is more arduous and needs more investigation as nuclear medicine imaging.

The Profile of Microorganisms Responsible for Port-Related Bacteremia in Pediatric Hemato-Oncological Patients.

Patients with pediatric cancer face an increased risk of infections. In most cases, these infections are associated with the use of a long-term central venous catheter. This study describes the epidemiology of a port-associated bacteremia as well as a profile of microorganisms responsible for port-associated bloodstream infections (PABSIs) in pediatric patients with cancer treated in a single center. The retrospective analysis included patients with cancer who had implanted a port, hospitalized between 2010 and 2015 at the Department of Pediatric Oncology, Hematology and Bone Marrow Transplantation, Poznan University of Medical Sciences. The medical records of patients were reviewed for demographic characteristics, diagnosis, port-related complications, and their management. Data were collected from patients’ electronic medical records containing complete information on medical examinations and supplementary tests, diagnosis, timing, and type of port-associated complications. In a study period, 277 ports were inserted to 241 patients. A total of 183 094 catheter days were analyzed. Sixteen patients had more than 1 insertion of a port. The commonest observed complication was PABSI (40.07%) and the incidence density was 0.6 per 1000 port-days. Staphylococcus was the most commonly isolated organisms from patients with PABSI. From all port-associated complications, bloodstream infections and mechanical complications were the most often observed complications. The commonest pathogens responsible for PABSI were coagulase-negative staphylococci. Pathogens resistant to standard antibiotic treatment play an important role in PABSI, with methicillin-resistant Staphylococcus epidermidis being the predominant pathogen. Port-associated bloodstream infections are a common reason for preterm removal of a port.

A Five-Year Data Report of Long-Term Central Venous Catheters Focusing on Early Complications.

Background Long-term venous access has become the standard practice for the administration of chemotherapy, fluid therapy, antibiotics, and parenteral nutrition. The most commonly used methods are percutaneous puncture of the subclavian and internal jugular veins using the Seldinger technique or surgical cutdown of the cephalic vein. Methods This study is based on a quality registry including all long-term central venous catheter insertion procedures performed in patients >18 years at our department during a five-year period. The following data were registered: demographic data, main diagnosis and indications for the procedure, preoperative blood samples, type of catheter, the venous access used, and the procedure time. In addition, procedural and early postoperative complications were registered: unsuccessful procedures, malpositioned catheters, pneumothorax, hematoma complications, infections, nerve injuries, and wound ruptures. The Seldinger technique using anatomical landmarks at the left subclavian vein was the preferred access. Fluoroscopy was not used. Results One thousand one hundred and one procedures were performed. In eight (0.7%) cases, the insertion of a catheter was not possible, 23 (2.1%) catheters were incorrectly positioned, twelve (1.1%) patients developed pneumothorax, nine (0.8%) developed hematoma, and three (0.27%) developed infection postoperatively. One (0.1%) patient suffered nerve injury, which totally recovered. No wound ruptures were observed. Conclusions We have a high success rate of first-attempt insertions compared with other published data, as well as an acceptable and low rate of pneumothorax, hematoma, and infections. However, the number of malpositioned catheters was relatively high. This could probably have been avoided with routine use of fluoroscopy during the procedure.

Interventions for Occluded Central Venous Catheters: A Meta-analysis.

Thrombotic occlusion is 1 of the most frequent complications in catheters implanted in children. To identify the interventions used to treat thrombotic events in long-term central venous catheters in pediatric patients with cancer. Electronic searches were performed in the Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Latin American and Caribbean Health Sciences Literature, LIVIVO, PubMed, Scopus, Web of Science, Google Scholar, OpenGrey, and ProQuest databases. There were no restrictions on language or publication period. This systematic review was performed in 2 phases and included clinical trials and observational studies on drugs used to treat thrombotic catheter events in pediatric patients with cancer. The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis checklist, and the protocol was registered at PROSPERO (identifier CRD42018083555). The authors evaluated the quality of included studies using the Methodological Index for Nonrandomized Studies and Grading of Recommendations Assessment, Development and Evaluation methods. The meta-analysis was performed by using Stata software. Ten studies were included. The drugs used to restore catheter function were alteplase, urokinase, and streptokinase. A meta-analysis of 6 studies revealed an overall restoration rate of 88% for alteplase. Reference studies were excluded when it was not possible to reliably extract data that met the inclusion criteria of this review. Sampling issues (absence of randomization, blinding, or a control group) were the main methodologic concerns for the included articles. On the basis of the evidence obtained, thrombolysis is effective and potentially safe in this population.

Time to and differential time to blood culture positivity for assessing catheter-related yeast fungaemia: A longitudinal, 7-year study in a single university hospital.

Time to positivity (TTP) and differential time to positivity (DTTP) between central and peripheral blood cultures are commonly used for bacteraemia to evaluate the likelihood of central venous catheter (CVC)-related bloodstream infection. Few studies have addressed these approaches to yeast fungaemia. This study aimed to evaluate TTP and DTTP to assess CVC-related yeast fungaemia (CVC-RYF). We retrospectively analysed the results from 105 adult patients with incident fungaemia, with CVC removed and cultured, collected from 2010 to 2017. The bottles were incubated in a BioMérieux BacT/ALERT 3D and kept for at least 5days. Of the 105 patients included, most were oncology patients (85.7%) and had of long-term CVC (79.6%); 32 (30.5%) had a culture-positive CVC (defined as CVC-RYF) with the same species as in blood culture, and 69.5% had culture-negative CVC (defined as non-CVC-RYF, NCVC-RYF). Candida albicans represented 46% of the episodes. The median TTP was statistically different between CVC-RYF and NCVC-RYF (16.8hours interquartile range (IQR) [9.7-28.6] vs 29.4hours [IQR 20.7-41.3]; P=.001). A TTP <10hours had the best positive likelihood ratio (21.5) for CVC-RYF, although the sensitivity was only 28%. DTTP was available for 52 patients. A DTTP >5hours had a sensitivity of 100% and a specificity of 71% for CVC-RYF. Since the median TTP was 17hours and the most performing DTTP >5hours, these delays are too long to take a decision in the same operational day. More rapid methods for detecting infected catheters should be tested to avoid unnecessary CVC withdrawal.

Dressings for the central venous catheter to prevent infection in patients undergoing hematopoietic stem cell transplantation: a systematic review and meta-analysis

To identify the most effective dressing for covering long-term central venous catheter exit site to prevent catheter-related infections and skin irritation in patients undergoing hematopoietic stem cell transplantation. Systematic Review. The search was performed in the following electronic databases: CINAHL, Cochrane Library CENTRAL, EMBASE, LILACS, PubMed, Scopus, and Web of Science. Google Scholar was used for the gray literature search. Seven studies were included which tested different arrangements of dressings: sterilized gauze and adhesive tape with a transparent polyurethane film (n = 2), transparent polyurethane film with a different replacement interval frequency (n = 2), transparent polyurethane film with and without chlorhexidine released continuously by the dressing at the site of intravascular catheter insertion (n = 2), and dressings vs. no dressings (n = 1). The meta-analysis for catheter-related infection prevention showed no difference between type of dressing (RR 1.76, [95% CI 0.82; 3.75], I2 0%) and for the replacement frequency at different intervals (RR 1.04, [95% CI 0.67; 1.61], I2 0%). The meta-analysis for skin irritation evaluated the transparent polyurethane film replacement frequency and indicated that a longer dressing replacement interval (10 to 15days) reduces the risk of developing this outcome (RR 0.71, 0.52; 0.96, 95% CI, I2 24%). Regarding the type of the dressing, there is no evidence indicating the best dressing. Although there is no evidence available for the ideal replacement frequency, the risk to develop skin irritation is reduced in longer dressing replacements intervals.

P4.45: Infective Endocarditis as a complication of central venous catheters used for Home Parenteral Nutrition: experience from a national Intestinal Failure Centre

Introduction:, The management of intestinal failure (IF) requires the safe and sustained delivery of parenteral nutrition (PN) via long-term central venous catheters (CVCs). Infective Endocarditis (IE) is a recognised complication of indwelling CVCs in a number of medical conditions, for example, the incidence of IE was 483 per 100 000 person-years in haemodialysis patients, while it was 6.5 per 100 000 person-years in the general US population. Indeed, recent ESPEN guidelines on the management of acute (type 2) and chronic (type 3) IF highlight IE as a potential complication. However, there are no published data on the incidence and outcomes of IE in patients with IF. Methods: This is an observational study conducted on all patients with type 2 or 3 IF admitted to a national IF Unit between January 2010 and December 2017. Patients with transthoracic(TTE) and/or transoesophageal(TOE) echocardiography evidence of IE were identified from a prospectively maintained IF database and hospital coded procedures. The diagnosis of IE was based upon Modified Duke’s Criteria, with positive blood cultures, together with a characteristic vegetation appearance on echocardiography, in combination with expert cardiology review. Details of organisms, heart valves involved and antibiotics prescribed were extracted from the patient notes, together with appropriate clinical outcomes. Results: 332 of 432 patients with indwelling CVCs admitted during the study period underwent a total of 534 echocardiograms. 513 TTE and 21TOE were performed. 2 patients were diagnosed with IE both involving native aortic valves and both visible on TTE and TOE. One patient (diagnosed with Enterococcus faecalis IE) had type 2 IF at admission from a referring hospital for ongoing treatment for IE with persistent pyrexia, splinter haemorrhages and regurgitant murmur; clinical symptoms resolved with IV Amoxicillin and Gentamicin but valve replacement was required due to severe Aortic Regurgitation. The second patient (Coagulase-negative Staphylococcus with type 3 IF) was admitted with a CRBSI, low grade pyrexia and intermittent rigors and treated with IV vancomycin and currently remains under cardiology follow up pending potential valve replacement. Conclusions: CVC-associated IE is a very rare complication of CVCs implanted for types 2 and 3 IF. However, as noted in our case series, the potential morbidity associated with this condition means that a high index of suspicion should be maintained.

Central Line-Associated Bloodstream Infections in Children With Hematologic and Oncologic Diseases: First Prevalence Results From a University Hospital.

Central line-associated bloodstream infections (CLABSIs) are still a major cause of morbidity and mortality in pediatric hematology-oncology patients in many countries. This cross-sectional study was a retrospective review of CLABSI in inpatient pediatric hematology-oncology cases with long-term central venous catheter at the Pediatric Hematology Department from January 2013 to June 2014. Characteristics of CLABSI events in pediatric patients with hematologic malignancies and related nonmalignant hematologic conditions are documented. CLABSI developed in 61.8% (n = 21) of the 34 hospitalized patients included in the study. The CLABSI rate was 7.8 per 1,000 inpatient central venous catheter days. Coagulase-negative staphylococci was the predominant pathogen in 47.6% of the patients with CLABSI. The high rate of CLABSI requires prevention strategies to reduce CLABSI immediately. This study provides guidance in prioritizing strategies for reducing rates of infection.

Ethanol Lock Therapy for the Prevention of Nontunneled Catheter-Related Bloodstream Infection in Pediatric Patients.

Ethanol lock therapy (ELT) has been reported as being effective in preventing central line-associated bloodstream infection (CLABSI) in tunneled (or long-term) central venous catheters (CVCs). To the best of our knowledge, no studies have evaluated this therapy in relation to nontunneled (or short-term) CVCs. To evaluate the effectiveness of ELT in preventing CLABSI in nontunneled CVC in pediatric patients. This randomized clinical trial was conducted with children aged 0-5 years and >2 kg in weight, in whom a double-lumen polyurethane nontunneled CVC had been inserted. Patients with catheters inserted in an emergency situation, critically ill patients, and/or those with a history of hypersensitivity or allergic reactions to ethanol were excluded from the study. The variables evaluated were CLABSI, etiological agents, adverse events, and the mechanical effects of ethanol on the catheter (breakage and obstruction). The CLABSI rate was lower in the ELT group compared with the control group (P = 0.0177). However, when the occurrence of CLABSI was evaluated per 1000 catheter-days, no significant difference was found between the groups (P = 0.077). The frequency of side effects and catheter breakage was greater in the ELT group (P = 0.0001 and P = 0.0005, respectively). The CLABSI rate was statistically significantly reduced in the ELT group compared with the controls, but the analysis of frequency per catheter-day showed no significant difference between the groups. Thus, we should not recommend ELT for CLABSI prophylaxis in nontunneled polyurethane CVC, which requires further clinical trials.

Application of Parafilm As a Physical Barrier on CVC Connections Is Feasible and May Reduce Clabsi Among Pediatric HCT Patients

Central line associated bloodstream infections (CLABSI) result in significant morbidity and mortality in hematopoietic cell transplantation (HCT) patients. Pediatric data is sparse, and previous/current interventions may impact bacterial flora and antibiotic resistance. Risks in pediatric HCT patients include prolonged immunosuppression, long-term central venous catheter (CVC) need, and external environmental contamination. Parafilm is made of paraffin and primarily utilized to seal/protect containers in laboratories; applied as a barrier, it significantly reduced CLABSI in TPN-dependent pediatric short gut patients. We hypothesized that parafilm application on CVC connections would be feasible and reduce CLABSI occurrence in pediatric HCT patients. The aims of this non-randomized pilot quality improvement initiative were to examine the feasibility of parafilm as a physical barrier on CVC tubing connections and obtain preliminary data to support its use preventing CLABSI among pediatric HCT patients. This IRB-approved cohort study included pediatric patients ages 0-21, with a tunneled external CVC, who were undergoing allogeneic or autologous HCT for any indication. Patients receiving other interventions to prevent CLABSI were ineligible. Parafilm was supplied in pre-cut 2 × 2 inch, single-use sections. It was applied over the CVC hub (if not connected) or around the CVC connection sites (if connected) and was reapplied at least once daily, as well as when connections were accessed or at the caregiver's discretion. Data were collected on patient, disease, and HCT characteristics as well as standard HCT outcomes and compared to a historical control group. The occurrence of NHSN/CDC-defined CLABSI was compared between groups using pairwise comparison, with significance defined as p Forty-eight patients undergoing first HCT from 6/2015-1/2017 received parafilm and were compared to historical control patients (n=71; HCT in preceding 16 months). No difference in age, sex, indication for HCT, stem cell source, or type of HCT was observed between groups. Patients receiving parafilm had a CLABSI rate of 3.69 per 1000 line days, compared to 4.37 for historical controls (p=0.6919). Univariate analysis of all patients demonstrated no impact of HCT type or sex on CLABSI rate, although the rate was lower in patients transplanted for a non-malignant disease compared to solid tumor (p=0.0326). Application of parafilm as a protective CVC barrier in pediatric HCT patients is feasible, and it may lead to a decrease in CLABSI. Sub-analyses are ongoing to see if parafilm may be more beneficial in subset(s) of patients, such as younger aged patients who remain in diapers or patients with graft-versus-host disease. Future trials will examine the use of a novel device, created specifically to protect CVC hubs/connection sites from environmental contamination, to reduce CLABSI.

Salvage Strategy for Long-Term Central Venous Catheter-Associated Staphylococcus aureus Infections in Children.

Introduction: Current international guidelines strongly recommend catheter removal in case of S. aureus central line-associated bloodstream infection (CLASBI), but a catheter salvage strategy may be considered in children given age-related specificities. No data is available regarding the outcome of this strategy in children. This study aims to evaluate catheter salvage strategy in children with S. aureus CLABSI, and to determine treatment failure rates and associated risk factors.Methods: We retrospectively analyzed data for all children <18 years having S. aureus CLABSI on a long-term central venous catheter in a tertiary hospital from 2010 to 2014. We defined catheter salvage strategy as a central venous catheter left in place ≥3 days after initiation of empiric treatment for suspected bacteremia, and catheter salvage strategy failure as the persistence or relapse of bacteremia with a S. aureus strain harboring the same antibiotic susceptibility pattern, or the occurrence or the worsening of local or systemic infectious complication between 72 h and 28 days after the first positive blood culture.Results: During the study period, 49 cases of S. aureus CLABSI on long-term central venous catheters were observed in 41 children (including 59% with long-term parenteral nutrition) and 6 (15%) isolates were resistant to methicillin. A catheter salvage strategy was chosen in 37/49 (76%) cases and failed in 12/37 (32%) cases. Initial presence of bloodstream co-infection, serum concentration of vancomycin under the targeted value and inadequate empiric treatment were significantly associated with catheter salvage therapy failure.Conclusions: The catheter salvage strategy of S. aureus CLABSI on a long-term central venous catheter was frequent in the studied hospital and failed only in one third of cases.

Breast oncology and the COVID-19 pandemic: Recommendations from the Brazilian Society of Clinical Oncology (SBOC)

The current pandemic moment of severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) has completely changed health services, with most services being directed to the treatment of affected patients. Even during this critical period, cancer patients need to be treated, as delayed treatment can compromise the chances of a cure. The Brazilian Society of Clinical Oncology (SBOC) has developed recommendations to guide decisions in breast cancer treatment during the SARS-CoV-2 pandemic through their Breast Tumors Committee. Due to the scarcity of relevant data, discussions on systemic treatment and surgical decisions related to breast cancer biological sub- types, chemotherapy schemes, anti-HER2 therapy, adjuvant endocrine therapy, breast surgery, radiotherapy, follow-up and routine exams, long-term central venous catheters, bisphosphonate and denosumab, genetic counseling and metastatic disease were evaluated and recommendations were issued. For newly diagnosed breast cancer, if appropriate, start systemic treatment with neoadjuvant endocrine therapy or neoadjuvant chemotherapy (NACT) with anti-HER2 blockage if HER2 positive disease. Surgery should be promptly considered if disease progression during NACT, malignant phyllodes tumor or breast sarcoma. These recommendations should be adjusted according to the reality of each service (private or public) and according to the epidemiological issues COVID19 presents in each area and revised recommendations may arise at any time.

Associated factors and clinical outcomes of bloodstream infection due to extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae during febrile neutropenia

Patients with neutropenia are vulnerable to serious infections. During the last decade, increased prevalence of extended-spectrum ß-lactamase (ESBL)-producing Enterobacteriaceae has affected immunocompromised patients. We conducted a single-center case-control study to evaluate factors associated with ESBL-positive bacteremia among neutropenic patients, and its clinical impact. The study included adult patients with hematologic or oncologic diseases diagnosed with ESBL-positive and ESBL-negative Escherichia coli or Klebsiella pneumoniae bacteremia during febrile neutropenia between January 2010 and October 2017 at the Shaare Zedek Medical Center, Jerusalem, Israel. Analyses included risk factors for ESBL-positive bacteremia, appropriateness of empiric antibiotics, mortality, length of stay, and intensive care unit (ICU) admission. Univariate and multivariate models were constructed. The cohort (80 patients), consisted of 54 ESBL-negative and 26 ESBL-positive Gram-negative bacteremia. Multivariate analysis suggested ESBL-positive bacteremia to be associated with long-term central venous catheter (CVC) (odds ratio (OR), 8.7; 95% confidence interval (CI), 1.6-48.1; P=0.01], index culture obtained 48 h post-admission (OR, 3.6; 95% CI, 1-12.3; P=0.04), and exposure to previous antimicrobial therapy (OR, 12.6; 95% CI, 2.1-74; P<0.01). There were no significant differences between groups with regard to length of stay, ICU admission, or mortality rates. Mortality was associated with high Pitt bacteremia score but not inappropriate empirical therapy. Previous antimicrobial therapy, long-term CVC, and hospital-acquired bacteremia were associated with ESBL bacteremia. Neutropenic patients with ESBL bacteremia have increased morality due to other factors than ESBL status. These findings should be validated in other centers and with larger populations.

2092. How Long Should You Delay Insertion of a Long-Term Central Venous Catheter (LTCVC) in Patients with Candida Bloodstream Infection (CBSI)?

BackgroundGuidelines suggest that among patients with candidemia, placement of an LTCVC, often needed for treatment, can proceed when “additional blood cultures show no growth” but the timeframe is not well defined. There is theoretical risk of relapsed CBSI after therapy if yeast are still circulating in the blood and adhere to the LTCVC. We sought to determine the blood culture time to detection (TTD) for candida to identify a timeframe for LTCVC insertion that would mitigate risk for relapsed CBSI.MethodsWe conducted a retrospective cohort study of all positive (+) blood cultures for Candida species (albicans, glabrata, tropicalis, parapsilosis, dubliniensis, krusei, and lusitaniae) isolated from August 1, 2013–December 31, 2017. Data were retrieved from the microbiology laboratory and the BD BACTEC™ blood culture system was used. TTD was recorded for each (+) blood culture in hours and the mean TTD was calculated by species.ResultsOne hundred and twenty-eight blood cultures were (+) for Candida species. C. glabrata was the most common species isolated, followed by C. albicans and C. parapsilosis. Overall, the mean TTD was 43 hours (range 7.1–117.7 hours); 19.5% were positive within 24 hours, 67.2% within 48 hours, and 86.7% within 72 hours, and none required more than 120 hours (table).ConclusionAmong patients with candidemia, the majority of blood cultures were positive within 72 hours after inoculation and all were positive within 120 hours; however, among the three most common species, 16.3% required more than 72 hours. Waiting 120 hours before insertion of a LTVC should mitigate risk for relapsed CBSITable.TTD for Candida Species Isolated from Blood Culture# (%)TTD (Hours)# (+) Within 24 Hours (%)# (+) Within 48 Hours (%)# (+) Within 72 Hours (%)# (+) Between>72–120 Hours (%)MeanMedian C. glabrata 52 (40.6)44338 (15.4)27 (51.9)8 (15.4)9 (17.3) C. albicans 27 (21.1)48493 (11.1)10 (37)10 (37)4 (14.8) C. parapsilosis 25 (19.5)45385 (20)12 (48)4 (16)4 (16) C. tropicalis 14 (10.9)34345 (35.7)6 (42.8)3 (21.4)0 C. krusei 6 (4.7)31292 (33.3)4 (66.7)00 C. dubliniensis 3 (2.3)23192 (66.7)1 (33.3)00 C. lusitaniae 1 (0.8)303001(100)00 Total 128433725 (19.5)61 (47.7)25 (19.5)17 (13.3)Disclosures All authors: No reported disclosures.

2110. Taurolidine-Citrate Lock Solution for the Prevention of Central-Line-associated Bloodstream Infection (CLABSI) in Pediatric Hematology-Oncology and Gastrointestinal Failure Patients with High Baseline CLABSI Rates

BackgroundCatheter- line-associated bloodstream infection (CLABSI) is a serious complication of patients on long-term central venous catheters (CVC). Taurolidine-citrate solution (TCS) is a catheter-lock solution with broad- spectrum antimicrobial action that prevents biofilm formation. The aim of this study was to evaluate the efficacy of TCS in reducing CLABSI rate in pediatric patients with long-term CVC at a tertiary children’s hospital.MethodsThis was an open-label trial of hematology-oncology (H/O) and gastrointestinal (GI) inpatients with the following inclusion criteria: Pediatric patients < 17 years of age, at least 1 previous CLABSI, required long-term CVC, e.g., long-term parenteral nutrition or undergoing chemotherapy for malignancy and have a minimum dwell time of at least 8 hours for TCS. The period of surveillance was from each patient’s first CVC insertion till December 14, 2017 or discontinuation of TCS. CLABSI was calculated based on the number of CVC-associated BSI per 1,000 catheter-days. Statistics were derived using SPSS 19.0 and the student T-test for paired samples and nonparametric Wilcoxon analysis for two-related-samples test with a P value of < 0.05. OpenEpi v3.01 was used to compare 2 person-time rates and rate ratios with 95% confidence intervals.ResultsThirty-four patients were recruited with a median age of 3.4 years (IQR 1.5–10.1 years). H/O patients constituted 58.8% (n = 20) and GI patients 41.2% (n = 14). The majority of CVC were Hickman line (n = 16, 47.1%) followed by Port-a-Cath (n = 8, 23.5%) and PICC (n = 10, 29.4%). The median duration of TCS usage was 138 days (IQR 62.50–307.25 days). The longest duration of TCS was 1737 days (4.8 years). Median pre- and post-TCS CLABSI rates for the whole cohort, H/O and GI patients were 14.92 ± 13.50 and 2.65 ± 4.31 (P < 0.001); 16.55 ± 12.96 and 2.81 ± 4.66 (P < 0.001); 12.59 ± 14.39 and 2.42 ± 3.91 (P = 0.011) per 1000 catheter days respectively. For the whole cohort, pre and post-TCS rate ratio was 0.20 (95% CI 0.12–0.33, P < 0.001). TCS reduced markedly the risk of CLABSI for the whole cohort by 80%; for H/O patients by 79% and GI patients by 88%.ConclusionTaurolidine-citrate solution was highly successful in reducing CLABSI rates by 80% in patients on long-term CVC with high baseline CLABSI rates.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

Interventions to obstructive long-term central venous catheter in cancer patients: a meta-analysis.

The aim of this systematic review was to identify the interventions used to treat obstructive events, whether thrombotic or non-thrombotic, in long-term central venous catheters (LT-CVC) in cancer patients. This review included clinical trials and observational studies reporting the drugs used to treat obstructive catheter events in cancer patients. The authors developed specific search strategies for CINAHL, Cochrane CENTRAL, LILACS, PubMed, Scopus, Web of Science, Google Scholar, Open Grey, and ProQuest. The authors evaluated methodological quality of included studies using criteria from Cochrane's Collaboration Tool and the Methodological Index for non-randomized studies (MINORS). The quality of evidence was analyzed by using GRADE's software. More than 9000 articles were found across the databases. After duplicates removed, the studies were selected in 2 phases. After that, only 15 studies were included. The drugs used to restoration of catheter function were urokinase (53.3%), alteplase (20%), tenecteplase (13.3%), reteplase (6.7%), recombinant urokinase (6.7%), and staphylokinase (6.7%). The results of meta-analysis of 14 studies showed an overall restoration rate of ~ 84%. The drug type meta-analysis demonstrates a success rate of ~ 84%, ~ 92%, and ~ 84% for urokinase, alteplase, and tenecteplase groups, respectively. The main methodological problem in included articles concerns the sample. The quality of evidence ranged from very low to high. The most common interventions used to treat thrombotic catheter occlusion in cancer patients were urokinase and alteplase. No evidence was found about the treatment for non-thrombotic occlusion, thus elucidating an important gap to be investigated.