Non-tunneled Central Venous Catheters Research Articles

MT28 A Systematic Literature Review of the Burden Associated with Insertion of Non-Tunneled Central Venous Catheters and the Effectiveness of Ultrasound-Guided Insertion

MT28 A Systematic Literature Review of the Burden Associated with Insertion of Non-Tunneled Central Venous Catheters and the Effectiveness of Ultrasound-Guided Insertion

Central line-associated bloodstream infection (CLABSI) with three different vascular access in neonatal intensive care unit

BackgroundCentral venous catheters (CVCs) are a mandatory aspect in the neonatal intensive care units. Unfortunately, bloodstream infection is a frequent complication of CVCs. A needleless connector is attached to the end of CVC to allow infusion of fluids. We aimed to assess the effect of needleless connectors on central line-associated blood stream infection, and to assess rate of occurrence of bloodstream infection with the use of three different types of venous access in neonates.MethodsThis study is a prospective, randomized, comparative study which was held at the Neonatal Intensive Care, Faculty of Medicine, Ain Shams University. The study recruited 120 neonates who were categorized into three groups according to the type of inserted CVC: group A with umbilical venous catheter, group B with peripherally inserted central catheter, and group C with non-tunneled central venous catheter, and each group was further subdivided into two groups according to the use of needleless connector. Criteria of central line-associated bloodstream infection (CLABSI) and central line-related bloodstream infection (CLRBSI) were applied.ResultsThe study included 120 neonates, a multivariable logistic regression analysis was held for two predictors (type of CVC and use of needleless connector) of CLABSI/CLRBSI, it revealed that the use of needleless connector was associated with significant lower incidence of CLABSI/CLRBSI (P value < 0.05, adjusted odds ratio [aOR] = 0.303), the use of peripheral inserted central catheter (PICC) was also associated with the lowest incidence of CLABSI/CLRBSI (P value = 0.015, aOR = 0.284). Another multivariable logistic regression analysis was done for four predictors (type of CVC, use of needleless connector, gestational age, and catheter dwell time) which revealed that the gestational age (P value = 0.001, aOR = 0.691) and catheter dwell time (P value = 0.004, aOR = 1.313) were the only independent predictors for the occurrence of CLABSI/CLRBSI.ConclusionThe use of needleless connector can lower the incidence of CLABSI/CLRBSI, PICC line was associated with the lowest incidence of CLABSI/CLRBSI among the three types of CVCs. Low gestational age and long catheter dwell time were found to be the main risk factors for increasing the incidence of CLABSI/CLRBSI.

Central venous catheter-related complications in older haemodialysis patients: A multicentre observational cohort study.

Central venous catheters (CVC) remain a commonly used vascular access option in haemodialysis, despite guidelines advising to preferably use arteriovenous fistulae. Compared to younger patients, the risk-benefit ratio of CVC in older patients might be more beneficial, but previous studies mainly focussed on catheter-related bacteraemia and/or assessed tunnelled CVC (TCVC) only. This study's aim was to compare all catheter-related infections and malfunctions in older patients with younger patients using all CVC subtypes. We used data from DUCATHO, a multicentre observational cohort study in The Netherlands. All adult patients in whom a CVC was placed for haemodialysis between 2012 and 2016 were included. The primary endpoint was the occurrence of catheter-related infections, comparing patients aged ⩾70 years with patients aged <70 years (reference). As secondary endpoints, catheter malfunctions and catheter removal due to either infection or malfunction were assessed. Using Cox proportional hazards and recurrent events modelling, hazard ratios (HR) with 95% confidence intervals (CI) were calculated with adjustment of prespecified confounders. Additionally, endpoints were assessed for non-tunnelled CVC (NTCVC) and TCVC separately. A total of 1595 patients with 2731 CVC (66.5% NTCVC, 33.1% TCVC) were included. Of these patients, 1001 (62.8%) were aged <70 years and 594 (37.2%) ⩾70 years. No statistically significant difference was found for the occurrence of catheter-related infections (adjusted HR 0.80-95% CI 0.62-1.02), catheter malfunction (adjusted HR 0.94-95% CI 0.75-1.17) and catheter removal due to infection or malfunction (adjusted HR 0.94-95% CI 0.80-1.11). Results were comparable when assessing NTCVC and TCVC separately. Patients aged ⩾70 to <70 years have a comparable risk for the occurrence of catheter-related infections and catheter malfunction. These findings may help when discussing treatment options with older patients starting haemodialysis and may inform the current debate on the best vascular access for these patients.

Pre-Procedure Thrombocytopenia and Leukopenia Association with Risk for Infection in Image-Guided Tunneled Central Venous Catheter Placement.

Placement of image-guided tunneled and non-tunneled large-bore central venous catheters (CVCs) are common procedures in interventional radiology. Although leukopenia and/or thrombocytopenia are common at the time of placement, the roles these factors may have in subsequent catheter-related infection have yet to be investigated. A single-institution retrospective review was performed in patients who underwent CVC placement in interventional radiology between 11/2018–6/2019. The electronic medical record was used to obtain demographics, procedure details, pre-placement laboratory values, and the subsequent 90-day follow-up. A total of 178 tunneled and non-tunneled CVCs met inclusion criteria during this time period. White blood cell (WBC) and platelet counts were found to be significant risk factors for subsequent infection. Administration of pre-procedure antibiotics was not found to be a significant factor for subsequent infection (p = 0.075). Leukopenia and thrombocytopenia at the time of CVC placement are both risk factors of line infection for tunneled large-bore CVCs. This should lead to the consideration of using a non-tunneled CVC when clinically feasible, or the delayed placement of these catheters until counts recover.

Retrospective Assessment of Patient and Catheter Characteristics Associated With Malpositioned Central Venous Catheters in Pediatric Patients.

The primary objective was to determine the prevalence and characteristics associated with malpositioned temporary, nontunneled central venous catheters (CVCs) placed via the internal jugular (IJ) and subclavian (SC) veins in pediatric patients. Single-center retrospective cohort study. Quaternary academic PICU. Children greater than 1 month to less than 18 years who had a CVC placed between January 2014 and December 2018. None. The primary outcome was the CVC tip position located on the first postprocedural radiograph. CVC tip was defined as follows: "recommended" (tip location between the carina and two vertebral bodies inferior to the carina), "high" (tip location between one and four vertebral bodies superior to the carina), "low" (tip position three or more vertebral bodies inferior to the carina), and "other" (tip grossly malpositioned). Seven hundred eighty-one CVCs were included: 481 (61.6%) were in "recommended" position, 157 (20.1%) were "high," 131 (16.8%) were "low," and 12 (1.5%) were "other." Multiple multinomial regression (referenced to "recommended" position) showed that left-sided catheters (adjusted odds ratio [aOR], 2.00, 95% CI 1.17-3.40) were associated with "high" CVC tip positions, whereas weight greater than or equal to 40 kg had decreased odds of having a "high" CVC tip compared with the reference (aOR, 0.45; 95% CI, 0.24-0.83). Further, weight category 20-40 kg (aOR, 2.42; 95% CI, 1.38-4.23) and females (aOR, 1.51; 95% CI, 1.01-2.26) were associated with "low" CVC tip positions. There was no difference in rates of central line-associated blood stream infection, venous thromboembolism, or tissue plasminogen activator usage or dose between the CVCs with tips outside and those within the recommended location. The prevalence of IJ and SC CVC tips outside of the recommended location was high. Left-sided catheters, patient weight, and sex were associated with malposition. Malpositioned catheters were not associated with increased harm.

Early removal of central venous catheter may not impact the in-hospital mortality in patients with acute leukemia.

Central venous catheters (CVCs) are generally required for chemotherapy in patients with acute leukemia, but catheter-related infection is one of the common causes of neutropenic fever. We investigated the in-hospital mortality according to early removal of CVCs and the factors influencing the mortality in patients with acute leukemia undergoing remission induction chemotherapy. This study retrospectively analyzed the hospital record data of 278 patients with acute leukemia treated with non-tunneled CVCs and remission induction chemotherapy in a single institution. Bloodstream infection was more common (p < 0.0001) and median peak C-reactive protein (CRP) levels after neutropenic fever were significantly higher (23.3 vs. 14.5mg/dl, p = 0.003) in the group with early removal than in the group with maintenance of the CVC. Multivariate analysis of the patients revealed a significant decrease in the mortality with female gender (odds ratio (OR): 0.19, 95% confidence interval (CI): 0.06-0.54, p = 0.002) and a significant increase in the mortality according to the peak CRP (OR 1.12, 95% CI: 1.07-1.17, p < 0.0001). By contrast, early removal of the CVC had no significant effect on the mortality (OR = 1.16, 95% CI: 0.54-2.47, p = 0.706) in univariate analysis. Furthermore, subsequent bloodstream infection after clinical decision for maintenance or early removal of the CVC was confirmed more frequently in the group with early removal (early removal, 22.6%; maintenance, 7.6%, p < 0.0001). Early removal of the CVC had no benefit regarding the mortality and prophylaxis of bloodstream infection in patients with acute leukemia undergoing remission induction chemotherapy. Therefore, maintaining a CVC for as long as possible may be considered, if catheter-related bloodstream infection is not strongly suspected.

Patterns of vascular access device use and thrombosis outcomes in patients with COVID-19: a pilot multi-site study of Michigan hospitals.

Venous thromboembolism (VTE) is an important complication of coronavirus disease 2019 (COVID-19). To date, few studies have described vascular access device use and VTE risk in this cohort. To examine the use of vascular access devices and incidence of VTE in patients hospitalized with COVID-19. We performed a retrospective, multi-center cohort study of patients hospitalized with COVID-19 who received a midline catheter, peripherally inserted central catheter (PICCs), tunneled or non-tunneled central venous catheter (CVC), hemodialysis (HD) catheter or a port during hospitalization. Mixed-effects multivariable logit models adjusting for VTE risk factors in the Caprini risk score were fit to understand the incremental risk of VTE in patients with vascular access devices vs. those that did not receive devices. Management of VTE was determined by examining anticoagulant use pre- vs. post-thrombosis. Results were expressed using odds ratios (ORs) and associated 95% confidence intervals (CI). A total of 1228 hospitalized COVID-19 patients in 40 hospitals, of which 261 (21.3%) received at least one vascular access device of interest, were included. The prevalence of acute, non-tunneled CVCs was 42.2%, acute HD catheters 18.4%, midline catheters 15.6%, PICCs 15.6%, tunneled CVCs 6.8%, and implanted ports 1.4%. The prevalence of VTE was 6.0% in the study cohort, and 10.0% among patients with vascular access devices. After adjusting for known VTE risk factors, patients that had a vascular access device placed were observed to have a four-fold greater odds of VTE than those that did not (OR 4.17, 95% CI 2.33–7.46). Patients who received multiple different catheters experienced more VTE events compared with patients that received only one type (21.5% vs. 6.1%, p < .001). Among the 26 patients with VTE, only 8 (30.8%) survived to discharge and among these, only 5 were discharged on therapeutic doses of anticoagulation. Hospitalized patients with COVID-19 that receive vascular access devices experienced higher rates of VTE than those that do not. Future studies to evaluate the nexus between COVID-19, vascular device use, and thrombosis appear are warranted.

Venous Thromboembolism in Pediatric Cancer Patients with Central Venous Catheter-A Systematic Review and Meta-analysis.

Pediatric cancer patients hold an increased risk of venous thromboembolism (VTE) due to their cancer. Central venous catheters (CVCs) further increase the VTE risk. This systematic literature review elucidates the VTE incidence in pediatric cancer patients with CVC. MEDLINE and EMBASE were searched in August 2020 without time limits. We included studies reporting original data on patients ≤18 years with any CVC type and any cancer type, who were examined for VTE with ≥7 days follow-up. In total, 682 unique records were identified, whereof 189 studies were assessed in full text. Altogether, 25 studies were included, containing 2,318 pediatric cancer patients with CVC, of which 17% suffered VTE. Fifteen studies (n = 1,551) described CVC-related VTE and reported 11% CVC-related VTE. Concerning cancer type, 991 children suffered from acute lymphoblastic leukemia (ALL) and 616 from solid tumors. Meta-analysis revealed VTE incidence (95% confidence interval) of 21% (8-37) for ALL and 7% (0.1-17) for solid tumors. Additionally, 20% of children with tunneled or nontunneled CVC and 12% of children with implantable ports suffered VTE. In conclusion, pediatric cancer patients with CVC have substantial VTE risk. Children with ALL and CVC have higher VTE incidence than children with solid tumors and CVC. Implantable port catheter should be preferred over tunneled or nontunneled CVC to reduce VTE risk. Thrombophilia investigation does not seem relevant in pediatric cancer patients with CVC and VTE. To prevent VTE, intensified catheter care is recommended, especially in children with ALL.

Ultrasound-guided cannulation of the superficial femoral vein for central venous access.

In some clinical conditions, central venous access is preferably or necessarily achieved by threading the catheter into the inferior vena cava. This can be obtained not only by puncture of the common femoral vein at the groin, but also-as suggested by few recent studies-by puncture of the superficial femoral vein at mid-thigh. We have retrospectively reviewed our experience with central catheters inserted by ultrasound-guided puncture and cannulation of the superficial femoral vein, focusing mainly on indications, technique of venipuncture, and incidence of immediate/early complications. From June 2020 to December 2020, we have inserted 98 non-tunneled central venous catheters (tip in inferior vena cava or right atrium) by ultrasound-guided puncture of the superficial femoral vein at mid-thigh or in the lower third of the thigh, all of them secured by subcutaneous anchorage. The success of the maneuver was 100% and immediate/early complications were negligible. Follow-up of hospitalized patients (72.5% of all cases) showed only one episode of catheter dislodgment, no episode of infection and no episode of catheter related thrombosis. The ultrasound approach to the superficial femoral vein is an absolutely safe technique of central venous access. In our experience, it was not associated with any risk of severe insertion-related complications, even in patients with low platelet count or coagulation disorders. Also, the exit site of the catheter at mid-thigh may have advantages if compare to the exit site in the inguinal area.

Stewardship Intervention to Optimize Central Venous Catheter Utilization in Critically Ill Children.

Introduction:We aimed to describe utilization and indication(s) for long-term central venous catheters (CVCs) in a pediatric intensive care unit (PICU) and identify potential strategies to decrease CVC utilization.Methods:We conducted a single-center prospective quality improvement initiative at a 30-bed PICU in a large, freestanding, academic children’s hospital. We created an electronic report to identify patients with an indwelling CVC for 7 days and older (defined as long term). We discussed the ongoing need for each long-term CVC with PICU clinicians at weekly interdisciplinary structured “CVC stewardship rounds.” We then made recommendations around expedited removal of CVCs. We conducted multiple Plan-Do-Study-Act cycles to categorize CVC indications, identify modifiable factors, and educate PICU clinicians. We hypothesized that CVC stewardship rounds would decrease long-term CVC utilization in our PICU.Results:From October 2016 to September 2017, 607 long-term CVCs were eligible for the stewardship intervention. Compared to the preintervention period, we recorded a significant increase in peripherally inserted central catheters and a decrease in nontunneled CVCs (P < 0.001). Most patients had single- or double-lumen CVCs in both the preintervention and intervention periods (86% and 91%, respectively). The utilization of overall long-term CVC devices, and those with modifiable indications, decreased during the intervention period.Conclusions:A single-center QI intervention focused on PICU CVC stewardship was associated with a decrease in CVC utilization.

To PICC or not to PICC? A cross-sectional survey of vascular access practices in the ICU.

Vascular access patterns in the intensive care unit (ICU) have shifted from non-tunneled central venous catheters (CVCs) towards peripherally inserted central catheters (PICCs). We evaluated perceptions of critical care practitioners regarding these devices and variation in evidence-based practice. A 35-question survey on ICU vascular access was deployed in 13 Michigan hospitals. Descriptive statistics summarized responses. Differences in utilization, perceptions and evidence-based practices between PICCs and CVCs, by participant and site-level characteristics, were assessed. 314 of 621 eligible providers responded to the survey (response rate 51%). 15% of providers reported not routinely using ultrasound when placing CVCs. Respondents whom were trainees, from larger hospitals, and from closed ICUs were more likely to use ultrasound (p<0.001). Additionally, 21% of respondents stated they did not specify number of CVC lumens, while 46% did not specify number of PICC lumens (p<0.001). The likelihood of specifying PICC lumens increased when vascular access protocols were in place (p=0.001). 2/3 of respondents (n=173, 66%) stated more research on ICU vascular access was needed. Variation in guideline-based vascular access practices exists in the ICU. Defined local protocols may improve guideline adherence. Studies evaluating vascular access decisions and patient safety in the ICU appear necessary.

Epidemiology of bloodstream infections in a Scottish haemodialysis population with focus on vascular access method

Infection is the second highest cause of mortality in end-stage renal disease, with a significant proportion relating to haemodialysis (HD) vascular access-related infection (VARI). To report the rate and antimicrobial resistance (AMR) of all-source bloodstream infections (BSIs) by vascular access type in a Scottish HD cohort. Retrospective analysis was undertaken of data on adult patients attending seven HD units during 2017. Total HD days for each vascular access type were calculated. BSIs were analysed with rates expressed per 1000 HD days. AMR was verified using health board microbiology databases. Excluding contaminant organisms, there was an overall BSI rate of 0.57 per 1000 HD days. The highest all-source and vascular access-related infection (VARI) BSI rates per 1000 HD days were in the non-tunnelled central venous catheter (CVC) group (3.11 and 2.07 respectively), followed by tunnelled CVC (1.10 and 0.67), arteriovenous graft (0.51 and 0.31), and finally arteriovenous fistula (0.29 and 0.02). The non-VARI BSI rates were lowest in the arteriovenous graft group. Staphylococci comprised the majority of events, with Staphylococcus aureus implicated in 29%. Gram-negative BSIs were prevalent, particularly in CVC groups, and associated with higher mortality. Multidrug-resistant (MDR) S.aureus and carbapenem resistance were relatively low. MDR Gram-negatives were high compared with the Scottish population. Arteriovenous fistula access is confirmed as having lowest all-source and VARI BSI rates, and arteriovenous graft access the lowest non-VARI BSI rates. Staphylococci remain the prevailing genus; however, the contributions of Gram-negative BSIs, the higher mortality, and proportion of MDR organisms in this group are notable.

Utilisation des cathéters veineux : lesquels choisir, comment prévenir leurs complications ?

Intravenous catheters are multiple and essential for daily practice. They are also responsible for high morbidity and mortality. Simple or echo-guided peripheral venous catheters, midlines, PICCline, tunneled or non-tunneled central venous catheters, and implantable venous access device are currently at our disposal. Thus, catheter selection, duration and indications for use, and prevention and treatment of complications vary according to the situation. The objective of this update is to provide the clinician with an overview of knowledge and rules of good practice on the use of catheters.

Continuous Low-Dose Heparin Infusion for Catheter-Related Thrombosis Prophylaxis in Critically-Ill Children

Introduction: Central venous catheters (CVC) are often required in critical care settings to provide life-sustaining care. Their usage has improved the quality of care in pediatric patients by providing a secure point of access which minimizes the number of peripheral needle sticks. However, CVC usage is not without risks. Children can experience acute CVC-related complications such as venous thromboembolisms (VTEs) and infections. Over the past 20 years, CVC utilization has increased and its associated complications (VTE, central line associated blood stream infection [CLABSI], catheter dysfunction) result in increased lengths of stay and hospital costs. Clinical studies identify CVCs as the single most important risk for DVT in children. Incidence rates in critically-ill children are widely divergent with historical rates of 2.7-18% and 24.7-32.5 per 1000 catheter days. In addition, other historical rates for another CVC-related complication, CLABSI, are limited but demonstrate a rate of 1.21-6.5% and 14.4 per 1000 catheter days. Prevention of catheter-related thrombosis with prophylactic anticoagulants, such as unfractionated heparin, low molecular weight heparin or warfarin, have been tested in several studies in specific subgroups of patients and the majority of studies in pediatric populations were not able to clearly demonstrate a benefit. Despite this, nearly 50% of surveyed Pediatric Intensive Care Unit (PICUs) utilize various forms and doses of heparin prophylaxis to prevent CVC-associated complications. The Penn State Health Children's Hospital PICU utilizes low dose unfractionated heparin infusions (LDUFHI) at 5-15 units/kg/hr for catheter patency and for the prevention of CVC associated complications. Methods: A retrospective chart review of all CVCs, which include non-tunneled CVC (NT-CVC), tunneled lines (TL) and peripherally inserted central catheters (PICC), utilized in the PICU at The Penn State Health Children's Hospital in 2015 was performed to determine if the usage of LDUFHI in critically ill children to maintain catheter patency results in a lower incidence of VTE and CLABSI without increasing bleeding complications in comparison to historically reported data (Beck et al.,J Pediatr. 1998;133(2):237-241; Faustino et al.,J Pediatr. 2013;162(2):387-391; Krishnaiah et al.,Pediatr Crit Care Med. 2012;13(3):e176-e180.). Results: We identified 178 subjects who had CVC which received LDUFHI in 2015. There were a total of 228 CVCs with the majority being non-tunneled CVCs (54%) followed by tunneled lines (34%) and PICCs (12%). Combined, these catheters resulted in 2086 days of use. There was a total of 5 VTEs events for an overall incidence rate of 2.19% and 2.39 per 1000 catheter days. NT-CVC had the lowest rate (1.63%) followed by TL (2.56%) and PICCs (3.7%). However, PICCs has a slightly lower rate when measuring by catheter days (NT-CVC = 2.2 per 1000 catheter days; TL = 4.01 per 1000 catheter days; PICC = 1.46 per 1000 catheter days). There were 3 CLABSI events for an incidence rate of 1.32% and 1.43 per 1000 catheter days (NT-CVC = 1.63% and 2.2 per 1000 catheter days; TL no events; PICC = 3.7% and 1.46 per 1000 catheter days). There were no episodes of heparin induced thrombocytopenia or major bleeding. Overall, the VTE and CLABSI incidence rates are dramatically lower than historical comparisons (VTE = 2.19% and 2.39 per 1000 catheter days versus 15.8-18% and 24.7-32.5 per 1000 catheter days; CLABSI = 1.32% and 1.43 per 1000 catheter days versus 6.5% and 14.4 per 1000 catheter days). In addition, this study can offer more accurate rates as incidence was also measured as a factor in catheter days. Conclusion: This study used a single tertiary pediatric intensive care site in a non-randomized fashion. These data suggest an overall lower incidence of catheter related VTE and CLABSI in critically-ill children who received LDUFHI when compared to published with comparable pediatric study populations. The incidence of complications such as CLABSI were also lower with LDUFHI usage when compared to published data involving critically ill children. The incidence rates were even lower than recently published data involving non-critically ill children. These findings suggest that a multicenter randomized study should be pursued. Disclosures No relevant conflicts of interest to declare.

Clinical impact of early reinsertion of a central venous catheter after catheter removal in patients with catheter-related bloodstream infections.

Early replacement of a new central venous catheter (CVC) may pose a risk of persistent or recurrent infection in patients with a catheter-related bloodstream infection (CRBSI). We evaluated the clinical impact of early CVC reinsertion after catheter removal in patients with CRBSIs. We conducted a retrospective chart review of adult patients with confirmed CRBSIs in 2 tertiary-care hospitals over a 7-year period. To treat their infections, 316 patients with CRBSIs underwent CVC removal. Among them, 130 (41.1%) underwent early CVC reinsertion (≤3 days after CVC removal), 39 (12.4%) underwent delayed reinsertion (>3 days), and 147 (46.5%) did not undergo CVC reinsertion. There were no differences in baseline characteristics among the 3 groups, except for nontunneled CVC, presence of septic shock, and reason for CVC reinsertion. The rate of persistent CRBSI in the early CVC reinsertion group (22.3%) was higher than that in the no CVC reinsertion group (7.5%; P = .002) but was similar to that in the delayed CVC reinsertion group (17.9%; P > .99). The other clinical outcomes did not differ among the 3 groups, including rates of 30-day mortality, complicated infection, and recurrence. After controlling for several confounding factors, early CVC reinsertion was not significantly associated with persistent CRBSI (OR, 1.59; P = .35) or 30-day mortality compared with delayed CVC reinsertion (OR, 0.81; P = .68). Early CVC reinsertion in the setting of CRBSI may be safe. Replacement of a new CVC should not be delayed in patients who still require a CVC for ongoing management.

P1318EPIDEMIOLOGY OF BLOODSTREAM INFECTIONS IN A SCOTTISH HAEMODIALYSIS POPULATION WITH FOCUS ON VASCULAR ACCESS METHOD

Abstract Background and Aims Haemodialysis (HD) vascular access infections account for approximately 28% of infection-associated hospitalisations in patients with end-stage renal disease1. Traditionally there has been focus on Staphylococcus aureus (S. aureus) infections, however there is increasing recognition of the burden of Gram-negative bloodstream infection (BSI) in the HD population2,3. Epidemiological analysis has enabled surveillance of the impact of antimicrobial protocols on BSI rate and outcome2. Scottish Registry data reflects that access methods are changing alongside the HD population phenotype, with increasing use of arterio-venous graft (AVG) and central venous catheters for incident and prevalent HD access3. In this study, the rate of BSI in a contemporary Scottish HD cohort is reported by microbial species and vascular access type: arterio-venous fistula (AVF), AVG, tunnelled central venous catheter (TCVC) or non-tunnelled central venous catheter (NTCVC). Method The Strathclyde Electronic Renal Patient Record (SERPR) database for the West of Scotland was utilised to obtain retrospective observational data all adult patients attending inpatient and outpatient renal services across seven dialysis units between 1st January 2017 and 31st December 2017. All BSIs were analysed as separate episodes if more than 14 days apart, regardless of the suspected source of infection, and expressed as events per 1000 HD days. The number of days each patient was exposed to each vascular access subtype was calculated utilising the prospectively recorded HD access observations. Prevalent HD vascular access type was noted for each BSI. Results There were 786 patients who underwent HD with 217 503 total HD days over the study period. A total of 147 separate BSIs occurred, involving 115 patients. A total of 168 organisms were encountered in these BSIs. There were 49 BSIs during 126, 674 HD days using AVF access, 14 BSIs during 25, 511 AVG HD days, 81 BSIs during 64, 353 TCVC HD days and 3 BSIs during 965 NTCVC HD days. Table 1 outlines the BSI rates by vascular access and organisms identified Staphylococci-related BSI comprised the majority of events (51.7%), with S. aureus implicated in 47% of these BSIs. Coagulase-negative staphylococci were the most commonly identified organisms in the AVF, TCVC and NTCVC groups, with S. aureus the leading organism in the AVG group. Gram-negative organisms accounted for the next largest proportion of BSIs (27%) and were more prevalent in the TCVC and NTCVC groups. Conclusion AVF access subtype was associated with the lowest BSI rate, and NTCVC the highest which is in keeping with previous studies and one of the drivers for AVF as the preferred HD access type internationally. Staphylococci continue to represent a large proportion of BSIs in this cohort, however other organisms are prevalent. BSIs caused by Gram-negative organisms and Candida species were represented more heavily in the TCVC and NTCVC population, perhaps representing co-morbidity of these groups.

SAT-215 INCIDENCE AND RISK FACTORS OF NON TUNNELED HEMODIALYSIS CATHETER INFECTIONS: A FOLLOW UP STUDY IN TWO HEMODIALYSIS CENTERS IN CAMEROON

Non-tunneled central venous catheter (NTCVC) are useful for urgent initiation of acute and chronic dialysis. However they are associated with a high risk of infection limiting the duration of their use to less than 3 weeks for jugular and one week for femoral catheters. Nevertheless, in many sub-Saharan African countries, NTCVC are used for longer periods even for chronic dialysis due to limited access to tunneled catheters and vascular surgery for arteriovenous fistulas. We sought to identify risk factors for NTCVC infections in patients on hemodialysis We prospectively followed up for 6 weeks, all consenting incident and prevalent patients using NTCVC for hemodialysis through a NTCVC in the two public hemodialysis units in Yaounde. We excluded prevalent catheters with a history of infection. The study variables of interest were: the profile of physician inserting central venous catheter(CVC), respect of asepsis during CVC manipulation by health personnel, frequency of catheter repositioning during dialysis, patient hygiene of catheter exit site, and occurrence of non-catheter-related bacterial infection. The outcome of interest was the occurrence of CVC infection defined as a body temperature >37.5˚C or <36.˚C in the presence of a purulent discharge at the catheter exit site with or without a positive catheter/blood culture. The study was approved by the ethics board of the hospitals. We followed up a total of 131 NTCVC in 131(65.6% male) participants. Most catheters(n=129; 98.5%) were placed by nephrology fellows, and the remainder by nephrologists. Reasons for catheter insertion were: urgent start of chronic dialysis for ESKD (n=67; 51.1%), AKI (n=41; 31.3%), and failed AV fistula (n=23; 17.6%). In all, there were (n=97;74%) incident and (n=34;26%) prevalent catheters. The sites of catheter insertion were: right internal jugular, (n=77;58.8% ), right femoral, (n=52;39.7% ), and left femoral,(n= 21.5%). The median [IQR] follow-up duration of the NTCVC was 36.0 [11.0-42.0] days and was significantly longer for prevalent catheters (42.0 [16-42] versus 29[11-42]; p=0.02). The median [IQR] follow-up duration of was 12.5 [8.0-40.0] days for femoral, and 42 [21.0-42.0] for jugular catheters. The overall incidence of catheter infection was 6.9 cases per 1000 catheter days. The incidence was significantly higher for femoral compared to jugular catheters (11.5 versus 4.8 per 1000 catheter days; p=0.02), and non-significantly higher for incident compared to prevalent catheters (7.4 versus 5.4 cases per 1000 catheter days; p=0.48). Poor patient hygiene of exit site (RR=21.4, [5.7 – 80.3] p= 0.00) and occurrence of non-catheter related bacterial infection (RR=4.9, [1.1 – 20.9] p=0.03) were independent risk factors of non-tunneled catheter infection. Our results suggest a need for improved patient education on care of the catheter exit site area, and limiting the use of the femoral site. The catheter infection risk associated with the presence of non-catheter bacterial infections requires further studies. There is an urgent need to reduce the duration of use of these catheters through patient education and cost containment of tunneled catheters and fistula surgery.

Influence of the Insertion Site on Central Venous Catheter-Related Complications in Patients Undergoing Allogeneic Hematopoietic Cell Transplantation.

Central venous catheters (CVCs) are extensively used in patients undergoing allogeneic hematopoietic cell transplantation (HCT). In these patients CVC are placed routinely either via the internal jugular vein (IJV) or the subclavian vein (SCV). Purpose of this study was to systematically analyze complications of CVC at different insertion sites in HCT recipients. In this retrospective analysis, all consecutive patients (n=56) who received a CVC (n=101) due to allogeneic HCT at our institution between January 2011 and June 2013 were included. Three-lumen standard, nontunneled CVCs were placed via either the IJV (n=60; 59%) or the SCV (n=41; 41%). Study endpoints were time to local inflammation at the insertion site, time to fever, time to a combined endpoint of inflammation and fever, central line-associated bloodstream infection (CLABSI), duration of catheterization, catheter lumen obstruction, deep-vein thrombosis, pneumothorax, and catheter-related death. The median duration of catheterization per CVC was almost identical for the IJV and SCV sites (18 days versus 17 days; P not significant). There were no differences in the frequency of CLABSI, deep-vein thrombosis, pneumothorax, and catheter lumen obstruction between IJV and SCV CVC insertion sites. None of the patients died due to a CVC-related cause. Local inflammation occurred less frequently (48% versus 71%; P = .025) and later (median time to local inflammation, 25 days versus 12 days; P = .01) in IJV CVCs versus SCV CVCs. There was a trend toward a median longer time to the occurrence of fever for IJV CVCs compared with SCV CVCs (20 days versus 13 days; P=.07). In the multivariate analysis, diagnosis of acute leukemia (hazard ratio [HR], 1.696; P = .036), SCV CVC (HR, 1.617; P =.039), and neutropenic CVC-days (HR, 2.477; P = .01) were identified as risk factors for the occurrence of local inflammation or fever. In contrast to earlier studies in patients without hematologic malignancies, these data demonstrate that CVCs placed in the SCV are not superior over IJV CVCs. Moreover, local inflammation occurred earlier and more frequently in patients with an SCV CVC.

A Randomized, Double-Blind, Placebo-Controlled Trial (TAURCAT Study) of Citrate Lock Solution for Prevention of Endoluminal Central Venous Catheter Infection in Neutropenic Hematological Patients.

Infection of long-term central venous catheters (CVCs) remains a challenge in the clinical management of cancer patients. We aimed to determine whether a lock solution with taurolidine-citrate-heparin would be more effective than placebo for preventing nontunneled CVC infection in high-risk neutropenic hematologic patients. We performed a prospective, multicenter, randomized (1:1), double-blind, parallel, superiority, placebo-controlled trial involving 150 hematological patients with neutropenia carrying nontunneled CVCs who were assigned to receive CVC lock solution with taurolidine-citrate-heparin or heparin alone. The primary endpoint was bacterial colonization of the CVC hubs. Secondary endpoints were the incidence of catheter-related bloodstream infection (CRBSI), CVC removal, adverse events related to the lock solution, and the 30-day case fatality rate. CVC lock solution with taurolidine-citrate-heparin was associated with less colonization of the CVC hubs than that with placebo, with no statistically significant differences: 4.1%, versus 10.1% (relative risk [RR] = 0.41, 95% confidence interval [CI] = 0.11 to 1.52), with a cumulative incidence of 4.17 (95% CI = 0.87 to 11.70) and 10.14 (95% CI = 4.18 to 19.79), respectively. There were no significant differences regarding the secondary endpoints. Only three episodes of CRBSI occurred during the study period. No adverse events related to the administration of the lock solution occurred. In this trial involving high-risk patients carrying nontunneled CVCs, the use of taurolidine-citrate-heparin did not show a benefit over the use of placebo. Nevertheless, the safety of this prevention strategy and the trend toward less hub colonization in the taurolidine-citrate-heparin group raise the interest in assessing its efficacy in centers with higher rates of CRBSI. (This study has been registered in ISRCTN under identifier ISRCTN47102251.).

PROVISION OF CENTRAL VENOUS ACCESS DURING ALLOGENEIC HAEMATOPOIETIC STEM CELL TRANSPLANTATION

Introduction. The transplantation of allogeneic haematopoietic stem cells (allo-HSCT) is impossible without a central venous catheter (CVC).Aim. To determine an optimal approach to providing venous access during allo-HSCT.Materials and methods. This prospective, non-randomised, single-centre study included 146 patients (70 men and 76 women, median age 37 years) who underwent the fi rst allo-HSCT. Prior to conditioning, one of the following CVCs was placed: Hickman or Leonard tunnelled double-lumen silicone catheters (BardAccessSystem); polyurethane non-tunnelled CVCs without (Certofi x Duo, B. Braun) or with an antibacterial coating (Certofi x Protect Duo, B. Braun). The following complications were recorded: early complications, mechanical complications, catheter-associated thrombosis (CAT), catheterrelated bloodstream infections (CRBSI), as well as catheter exit-site and tunnel infections.Results. A total of 320 CVCs were placed (146 prior to allo-HSCT and 174 in the post-transplant period); 259 of the CVCs were non-tunnelled and 61 were tunnelled. Non-tunnelled CVCs were used for 1–123 days (median 22 days), whereas tunnelled CVCs were implanted for 9–621 days (median 146 days). The use of non-tunnelled CVCs was associated with 2.7 % (1.0/1000 catheter days) of mechanical complications and 9 % of CAT (1.4 / 1000 catheter days). The use of tunnelled CVCs was associated with the following complications: accidental removal — 1 (1.6 %), catheter rupture — 4 (6.5 %), CAT — 5 (8.2 %) patients (0.3 / 1000 catheter days); 18 (29.5 %) patients exhibited catheter obstruction, with CVC function being restored in 14 (77.7 %) patients, whereas in 4 (22.3 %) patients the CVC was removed. The incidence of CRBSI associated with non-tunnelled and tunnelled CVCs was 4.4 and 1.5 per 1000 catheter days, respectively. The study revealed no significant differences in the probability of developing CRBSI between non-tunnelled CVCs with and without antibacterial coating (p = 0.298), as well as between non-tunnelled and tunnelled CVCs in the fi rst 28 days after the catheter placement (p = 0.424). The risk of developing CRBSI when using tunnelled CVCs increased after 150 days of use.Conclusion. Allo-HSCT can be performed using any CVC type. Our study revealed no advantages in employing nontunnelled CVCs with an antibacterial coating compared to those having no coating. Tunnelled CVCs (as opposed to nontunnelled ones) provide the opportunity to employ a single catheter throughout the entire transplantation and post-transplant period. It should be noted that tunnelled CVCs should not be used for more than 150 days, since prolonged use of such CVCs significantly increases the risk of infection.Conflict of interest: the authors declare no conflict of interest.Financial disclosure: the study had no sponsorship.