Nosocomial Bloodstream Infections Research Articles

Utilização de cateter central de inserção periférica e ocorrência da infecção da corrente sanguínea em uma Unidade de Terapia Intensiva Neonatal

Objective: To analyze the prevalence of hospital primary bloodstream infections in a neonatal intensive care unit (NICU). Methods: A retrospective study involving analyses of records of patients admitted to the NICU from January to December 2010 was conducted. The incidence density of catheter-associated bloodstream infections per 1000 catheter-days was calculated. Results: Among 192 newborns, 16 (8.3%) who used peripherally inserted central catheters had bloodstream infections. The infection density confirmed by blood culture reached 5.9, while the density based on clinical criteria accounted for 3.5 per 1000 patients with central vascular catheter-days, with the following distribution by weight range: 10.31 (750-999 g), 2.76 (1000-1499 g), 5.65 (1500-2499 g), and 6.79 (>2500 g) per 1000 patients with vascular catheter-days. The average time between catheter insertion and the development of infection was 11 days. The most common insertion site was the jugular vein (37.5%). Mortality rates associated with nosocomial bloodstream infections reached 31%. Conclusions: The use of peripherally inserted central catheter is a practice not without risk considering that this is an invasive device and can predispose the occurrence of nosocomial infection.

Phenotypic and Genotypic Diversity of Multidrug-Resistant Pseudomonas aeruginosa Isolates from Bloodstream Infections Recovered in the Hospitals of Belo Horizonte, Brazil

Background: Pseudomonas aeruginosa commonly causes nosocomial bloodstream infections and the emergence of a variety of β-lactamases (BLs) is worrying. In 5 hospitals in Belo Horizonte, Brazil, the presence of phenotypes encoding BL genes was established and the genetic diversity of the P. aeruginosa strains recovered from bloodstream infections was analyzed. Materials and Methods: The isolates were investigated using a disk diffusion (DD) method and the Etest®, for encoding metallo-β-lactamases (MBLs), oxacillinases and cephalosporinases. Genes and genetic diversity were evaluated by random amplified polymorphic DNA (RAPD) genotyping and enterobacterial repetitive intergenic consensus (ERIC)-PCR. Results: Twelve strains (30%) were positive for MBLs by Etest and DD, 15 were cephalosporinase-positive and 87.5% were positive for bla_SPM-1 and bla_VIM-1. Twenty-three strains (57.5%) were grouped into profile A, 32.5% into profile B and 10% into profile C by RAPD genotyping. ERIC-PCR revealed a varying degree of similarity between strains, ranging from 45 to 100%. Conclusions: The results suggest distinct clonal populations in the 5 hospitals studied, indicating a potentially problematic epidemiological situation in Belo Horizonte, Brazil.

Nosocomial bloodstream infections in a Finnish tertiary care hospital: a retrospective cohort study of 2175 episodes during the years 1999–2001 and 2005–2010

Background: Nosocomial infections are major causes of morbidity in hospitalized patients. Methods: Retrospective laboratory-based surveillance during 1999–2001 and 2005–2010 identified 2175 cases of nosocomial bloodstream infections (BSIs) in Tampere University Hospital (TAUH), Finland. Results: Analysis revealed that 57% of BSIs were caused by a gram-positive organism, 27% by a gram-negative organism, 5% by a fungal organism, and 11% were polymicrobial. The most common cause of nosocomial BSI was coagulase-negative staphylococci (23%). Candida species caused 5% of the infections. The 7-day and 30-day case fatalities were 8% (161/2158) and 15% (313/2175), respectively, and were highest in BSIs caused by Candida albicans (22% and 44%) and Pseudomonas aeruginosa (17% and 25%). The median age of patients was 54 years in 1999–2001, 57 years in 2005–2007, and 60 years in 2008–2010 (p < 0.001). The median time from hospital admission to the onset of BSI was 11 days (quartiles 5–18 days). This period was shortest for Streptococcus agalactiae BSI and longest for Candida non-albicans fungemia (1 vs 19 days). The case fatality rate in nosocomial BSI decreased during the years studied: 7-day and 30-day case fatalities were 9% and 16% during 1999–2001, 8.5% and 16% during 2005–2007, and 5% and 12% during 2008–2010, respectively (p < 0.003 and p = 0.022, respectively). Conclusions: Gram-positive infections predominate in nosocomial BSIs. The median age of patients with nosocomial BSI has risen during the study years. The case fatality associated with nosocomial BSI has decreased.

Different scenarios for Candida parapsilosis fungaemia reveal high numbers of mixed C. parapsilosis and Candida orthopsilosis infections.

Nosocomial fungal bloodstream infections (BSI) are increasing significantly in hospitalized patients and Candida parapsilosis has emerged as an important pathogen responsible for numerous outbreaks. The objective of this study was to evaluate C. parapsilosis sensu lato infection scenarios, regarding species distribution and strain relatedness. One hundred isolates of C. parapsilosis sensu lato derived from blood cultures and catheter tips were analysed by multiplex microsatellite typing and by sequencing D1/D2 regions of the ribosomal DNA. Our results indicate that 9.5 % of patients presented infections due to C. parapsilosis and Candida orthopsilosis, 57.1 % due to C. parapsilosis, 28.3 % due to C. orthopsilosis and 4.8 % due to Candida metapsilosis. Eighty per cent of the C. parapsilosis BSIs were due to a single strain that was also identified in the catheter, but in 10 % of the cases C. parasilosis was identified in the catheter but the BSI was due to C. orthopsilosis. There is a significant probability that C. parapsilosis isolates collected from the same patient at more than 3 months interval are of different strains (P = 0.0179). Moreover, several isolates were identified persistently in the same hospital, infecting six different patients. The incidence of polyfungal BSI infections with C. parapsilosis and C. orthopsilosis is reported herein for the first time, emphasizing the fact that the species identified in the catheter is not always responsible for the BSI, thus impacting the treatment strategy. The observation that strains can remain in the hospital environment for years highlights the possible existence of reservoirs and reinforces the need for accurate genotyping tools, such as the markers used for elucidating epidemiological associations and detecting outbreaks.

Increasing incidence of hospital-acquired and healthcare-associated bacteremia in northeast Thailand: a multicenter surveillance study.

BackgroundLittle is known about the epidemiology of nosocomial bloodstream infections in public hospitals in developing countries. We evaluated trends in incidence of hospital-acquired bacteremia (HAB) and healthcare-associated bacteremia (HCAB) and associated mortality in a developing country using routinely available databases.MethodsInformation from the microbiology and hospital databases of 10 provincial hospitals in northeast Thailand was linked with the national death registry for 2004–2010. Bacteremia was considered hospital-acquired if detected after the first two days of hospital admission, and healthcare-associated if detected within two days of hospital admission with a prior inpatient episode in the preceding 30 days.ResultsA total of 3,424 patients out of 1,069,443 at risk developed HAB and 2,184 out of 119,286 at risk had HCAB. Of these 1,559 (45.5%) and 913 (41.8%) died within 30 days, respectively. Between 2004 and 2010, the incidence rate of HAB increased from 0.6 to 0.8 per 1,000 patient-days at risk (p<0.001), and the cumulative incidence of HCAB increased from 1.2 to 2.0 per 100 readmissions (p<0.001). The most common causes of HAB were Acinetobacter spp. (16.2%), Klebsiella pneumoniae (13.9%), and Staphylococcus aureus (13.9%), while those of HCAB were Escherichia coli (26.3%), S. aureus (14.0%), and K. pneumoniae (9.7%). There was an overall increase over time in the proportions of ESBL-producing E. coli causing HAB and HCAB.ConclusionsThis study demonstrates a high and increasing incidence of HAB and HCAB in provincial hospitals in northeast Thailand, increasing proportions of ESBL-producing isolates, and very high associated mortality.

English

Candidaemia is the fourth most common cause of nosocomial bloodstream infections. The objective of this paper was to evaluate the risk factors associated with mortality in patients with candidaemia with respect to Candida species and their susceptibilities, retrospectively. All consecutive patients who developed candidaemia at an 800-bed training and research hospital were enrolled in this retrospective, observational, single centre study during the period June 2006 to December 2011. A total of 97 candidaemia episodes were identified in 97 patients during the study period with an overall incidence of four episodes/10 000 admissions in adults. Crude 30-day mortality rates among patients with candidaemia were 56% (55 of 97 cases). Urinary catheterization, immunosuppressive therapy, acute physiology and chronic health evaluation (APACHE) II score (≥ 16) and hypoalbuminaemia were found to be independent risk factors for fatal candidaemia. Adult cases with candidaemia who have risk factors associated with mortality are more likely to have poor prognosis despite appropriate and timely initiated antifungal drug treatment. Empiric antifungal drug should be tailored according to the severity of the patients' conditions and local antifungal susceptibility.

The Role of Corticosteroids in Adult Respiratory Distress Syndrome caused by Viridans Group Streptococci Bacteremia in Neutropenic Patients.

In the past decades, viridans group Streptococci (VGS) have emerged as an important cause of bacteremia in neutropenic patients with cancer. The clinical course of VGS bacteremia can be devastating including septic shock and adult respiratory distress syndrome (ARDS). It has been suggested that septicemia with VGS triggers the development of noncardiogenic pulmonary edema in patients with pre-existing damage of the lungs due to aggressive cytotoxic treatment. Thus, the preemptive administration of corticosteroid to patients diagnosed with VGS bacteremia with early onset of respiratory failure has been employed to prevent ARDS. While this management strategy has been suggested in the literature, little published data are available to validate this practice. In this study, we sought to review the benefit of early administration of corticosteroid to patients who developed symptom or early signs of respiratory failure while being neutropenic with VGS bacteremia.

Molecular epidemiology and antimicrobial susceptibility profiles of methicillin-resistant Staphylococcus aureus blood culture isolates: results of the Quebec Provincial Surveillance Programme.

The objectives of this study were to characterize methicillin-resistant Staphylococcus aureus (MRSA) blood culture isolates and to determine their relative importance in both nosocomial and community-acquired infections. A total of 535 MRSA blood culture isolates were analysed. In vitro susceptibility to 14 agents was determined. The genes nuc, mecA and coding for PVL toxin were identified by PCR. All isolates were characterized by PFGE or spa typing to assess their genomic relationships. Most MRSA isolates were retrieved from nosocomial bloodstream infections (474, 89%) and were of the CMRSA2 genotype. Healthcare-associated (HA)-MRSA bloodstream infections were associated with older age (70-89 years, P = 0·002) and most often secondary to central line infections (P = 0·005). Among MRSA strains associated with community-acquired (CA)-MRSA, 28·8% were isolated in intravenous drug users. CA-MRSA genotypes were more frequently found in young adults (20-39 years, P < 0·0001) with skin/soft tissue as the primary sources of infection (P = 0·006). CMRSA10 genotype was the predominant CA-MRSA strain. All MRSA isolates were susceptible to doxycycline, tigecycline, trimethoprim/sulfamethoxazole and vancomycin. Both the presence of the genes coding for PVL toxin (89·8%) and susceptibility to clindamycin (86·5%) were predictive of CA-MRSA genotypes. Whereas in the USA, HA-MRSA have been replaced by USA300 (CMRSA10) clone as the predominant MRSA strain type in positive blood cultures from hospitalized patients, this phenomenon has not been observed in the province of Quebec.

Candidaemia observed at a university hospital in Milan (northern Italy) and review of published studies from 2010 to 2014.

Candida species represent the fourth leading cause of nosocomial bloodstream infections (BSI) worldwide. However, candidaemia rates and species involved vary geographically. To evaluate the epidemiological pattern, risk factors for mortality and antifungal therapy of Candida BSI over a 5-year period (2008-2012) in a university hospital in northern Italy together with a review of the recent literature concerning candidaemia. A retrospective cohort study cross-linked with microbiology database was performed. A total of 89 Candida BSI were identified in 42 males (47 %) and 47 females (52.8 %). The median age was 69 years (interquartile range 55-78) with 61.8 % of patients being older than 65 years. Considering all hospitalized patients, the overall incidence rate of candidaemia increased significantly from 2008 to 2012 (from 0.4 to 1.68 episodes per 10,000 patient/days) (p = 0.0001) with a mean linear increase in 5 new cases per year. Candida albicans was the predominant species isolated (64 %) followed by C. glabrata (19.1 %). The latter species was observed with significantly higher frequency in Internal Medicine and Intensive Care Units (ICU). In-hospital crude mortality was 41.6 %. Candidaemia is an increasing BSI in our university hospital, in accordance with that observed in northern Italy, and it is still associated with high in-hospital crude mortality.

New insights into innate immune control of systemic candidiasis.

Systemic infection caused by Candida species is the fourth leading cause of nosocomial bloodstream infection in modern hospitals and carries high morbidity and mortality despite antifungal therapy. A recent surge of immunological studies in the mouse models of systemic candidiasis and the parallel discovery and phenotypic characterization of inherited genetic disorders in antifungal immune factors that are associated with enhanced susceptibility or resistance to the infection have provided new insights into the cellular and molecular basis of protective innate immune responses against Candida. In this review, the new developments in our understanding of how the mammalian immune system responds to systemic Candida challenge are synthesized and important future research directions are highlighted.

Validation of nosocomial infection in neonatology: A new method for standardized surveillance

Nosocomial infections (NIs) are a leading cause of mortality and morbidity in premature infants. We present a new method for detecting and confirming NIs in a neonatal intensive care unit. Newborns with birth weight < 1,500 g or gestational age (GA) < 33 weeks were included prospectively over 2 years in a single-center tertiary neonatal intensive care unit. The computerized physician order entry system (CPOE) generated alerts when antibiotics were prescribed for at least 5 consecutive days and these cases were reviewed by an expert group following international recommendations. Four hundred sixty-one neonates were included, with a mean GA of 30 weeks (range, 26-32 weeks) and mean birth weight 1,270 g (range, 950-1600 g). The CPOE flagged 158 cases of potential NI, 85.1% of which were classified as true NI and 14.9% of which were false positive. Incidence and device-associated nosocomial bloodstream infection rates were 21.9% and 10.8 per 1,000 central venous catheter days, respectively. GA ≤ 28 weeks (odds ratio, 2.18; 95% confidence interval, 1.2-4) and > 7 central venous catheter days (odds ratio, 1.47; 95% confidence interval, 1.3-1.7) were independently associated with the risk of nosocomial bloodstream infection. Combining CPOE and interdisciplinary review may improve the accuracy of NI recording in a neonatal intensive care unit.

Sequential hand hygiene promotion contributes to a reduced nosocomial bloodstream infection rate among very low-birth weight infants: An interrupted time series over a 10-year period

Sustained high compliance with hand hygiene (HH) is needed to reduce nosocomial bloodstream infections (NBSIs). However, over time, a wash out effect often occurs. We studied the long-term effect of sequential HH-promoting interventions. An observational study with an interrupted time series analysis of the occurrence of NBSI was performed in very low-birth weight (VLBW) infants. Interventions consisted of an education program, gain-framed screen saver messages, and an infection prevention week with an introduction on consistent glove use. A total of 1,964 VLBW infants admitted between January 1, 2002, and December 31, 2011, were studied. The proportion of infants with ≥1 NBSI decreased from 47.6%-21.2% (P<.01); the number of NBSIs per 1,000 patient days decreased from 16.8-8.9 (P<.01). Preintervention, the number of NBSIs per 1,000 patient days significantly increased by 0.74 per quartile (95% confidence interval [CI],0.27-1.22). The first intervention was followed by a significantly declining trend in NBSIs of -1.27 per quartile (95% CI, -2.04 to -0.49). The next interventions were followed by a neutral trend change. The relative contributions of coagulase-negative staphylococci and Staphylococcus aureus as causative pathogens decreased significantly over time. Sequential HH promotion seems to contribute to a sustained low NBSI rate.

Surveillance of Candida spp bloodstream infections: epidemiological trends and risk factors of death in two Mexican tertiary care hospitals.

IntroductionLarger populations at risk, broader use of antibiotics and longer hospital stays have impacted on the incidence of Candida sp. bloodstream infections (CBSI).ObjectiveTo determine clinical and epidemiologic characteristics of patients with CBSI in two tertiary care reference medical institutions in Mexico City.DesignProspective and observational laboratory-based surveillance study conducted from 07/2008 to 06/2010.MethodsAll patients with CBSI were included. Identification and antifungal susceptibility were performed using CLSI M27-A3 standard procedures. Frequencies, Mann-Whitney U test or T test were used as needed. Risk factors were determined with multivariable analysis and binary logistic regression analysis.ResultsCBSI represented 3.8% of nosocomial bloodstream infections. Cumulative incidence was 2.8 per 1000 discharges (incidence rate: 0.38 per 1000 patient-days). C. albicans was the predominant species (46%), followed by C. tropicalis (26%). C. glabrata was isolated from patients with diabetes (50%), and elderly patients. Sixty-four patients (86%) received antifungals. Amphotericin-B deoxycholate (AmBD) was the most commonly used agent (66%). Overall mortality rate reached 46%, and risk factors for death were APACHE II score ≥16 (OR = 6.94, CI95% = 2.34–20.58, p<0.0001), and liver disease (OR = 186.11, CI95% = 7.61–4550.20, p = 0.001). Full susceptibility to fluconazole, AmBD and echinocandins among C. albicans, C. tropicalis, and C. parapsilosis was observed.ConclusionsThe cumulative incidence rate in these centers was higher than other reports from tertiary care hospitals from Latin America. Knowledge of local epidemiologic patterns permits the design of more specific strategies for prevention and preemptive therapy of CBSI.

Antibiotic Resistance of Gram-Negative Bacilli Isolated from Pediatric Patients with Nosocomial Bloodstream Infections in a Mexican Tertiary Care Hospital

Background: Gram-negative bacilli are the most common bacteria causing nosocomial bloodstream infections (NBSIs) in Latin American countries. Methods: The antibiotic resistance profiles of Gram-negative bacilli isolated from blood cultures in pediatric patients with NBSIs over a 3-year period in a tertiary care pediatric hospital in Mexico City were determined using the VITEK-2 system. Sixteen antibiotics were tested to ascertain the resistance rate and the minimum inhibitory concentration using the Clinical Laboratory Standards Institute (CLSI) broth micro-dilution method as a reference. Results: A total of 931 isolates were recovered from 847 clinically significant episodes of NBSI. Of these, 477 (51.2%) were caused by Gram-negative bacilli. The most common Gram-negative bacilli found were Klebsiella pneumoniae (30.4%), Escherichia coli (18.9%), Enterobacter cloacae (15.1%), Pseudomonas aeruginosa (9.9%), and Acinetobacter baumannii (4.6%). More than 45 and 60% of the K. pneumoniae and E. coli isolates, respectively, were resistant to cephalosporins, and 64% of the E. coli isolates were resistant to fluoroquinolones. A. baumannii exhibited low rates of resistance to antibiotics tested. In the E. cloacae and P. aeruginosa isolates, no rates of resistance higher than 38% were observed. Conclusions: In this study, we found that the proportion of NBSIs due to antibiotic-resistant organisms is increasing in a tertiary care pediatric hospital of Mexico.

Development and validation of a clinical model to predict the presence of β-lactam resistance in viridans group streptococci causing bacteremia in neutropenic cancer patients.

Concern for serious infection due to β-lactam-resistant viridans group streptococci (VGS) is a major factor driving empiric use of an anti-gram-positive antimicrobial in patients with febrile neutropenia. We sought to develop and validate a prediction model for the presence of β-lactam resistance in VGS causing bloodstream infection (BSI) in neutropenic patients. Data from 569 unique cases of VGS BSI in neutropenic patients from 2000 to 2010 at the MD Anderson Cancer Center were used to develop the clinical prediction model. Validation was done using 163 cases from 2011 to 2013. In vitro activity of β-lactam agents was determined for 2011-2013 VGS bloodstream isolates. In vitro resistance to β-lactam agents commonly used in the empiric treatment of febrile neutropenia was observed only for VGS isolates with a penicillin minimum inhibitory concentration (MIC) of ≥ 2 µg/mL. One hundred twenty-nine of 732 patients (17%) were infected with VGS strains with a penicillin MIC ≥ 2 µg/mL. For the derivation and validation cohorts, 98% of patients infected by VGS with a penicillin MIC of ≥ 2 µg/mL had at least 1 of the following risk factors: current use of a β-lactam as antimicrobial prophylaxis, receipt of a β-lactam antimicrobial in the previous 30 days, or nosocomial VGS BSI onset. Limiting empiric anti-gram-positive therapy to neutropenic patients having at least 1 of these 3 risk factors would have reduced such use by 42%. Simple clinical criteria can assist with targeting of anti-gram-positive therapy to febrile neutropenic patients at risk of serious β-lactam-resistant VGS infection.

Dramatic increase in vancomycin-resistant enterococci in Germany

Among European countries, Germany has one of the highest proportions of vancomycin-resistant Enterococcus faecium bloodstream infections. The aim of this study was to investigate the development of vancomycin-resistant enterococci (VRE) in German hospitals and to consider the regional distribution of VRE in Germany. Data from three components of the German national nosocomial surveillance system (KISS) from the period 2007-12 were used for analysis: ICU-KISS data on nosocomial primary bloodstream infections and urinary tract infections from intensive care units (ICUs); OP-KISS data on surgical site infections from surgical departments; and Pathogen-KISS data concentrating on VRE cases (infections and colonizations) in ICUs. Trends over time were calculated and a map according to German federal states was prepared. Data from up to 645 ICUs and 681 surgical departments for 2 year periods from 2007 to 2012 were analysed. The proportion of VRE increased significantly for surgical site infections (526%; P < 0.01) and bloodstream infections (265%; P < 0.01) and non-significantly for urinary tract infections (278%; P = 0.07). A large subgroup of ICUs also reported VRE cases in the same period, with a significant increase of 282%. The mapping of federal states showed large variation in VRE proportions and incidence rates in a belt of states with significantly higher VRE proportions from west (North Rhine-Westphalia) to east (Saxony). The high overall VRE proportion in Germany is mainly due to the situation in four states. There is an urgent need to analyse the epidemiology of VRE in detail to develop appropriate infection control strategies.

Prior use of four invasive procedures increases the risk of Acinetobacter baumannii nosocomial bacteremia among patients in intensive care units: a systematic review and meta-analysis

Acinetobacter baumannii is considered a leading cause of nosocomial bloodstream infections in intensive care units (ICUs), but there is disagreement as to whether certain invasive ICU procedures increase the risk of this infection. To help address this question, we performed a systematic review of the literature on whether previous catheterization (central venous, arterial, and urinary), mechanical ventilation, nasogastric tube use, and abdominal or thoracic drainage are associated with the development of A. baumannii nosocomial bacteremia in ICUs. Two reviewers searched PubMed, EMBASE, and Medline for the period January 1999 to February 2013. For each of seven invasive procedures, patients in the included studies were classified into two groups: those who had previously undergone that procedure and those who had not. The frequencies of A. baumannii nosocomial bacteremia were determined for each group. Five studies were included in the meta-analysis: three provided data for thoracic drainage, four for abdominal drainage, and five for the other invasive procedures. The following prior interventions were associated with an elevated risk of A. baumannii nosocomial bacteremia: mechanical ventilation (odds ratio (OR) 4.79, 95% confidence interval (CI) 3.09-7.43), central venous catheterization (OR 6.25, 95% CI 2.58-15.11), urinary catheterization (OR 2.55, 95% CI 1.49-4.36), and nasogastric tube use (OR 4.70, 95% CI 2.79-7.91). Available evidence suggests that prior central venous or urinary catheterization, mechanical ventilation, and nasogastric tube use are associated with a higher risk of A. baumannii nosocomial bacteremia in the ICU.

Expansion of Foxp3(+) T-cell populations by Candida albicans enhances both Th17-cell responses and fungal dissemination after intravenous challenge.

Candida albicans remains the fungus most frequently associated with nosocomial bloodstream infection. In disseminated candidiasis, the role of Foxp3+ regulatory T (Treg) cells remains largely unexplored. Our aims were to characterize Foxp3+ Treg-cell activation in a murine intravenous challenge model of disseminated C. albicans infection, and determine the contribution to disease. Flow cytometric analyses demonstrated that C. albicans infection drove in vivo expansion of a splenic CD4+Foxp3+ population that correlated positively with fungal burden. Depletion from Foxp3hCD2 reporter mice in vivo confirmed that Foxp3+ cells exacerbated fungal burden and inflammatory renal disease. The CD4+Foxp3+ population expanded further after in vitro stimulation with C. albicans antigens (Ags), and included at least three cell types. These arose from proliferation of the natural Treg-cell subset, together with conversion of Foxp3− cells to the induced Treg-cell form, and to a cell type sharing effector Th17-cell characteristics, expressing ROR-γt, and secreting IL-17A. The expanded Foxp3+ T cells inhibited Th1 and Th2 responses, but enhanced Th17-cell responses to C. albicans Ags in vitro, and in vivo depletion confirmed their ability to enhance the Th17-cell response. These data lead to a model for disseminated candidiasis whereby expansion of Foxp3+ T cells promotes Th17-cell responses that drive pathology.

Should prophylactic thrombolysis be routine in clinical practice? Evidence from an autopsy case of septicemia

BackgroundCentral venous catheters provide easy access for intravenous infusion and nutrition, but they can bring about complications such as catheter-related infections. Infected central venous catheters often cause nosocomial bloodstream infections with high morbidity and mortality. However, most of the morphological data that have been published are derived from in vitro and in vivo studies and few reports of direct evidence obtained from patient-derived samples have been described. Here we present visual evidence of catheter-related candidemia. To our knowledge, this is the first reported conventional histopathological evidence of a Candida-infected intraluminal thrombus in a patient’s central venous catheter.Case presentationA 62-year-old Japanese female with obstructive jaundice, gastrointestinal bleeding, and liver metastasis from pancreatic head cancer was given an implantable subcutaneous central venous port for nutrition and chemotherapy administration. High fever ensued on day 16 after the central venous port insertion and blood cultures revealed Candida albicans. Although the patient was given 300 mg/day of fosfluconazole according to the suggestion of the infection control team, she died from respiratory failure. Postmortem computed tomography revealed findings consistent with acute respiratory distress syndrome, suggesting that the patient’s course was complicated by catheter-related sepsis. Autopsy revealed a subcutaneous abscess around the port, from which C. albicans was cultured. However, no catheter-adherent thrombus, thrombosis of the great central veins, or endocardial vegetations were detected in the patient. Histological analysis revealed scattered abscesses in several organs including lungs and kidneys. Hyaline membrane formation and Candida colonies were found in the lungs. The central venous port tube, together with the part of the subclavian vein into which it had been inserted, was involved in an intraluminal fibrin thrombus containing neutrophils and macrophages, indicating that the thrombus existed while the patient was alive. Histopathological examination following use of the periodic acid-Schiff reagent and the Grocott stain revealed scattered Candida in the thrombus.ConclusionsProphylactic thrombolysis should be encouraged to prevent central venous catheter-related candidiasis in clinical practice.

Incidence of nosocomial hemodialysis-associated bloodstream infections at a county teaching hospital

Infections are an important cause of morbidity and mortality in patients undergoing hemodialysis. Limited information is to be found regarding nosocomial hemodialysis-associated bloodstream infections (HABSI). We sought to determine the rate of nosocomial HABSI and its associated risk factors at Riverside County Regional Medical Center. Inpatients who received hemodialysis during 2011 and 2012 were included, and outcomes were recorded along with risk factors. Data was analyzed with SPSS Inc software. A total of 619 patients was included. Fourteen HABSI were detected, with a rate of 3.33/1,000 hemodialysis sessions and 1.03/1,000 patient-days. An association was detected between HABSI and vascular access type (highest risk with nontunneled catheters), length of hospital stay, number of hemodialysis sessions, and hemoglobin A1c level. A correlation was also noted between HABSI because of MRSA and colonization of nares with MRSA. A predominance of staphylococci infections was detected. The rate of HABSI observed at Riverside County Regional Medical Center was lower than similar studies (2.5 per 1,000 patient-days and 3.95 per 1,000 hemodialysis sessions). The most important risk factors were determined to be nontunneled catheters, hemoglobin A1c greater than 7%, and nares colonization for HABSI because of MRSA. Infection prevention efforts in the inpatient hemodialysis population should focus on control of hyperglycemia and decolonization of nares from MRSA.