Presence Of Central Line Research Articles

A Clot in Transit: A Cause of Death or a Bystander?

The clot in transit is a rare manifestation of thromboembolic disease occurring usually in the setting of PE and frequently associated with poor outcomes. The best therapeutic option is not well established. We describe a series of 35 patients diagnosed with clots in transit including their therapeutic interventions and outcome between the period January 2016 to December 2020. a retrospective chart review of all patients with an Echocardiogram showing thrombi in the right heart chambers including patients with thrombus in the presence of central lines or other devices. We exclude patients where masses were described as tumors or vegetation and masses in the presence of bacteremia. There were 35 patients with echocardiographic evidence of a thrombus in the right heart chambers. In 12 of those patients, the thrombus was related to an intracardiac catheter. 37.1% of CT chest was done along with Echocardiogram and showed a concomitant PE in 77%. On echocardiogram, 66% of the thrombi were mobile. RV strain was present in 17% while abnormal RVSP (>30 mmHg) was present in 74%. Respiratory support was required in 37.1% and only 17% required inotropic support. There was a total or partial resolution in 80% those who had repeated echocardiogram after four weeks of therapy. Heparin was started in the majority of patients (74%). Warfarin was the most frequently used follow-up anti-coagulant in 51.4%. The mortality rate was significantly higher in those patients with RVSP >50, UFH group, O2 or inotropic support. 26% of patients died within the first 28 days after the diagnosis, while first 7 days mortality was 6% only. a clot in transit in our study was not directly associated with poor outcomes in the first week of therapy, UFH is still the most frequently used initial method to treat clots in transit. However, only 26% had a total resolution of clot within 4 weeks of treatment.

Retrospective analysis of sepsis in cutaneous T-cell lymphoma reveals significantly greater risk in Black patients

Sepsis is a leading cause of morbidity, mortality, and resource utilization among patients with cutaneous T-cell lymphoma (CTCL). To characterize the demographic, clinical, and microbial attributes distinguishing patients with CTCL sepsis from other patients with non-Hodgkin lymphoma (NHL) sepsis and patients with CTCL in general. Two-part retrospective cohort study at an academic medical center from 2001-2019 involving patients with CTCL (n=97) and non-CTCL NHL (n=88) admitted with sepsis, and a same-institution CTCL patient database (n=1094). Overall survival was estimated by Kaplan-Meier analyses. Patients with CTCL sepsis were more likely to be older, Black, experience more sepsis episodes, die or be readmitted within 30days of an inpatient sepsis episode, and develop Gram-positive bacteremia than patients with non-CTCL NHL sepsis. Staphylococcus aureus and Escherichia coli were the most frequently speciated organisms in CTCL (26%) and non-CTCL NHL (14%), respectively. No between-group differences were identified regarding sex, presence of central line, chemotherapy use, or disease stage. Compared with general patients with CTCL, patients with sepsis were Black and exhibited advanced-stage disease, higher body surface area involvement, and higher lactate dehydrogenase levels. Single institution, retrospective nature may limit generalizability. Awareness of CTCL-specific risk factors is crucial for guiding sepsis prevention and improving patient outcomes.

Methicillin-resistant Staphylococcus aureus bacteremia during the coronavirus disease 2019 (COVID-19) pandemic: Trends and distinguishing characteristics among patients in a healthcare system in New York City.

During the pandemic, the rate of healthcare facility-onset methicillin-resistant Staphylococcus aureus (MRSA) bacteremia was 5 times greater in patients admitted with coronavirus disease 2019 (COVID-19). The presence of central lines and mechanical ventilation likely contribute to this increased rate. The number of central-line-associated bacteremia cases may be underestimated in patients with COVID-19.

62. Follow-Up Blood Culture Practices for Gram-Negative Bloodstream Infections in Immunocompromised Hosts at a Large Academic Medical Center

BackgroundRoutine follow-up blood cultures (FUBC) are strongly recommended for Staphylococcus aureus and Candida spp. bloodstream infections (BSI), but the role of FUBC in Gram-negative (GN) BSI remains controversial. Factors that may result in persistent GN BSI include critical illness, endovascular infection, lack of source control, multidrug resistant organisms (MDRO), end-stage renal disease, or immunocompromised status. As such, FUBC in patients with any of these factors may be warranted to improve clinical outcomes, but the true balance of benefit versus harm remains unknown. Our objective was to evaluate the role of FUBC in immunocompromised patients with GN BSI.MethodsThis was a retrospective observational cohort of adult, immunocompromised patients treated for confirmed GN BSI between January 2019 and December 2020 at University of Maryland Medical Center. Immunocompromise was defined as active hematologic or solid tumor malignancy at time of BSI diagnosis, history of hematopoietic stem cell transplantation (HSCT) or solid organ transplantation (SOT), or absolute neutrophil count (ANC) < 1000 cells/mm3 at any time 30 days prior to BSI diagnosis. FUBC were defined as blood cultures drawn between 24 hours and 7 days from index blood culture, within the same hospital encounter. Positive FUBC was defined as a FUBC with same pathogenic GN organism identified. Comparison of patient and microbiologic characteristics was made between patients with and without FUBC.ResultsA total of 146 patients with GN BSI were included. Baseline characteristics are reported in Table 1. FUBC were collected in 129 (88.4%) patients. Neutropenia (49.6% vs. 19.4%, P=0.122), presence of central line (69.8% vs. 30.2%, P=0.061), and hospital-acquired origin of BSI (63.6% vs. 36.4%, P=0.395) resulted in increased frequency of FUBC. Patients with FUBC had a significantly longer post-BSI mean (SD) length of stay (17.3 [35.4] vs. 6.5 [6.0] days; P=0.005). Positive FUBC occurred in only 2 cases (1.4%) and both patients had persistent fevers at time of FUBC. Table 1. Baseline Characteristics ConclusionPositive FUBC were uncommon in this immunocompromised cohort with GN BSI, which challenges the need for routine collection of FUBC in this patient population.Disclosures Ciera L. Bernhardi, PharmD, Servier Pharmaceuticals (Advisor or Review Panel member) J. Kristie Johnson, PhD, D(ABMM), GenMark (Speaker’s Bureau) Kimberly C. Claeys, PharmD, GenMark (Speaker’s Bureau)

Evaluation of Specific Risk Factors and Outcomes of Colistin-Resistant Klebsiella pneumoniae Infections in a Tertiary Care Centre - An Observational Study

Background: Incidence of multidrug resistant Klebsiella pnumoniae infections are increasing globally especially in ICUs. Aim: We evaluated the burden of colistin resistant K. pneumoniae (ColR KP) and the risk factors associated with the outcome of these patients. Methods: Consecutive patients developing K. pneumoniae infections were included. K. pneumoniae from endotracheal tube and catheterized urine sample, having cell count &lt;105 cfu/ml, and which did not necessitate a change in antibiotics as per the treating physicians was considered as colonizer. Demographic and clinical details were collected and samples were processed as per standard protocol. Any growth was identified and its antimicrobial susceptibility was carried out by using Vitek 2 automated system. Minimum inhibitory concentration of &gt;4 μg/ml for Colistin was considered as resistant. The resistant isolates were confirmed with Broth microdilution method. Risk factor associated with the outcome of ColR KP was analyzed. Findings: Burden of K. pneumoniae infection was 50.02 per 1000 admissions. K. pneumonie (n=155) was isolated from patients with ventilator associated pneumonia (84, 54.2%), followed by blood stream infection (49, 31.6%) and urinary tract infection (22, 14.2%). ColR KP and intermediate (ColI KP) isolates were 58 (37.41%) and 97 (62.6%) respectively. Among ColR KP infected patients 32 (55.1%) died whereas 26 (44.8%) patients were discharged. Higher mortality was witnessed in ColI KP cases (75, 77.3%) compared to ColR-KP cases (32, 55.1%) (p=0.004; OR=2.77; 95% CI=1.37 to 5.59). Colistin resistance and presence of central line were independently associated with mortality. Conclusion: Colistin resistant K. pneumoniae infections among ICU patients are on rise. Presence of central venous catheter and resistance to colistin were independent predictors of mortality.

Feeding Practices, Lines, and Hospital-Acquired Infection during the Sustenance Phase of Infection Control Quality Improvement

Abstract Objectives Nosocomial infections are a significant threat to the survival and neurodevelopment of neonates .The present study attempts to correlate enteral feeding practices as measured by nil per oral (NPO days) with bloodstream infection (BSI) rates and central line-associated bloodstream infection (CLABSI) over a period of 2 years and 3 months. Methods This was a prospective observational study done in a tertiary level neonatal intensive care unit (NICU). Data were recorded on the presence of central lines or peripheral intravenous (IV) lines, receipt of intravenous fluids (IVF), total parenteral nutrition (TPN) or IV antibiotics, and mechanical ventilation status. BSI and CLABSI, regarded as sentinel events, were recorded and root cause analysis done. Results A total of 3,448 infants constituting 17,846 patient days with mean gestational age and birth weight of 34.3 ± 3 weeks and 1,868 ± 434 g, respectively were studied. NPO per 1,000 days shows a significant positive correlation with BSI (ρ = 0.513; p = 0.004), CLABSI (ρ = 0.425; p = 0.021), antibiotic days (ρ = 0.7; p &lt; 0.000), IV fluid days (ρ = 0.459; p = 0.014), and central line days (ρ = 0.634; p &lt; 0.001). The IV fluid days showed correlation with BSI (ρ = 0.4, p ≤ 0.03) and CLABSI (ρ = 0.43, p = 0.02). Conclusion BSI in NICU correlates with higher NPO and IV fluid days. Strengthening of enteral feeding practices reduces health care-associated infections.

Risk Factors Associated with Colonization of Intestine by Carbapenem Resistant Enterobacteriaceae in a Pediatric ICU

Objectives: Asymptomatic colonization of the gastrointestinal tract by Carbapenem Resistant Enterobacteriaceae (CRE) constitutes a reservoir for transmission that may remain unidentified in hospitals that do not implement active surveillance testing. Aim: To assess the magnitude of colonization of carbapenem resistant Enterobacteriaceae and to analyze various risk factors associated with this colonization in children admitted in PICU. Methods: Three-hundred patients admitted to Pediatric Intensive Care Unit (ICU) which tested negative for CRE colonization upon admission were studied for colonization of intestine by CRE after two days of stay in ICU. Risk factors were analyzed with respect to CRE colonized and non CRE colonized groups. Results: Thirty-two (10.67%) patients were found to be colonized with CRE; Klebsiella pneumoniae being the predominant species followed by Escherichia coli using CDC screening method. Univariate analysis of risk factors revealed acute bronchopneumonia, acute febrile illness, Gullian-Barre syndrome to be significantly associated with colonization with CRE. Also, sepsis, presence of central line, mechanical ventilation, protein energy malnutrition and intake of steroids, Piperacillin-Tazobactam was found to be highly significant (p<0.001). The odds of developing colonization were significantly higher in children with renal and respiratory disease, sepsis and with intake of broad-spectrum antibiotics. Conclusions: Antimicrobial resistance is a huge public health problem in developing countries and these colonized patients can act as reservoirs of multi drug resistant bacteria resulting in untreatable healthcare associated infections. Large scale epidemiological surveillance studies of CRE using affordable phenotypic methods along with stringent infection prevention control strategies are required. J Microbiol Infect Dis 2020; 10(2):75-81.

118. Factors Associated with Positive Follow-up Blood Cultures in Gram-Negative Septicemia

BackgroundBloodstream infections remain a significant cause of morbidity and mortality. No guidelines for the management of noncatheter-associated Gram-negative septicemia exist. There is considerable debate regarding the role of follow-up blood cultures. Studies have shown inadequate antibiotic therapy increases mortality in Gram-negative sepsis. We evaluated factors associated with a higher likelihood of positive follow-up blood cultures (FUBC).MethodsA retrospective cohort study was conducted to look at factors associated with an increased likelihood of positive FUBC. Data were obtained via Epic chart review. Empiric antimicrobial regimens were reviewed in all patients with MDRO infections.ResultsWe identified 1,527 patients ≥18 years admitted with gram-negative septicemia from January 1, 2013 through January 1, 2018. A total of 8.4% had positive FUBC. Patients with positive FUBC had a younger median age than the no-growth group (64.7 vs. 69.4, P <0.001). Admission systolic blood pressure was lower in the group with positive FUBC than the no-growth group (107 vs. 116, P = 0.008). The odds ratio for positive FUBC for cardiac device was 2.08 (95% CI = [0.97, 4.35], P = 0.061); central line infection (vs. urinary tract infection) adjusted odds ratio was 2.08 (95% CI = [1.10, 3.95], P = 0.025). The positive FUBC group had a larger proportion of multidrug-resistant organisms (MDRO) (21.9% vs. 10.4%, P < 0.001) with an odds ratio of 2.40 (95% CI = [1.53, 3.78]). In this group, those who received inadequate empiric antibiotics had a significantly higher percentage of repeat positive results (78.6% vs. 57.1%, P = 0.033). In summary, patients with either an MDRO, a central line infection (vs. urinary tract infection), or the presence of a cardiac device (vs. no cardiac device present) had over twice the odds of positive FUBC than those without.ConclusionThough the role of FUBC for Gram-negative septicemia has been brought into question, our results show that the presence of central lines, cardiac devices, infections with MDRO organisms, or inadequate empiric antibiotics on admission were factors strongly correlated with subsequent positive FUBC. Therefore, we believe that repeating blood cultures in this subset of patients require further study and consideration.Disclosures All authors: No reported disclosures.

587. Risk Factors for Nosocomial Methicillin-Resistant Staphylococcus aureus (MRSA) Colonization in a Neonatal Intensive Care Unit (NICU): A Case–Control Study

Background Staphylococcus aureus (SA) is a leading cause of nosocomial infection in NICUs. Colonization is a prerequisite for most SA infections. Previously recognized risk factors for colonization include the length of stay (LOS), multiple gestation, low birth weight, Caesarean delivery and multibed location. The objective of this study was to determine risk factors for MRSA colonization in a Level IV NICU independent of LOS and gestational age (GA) in the context of a circulating MRSA clone.MethodsWeekly MRSA colonization cultures were performed from April 2017 through March 2018. Case–control study. Cases: Infants with newly acquired MRSA colonization and at least one previous negative culture. Controls: Infants with negative surveillance cultures, matched 1:1 with cases by GA and LOS. Factors compared: (a) neonatal demographics; (b) maternal factors; (c) neonatal factors since admission including antimicrobial therapy; (d) neonatal factors during the week prior to MRSA acquisition, including bed location, number of location changes, presence of central line, respiratory support, NICU census, ATP surface bioburden testing pass rate, MRSA colonization pressure.Results50 case infants were matched with controls. Forty-five of the 50 isolates were mupirocin-resistant and related by pulse-field gel electrophoresis On matched univariable analysis, the following were significantly associated with a risk for MRSA acquisition: (1) Bed location in the acute area (P = 0.03), (2) The requirement of any level of respiratory support during the week prior to MRSA detection (P = 0.04), (3) Higher ATP pass rate during the week of and week prior (P = 0.01), (4) Higher MRSA colonization pressure during the prior week (P = 0.002), (5) Not having a hearing test during the time between the previous negative culture and MRSA acquisition (P = 0.01). A multivariable conditional logistic regression model (that excluded ATP pass rate) found that only colonization pressure was associated with acquisition of MRSA colonization.ConclusionIndependent of LOS and GA, MRSA colonization pressure, ATP pass rate and higher patient acuity, reflected by location within the acute area and requiring respiratory support, are significantly associated with MRSA acquisition in the NICU; only colonization pressure remained associated in a multivariable model.Disclosures All authors: No reported disclosures.

Risk of Venous Thromboembolism in Acute Leukemias: A Meta-Analysis

Background: Venous thromboembolism (VTE) is an important cause of morbidity and mortality in cancer patients (pts). The risk of VTE, however, differs according to cancer type. Pts with hematologic malignancies are at an increased risk of VTE events, either due to the underlying disease biology or related to treatment. This risk exists even in acute leukemia (AL), which is characterized by profound thrombocytopenia and coagulopathies that present treatment challenges. Advances in anti-leukemic therapies and improved supportive care over the last several decades may have impacted the extent to which an average patient is at risk for VTE We performed a meta-analysis of published literature on VTE rates in AL pts and evaluated trends in VTE incidence in relation to the reported study time period.Methods: This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed, EMBASE, Medline, Scopus and Cochran databases to identify relevant studies published between January 1980 and June 2018. All studies including randomized controlled, retrospective or observational studies in AL pts which investigated VTE as an endpoint were included. Abstracts, posters, review articles, and case reports were excluded. Articles were excluded if they did not provide disease-level data. The search terms included “venous thromboembolism”, “deep venous thrombosis”, “pulmonary embolism”, and “leukemia”. Furthermore, citations were supplemented by cross checking the reference lists of eligible studies and relevant reviews to identify additional published data. We collected study period, study design, study publication date, AL subtype, total patients, and rates of VTE. When reported, we collected information on VTE prophylaxis and presence of central lines. Meta-analysis of VTE rates was performed using an established Bayesian logistic random effects model. The model assumes that the log odds of VTE is exchangeable across studies with Gaussian distribution and random hierarchical mean and standard deviation. For both analyses, the hierarchical mean assumed a Gaussian prior with mean 0 and variance = 200. The inter-study standard deviation was assumed uniform (0,10). Given treatment and patient heterogeneity among distinct subtypes of AL, analyses were undertaken separately for each AL subtype. Results for individual studies and the combined inter-study mean VTE rate are described by the resultant posterior medians and 95% highest posterior density (HPD) intervals.Results: From the initial search, 2527 articles were identified. Among these, 938 were duplicate publications, 1408 did not meet content inclusion criteria, 150 were review articles or case reports, 2 studies lacked disease level data, thus, leaving 31 studies for analysis. A total of 29 studies focused on ALL, 11 on AML, 11 on APL, and some studies included multiple disease populations. The inter-study mean incidence of VTE for ALL was 8.67% (95% HPD 6.01%-11.58%), fig 1a, for AML was 7.25% (95% HPD 4.12%-11.09%), fig 1b, and for APL was 12.94% (95% HPD 7.04%-20.67%), fig 1c. .. Our graphical analysis indicates an increase in risk of VTE with time for ALL (fig 2a), AML (fig 2b), and APL (fig 2c).Conclusion: In the present meta-analysis, we determined that the overall incidence of VTE in AL pts ranged from 7-13%. Among AL subtypes, APL pts had the highest rate of VTE. We observed an increased risk of VTE over time. We postulate this is multifactorial and may be related to an increase in case findings from increased screening, aging sedentary population, and increased use of prothombotic agents. Notable strengths of this study include the largest review of association of VTE with AL and evolving risk of VTE with time. These findings need to be considered in light of several limitations - lack of comparator group limiting ability to generate pooled relative risks for VTE, heterogeneity in study populations and reporting and scare data on VTE prophylaxis. Further data are required to determine the mechanism for the increase in risk. Given the VTE risk and its known impact on morbidity, mortality and associated health care costs, prospective studies are warranted in AL pts to facilitate establishment of guidelines for prophylaxis and management of thrombotic complications. DisclosuresCarraway:Amgen: Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Speakers Bureau; FibroGen: Consultancy; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Novartis: Speakers Bureau; Balaxa: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jazz: Speakers Bureau. Advani:Amgen: Research Funding; Novartis: Consultancy; Glycomimetics: Consultancy; Pfizer: Honoraria, Research Funding. Nazha:MEI: Consultancy. Gerds:Apexx Oncology: Consultancy; Celgene: Consultancy; CTI Biopharma: Consultancy; Incyte: Consultancy. Sekeres:Opsona: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Opsona: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees.

372. Attributable Mortality of Candidemia After Introduction of Echinocandins

BackgroundCandidemia is among the most frequent nosocomial blood stream infections and associated with considerable morbidity and mortality. Landmark case–control studies estimated an attributable mortality of 38% and 49%. After introduction of echinocandins, attributable mortality may have decreased.MethodsIn a case–control design, 100 consecutive, hospitalized patients with candidemia were enrolled at the University Hospital of Cologne. These cases had at least one blood culture positive for Candida spp. >48 hours post admission. We enrolled patients from January 2017 backwards until February 2014. Controls were patients without candidemia matched for age, sex, calendar year, duration of hospitalization, main admission diagnosis, and Patient Clinical Complexity Level. Risk factors for candidemia captured were malignancy, diabetes, infection other than candidemia, liver cirrhosis, hemodialysis, congestive heart failure, coronary artery disease, chronic lung disease, intensive care, mechanical ventilation, and presence of central lines. For each control patient, we considered the day of candidemia of its matched case to compare post diagnosis length of stay. We estimated attributable mortality until day 30 post candidemia diagnosis. We performed χ2-test for categorical and Student’s t-test for continuous variables, and defined a two-tailed P-value of <0.05 statistically significant.ResultsCases and controls were 68% males. Median age was 62 and 63 years, and 25th and 75th percentile 55 and 74 years in both groups. Candidemia occurred a median 18 days post admission. For cases and controls, median length of stay post diagnosis was 17 and 15.5 days (P = 0.13), for those controls who died 12 and 19 days (P = 0.21), and for survivors 24 and 13 days (P = 0.006). Day 30 mortality rates were 38% and 11% for cases and controls (P = 0.03); thus attributable mortality was 27% (95% CI, 16%–28%).ConclusionAttributable mortality of nosocomial candidemia is still substantial, but was lower in our study when compared with literature from before introduction of echinocandins.Disclosures O. Cornely, Actelion, Amplyx, Arsanis, Astellas, AstraZeneca, Basilea, Bayer, Cidara, F2G, Gilead, GSK, Leeds University, Matinas, MedPace, Melinta, Merck/MSD, Miltenyi, Pfizer, Rempex, Roche, sanofi pasteur, Scynexis, Seres, Medicines Company: Research Contractor, Research grant and Research support. Allecra Therapeutics, Amplyx, Actelion, Astellas, Basilea, Cidara, Da Volterra, F2G, Gilead, IQVIA, Janssen, Matinas, Menarini, Merck/MSD, Paratek, PSI, Scynexis, Seres, Summit, Tetraphase, Vical: Consultant, Consulting fee. Astellas, Basilea, Gilead, Merck/MSD, Pfizer: Speaker’s Bureau, Speaker honorarium.

A Prospective Study of Febrile Neutropenia in Pediatric Cancer Patients in Jordan

To describe the characteristics and clinical course of febrile neutropenia (FN) in pediatric patients admitted to a comprehensive cancer center in Jordan. This is a 6-month prospective observational study. Patients admitted with FN were identified. Patient demographics, duration since last chemotherapy, use of granulocyte colony-stimulating factor, presence of central lines, transfer to the intensive care unit, length of hospital stay, mortality, and the results of all cultures were recorded. One hundred and nine episodes for 88 patients were included, with a median age of 6 years (range, 1 to 19 y) and 55% were females. Median duration since last chemotherapy was 7 days (range, 1 to 33 d); median duration of hospital stay was 7 days (range, 1 to 81 d). Transfer to the intensive care unit was required for 11% of episodes, and there were no deaths. Positive cultures were reported in 18.4% episodes. Pathogens isolated were gram-positive organisms (50%), gram-negative organisms (20%), viral (25%), and fungal (5%). Positive blood cultures were significantly more in episodes with central lines compared with those with no central lines (P=0.04). FN episodes had favorable outcomes and were mostly associated with negative cultures. There were differences between the microbiologic profiles reported in this study, compared with what has been previously described.

Neonatal Intensive Care Unit Candidemia: Epidemiology, Risk Factors, Outcome, and Critical Review of Published Case Series

Evaluation of epidemiological trends, risk factors, and clinical outcome associated with candidemia at a neonatal intensive care unit is reported. From January 2005 to December 2009, forty candidemia cases were identified. C. albicans and C. parapsilosis were the most common species recovered (69 and 24%, respectively). All C. parapsilosis strains were susceptible to antifungals, whereas, C. albicans exhibited higher resistance rates to azoles. Low birth weight, low gestational age, presence of central lines, endotracheal intubation, total parenteral nutrition, previous use of antibiotics, steroids, previous episode(s) of bacteremia and prolonged stay in intensive care unit were common features associated with candidemia. C. albicans was most often isolated from extremely low birth weight neonates as compared to non-albicans Candida (P<0.01). Mortality rate was 35.7% and was associated with low gestational age (P<0.01), low birth weight (P<0.01), and presence of renal failure (P<0.05). Furthermore, a critical review of recent published case series is presented.

Unsuspected Pulmonary Emboli Identified on Routine Cancer Staging MDCT Scans: Impact on Cancer Survival

Background: While symptomatic venous thromboemboli (VTE) clearly have an adverse impact on survival among cancer patients, the outcome of cancer patients with unsuspected pulmonary emboli (PE) found on routine cancer staging multi-row detector CT (MDCT) scans is unknown. In order to evaluate survival among cancer patients with unsuspected PE, we expanded on a previous study (O'Connell, JCO 2006; 24:4928) of such patients.Methods: We performed a retrospective chart review of cancer patients with unsuspected PE found on routine cancer staging MDCT scans between May, 2003 and August, 2006. Two patients matched for age, cancer type and stage (“controls”) were identified for each patient with unsuspected PE (“cases”). Patients with known VTE, patients already receiving anticoagulation for any reason and patients with multiple active cancers were excluded. We recorded cancer characteristics, signs and symptoms typical of PE, risk factors, presence of PE on subsequent staging scans, time to death, and cause of death. We used conditional logistic regression analysis to compare the baseline characteristics. To evaluate the impact of unsuspected PE and other covariates on survival, we used stratified Cox proportional hazard analysis and the logrank test.Results: Seventy patients with unsuspected PE and 137 matched controls were evaluated. There were no significant differences between the groups in terms of matching factors, gender, or sites of metastases. Cases were more likely to have had prior VTE and to have had surgery within the previous 2 months than were controls (p=0.008, p=0.0002, respectively). There were no differences in the time from cancer diagnosis to the index MDCT scan, use of erythropoietin, exposure to chemotherapy, presence of central lines, hormonal therapy or use of antiplatelet medication between cases and controls. As previously reported in the smaller series, cases were more likely to actually have complained to someone on the medical team of shortness of breath and fatigue than were control patients (p =0.0009, p=0.001, respectively); case patients were also more likely than control patients to complain of cough (p=0.019). There were no statistically significant differences in other signs or symptoms such as hypoxia, fever, limb pain or swelling, chest pain or tachycardia. Of the 70 patients with unsuspected PE, 17 (24.3%) had isolated subsegmental clots and 53 (75.7%) had more proximal clots. Fifty-nine of the 70 patients (84.3%) with PE received some form of anticoagulation as treatment. Using a stratified analysis adjusting for the presence of brain, liver and lung metastases and for use of erythropoietin we found that proximal unsuspected PE conferred a hazard ratio for death of 1.79 (95% CI 1.10–2.90, p =0.018) (Kaplan-Meier curves, Figure 1). Symptomatic patients with unsuspected proximal PE, in particular, had poorer overall survival than matched controls (5 months vs. 14 months, p=0.009, logrank test). Use of erythropoietin, metastases to lung, liver or lymph nodes, gender, and active treatment with chemotherapy had no significant impact on survival; brain metastases, however, conferred poorer overall survival (20.5 vs. 61 months, p=0.003) independent of PE.Conclusion: These data support our previous findings in the smaller series that patients with unsuspected PE detected on routine staging MDCT scans are more likely to be symptomatic than are matched control patients, particularly with shortness of breath, fatigue and cough. Unsuspected PE have a significant adverse impact on overall survival among cancer patients; this impact is more pronounced among those patients reporting PE-related symptoms. [Display omitted]

Venous thromboembolism in ovarian cancer patients receiving erythropoietin (Epo)/darbepoetin (Darbe) for chemotherapy-induced anemia (CIA)

16514 Background: Cancer patients are at higher risk of developing venous thromboembolism (VTE) than the general population. With VTE incidence of 5.2% - 5.6%, ovarian cancer ranks third among malignancies associated with the highest incidence of VTE, following kidney (5.7%) and pancreas (8.2%) cancers. Both Epo/Darbe are associated with increased risks of VTE ranging from 4.2% to 7.1%. We reviewed the incidence of VTE among patients with ovarian cancer receiving Epo/Darbe for CIA. Methods: We performed retrospective charts reviews of patients with ovarian malignancy who received Epo/Darbe for CIA in 2005–2006 and who developed VTE during this period. Results: In 2005–2006 among 411 patients with ovarian cancer seen in RPCI Gynecologic Oncology Clinic, 48 (12%) were diagnosed with VTE. During this time 115 ovarian cancer patients were receiving Epo/Darbe for CIA. 13 (11%) of these patients developed VTE while receiving EPO/Darbe, 10 deep venous thrombosis (DVT) and 3 pulmonary embolism (PE). Among them, 9 were treated for recurrent disease and only 1 had a surgery 4 weeks preceding VTE. All 13 patients were receiving chemotherapy during VTE diagnosis: 5 carboplatin/paclitaxel, 6 cisplatin with gemcitabine, 1 docetaxel, and 1 doxorubicin. 10 patients were receiving Darbe for CIA and 3 were receiving Epo. The mean cumulative dose of Darbe was 1410 mcg with mean onset of VTE in130 days from the start of Epo/Darbe. Conclusions: The rate of VTE among RPCI ovarian cancer patients, including those receiving Epo/Darbe appears to be higher than that reported in the literature. This warrants further evaluation of the incidence of VTE among patients with ovarian cancer, especially the subset receiving Epo/Darbe for CIA. Risk Factor Number of Patients (N 13) Time from surgery (weeks) Mean: 48 Age at VTE (years) Mean: 66 <40: 0 40–60: 3 (23%) >60: 10 (77%) Prior VTE 0 Presence of central line 7 (54%) BMI >30 2 (15%) Exogenous Estrogens 2 (15%) Chemotherapy 13 (100%) Smoking 2 (15%) Advanced Disease 11 (85%) No significant financial relationships to disclose.

Thrombotic complications in childhood acute lymphoblastic leukemia: a meta-analysis of 17 prospective studies comprising 1752 pediatric patients

AbstractThe risk of thrombosis in children with acute lymphoblastic leukemia (ALL) reportedly ranges between 1% and 37%. Epidemiologic studies have usually been hampered by small numbers, making accurate estimates of thrombosis risk in ALL patients very difficult. The aim of this study was to better estimate the frequency of this complication and to define how the disease, its treatment, and the host contribute to its occurrence. We made an attempt to combine and analyze all published data on the association between pediatric ALL and thrombosis, by using a meta-analytic method. The rate of thrombosis in 1752 children from 17 prospective studies was 5.2% (95% CI: 4.2-6.4). The risk varies depending on several factors. Most of the events occurred during the induction phase of therapy. Lower doses of asparaginase (ASP) for long periods were associated with the highest incidence of thrombosis, as were anthracyclines and prednisone (instead of dexamethasone). The presence of central lines and of thrombophilic genetic abnormalities also appeared to be frequently associated with thrombosis. In conclusion, the overall thrombotic risk in ALL children was significant, and the subgroup analysis was able to identify high-risk individuals, a finding that will hopefully guide future prospective studies aimed at decreasing this risk.

Predictors of acquiring a nosocomial bloodstream infection on extracorporeal membrane oxygenation

Purpose: The aim of this study was to identify independent predictors of acquiring a nosocomial bloodstream infection (BSI) during extracorporeal membrane oxygenation (ECMO). Methods: This retrospective cohort consisted of 202 neonates treated with ECMO from 1989 to 1998 at the author' institution. Data collected included patient demographics, primary and secondary diagnoses, white blood cell counts, antibiotic usage, presence of central lines, operative procedures, and outcome. Surveillance blood cultures were drawn daily from the circuit using sterile technique to identify acquired pathogens. Statistical analyses included logistic regression, Cox proportional regression analysis, and discriminate analysis. Results: There were 1,245 blood cultures drawn on 202 patients (6.2 cultures per patient), and a nosocomial BSI was identified in 7 patients (3.4%) during this 10-year span. These were infections that were neither present nor incubating on admission. Pre-ECMO diagnoses of patients who had a nosocomial BSI while on bypass included group B beta-hemolytic streptococcal sepsis (n = 2), herpes simplex viral sepsis (n = 1), congenital diaphragmatic hernia (n = 2), persistent pulmonary hypertension (n = 1), and congenital heart disease (n = 1). The median time on ECMO before obtaining a positive culture was 390 hours. The infectious agents responsible for these BSIs included Staphylococcus epidermidis (n = 5), Staphylococcus aureus (n = 1), and Escherichia coli (n = 1). The major factor associated with acquiring a nosocomial BSI on ECMO was the duration of bypass (391 v 141 hours, P =.002). Additionally, patients in the BSI group were more likely to have had an arterial catheter in place (16 v 7 days, P =.009) and to have received more screening blood cultures (16 v 6 cultures, P < 001). White blood cell counts, absolute neutrophil counts, and immature/total (I/T) ratios were not useful in predicting a nosocomial BSI. Of the 31 patients who required ECMO for more than 10 days, 7 (23%) had a positive blood culture, and 5 of these 7 infants (71%) died (P =.03). Conclusions: The only predictor of acquiring a nosocomial BSI on ECMO was the duration of support for greater than 10 days. Because classical predictors of infection are unreliable while the patient is on ECMO, the authors suggest that obtaining daily surveillance blood cultures beginning on the tenth day should be performed with prolonged ECMO courses. The authors confirmed previous reports of the association between a prolonged ECMO course and a high mortality rate. However, the authors speculate that, in actuality, the primary diagnosis leads to the prolonged course of support and is the major factor in the infant' demise. J Pediatr Surg 36:487-492. Copyright © 2001 by W.B. Saunders Company.

Polymicrobial Bacteremia in the Late 1980s: Predictors of Outcome and Review of the Literature

Although polymicrobial bacteremia has been described in several previous series, there has been no recent study of patients using rigorous statistical analysis. Our objective was to characterize a present-day patient population with polymicrobial bacteremia and to define factors prognostic of survival. Polymicrobial bacteremia accounted for 6% of all positive blood cultures at a university hospital and a Veterans Administration hospital over a 2 1/2 year period in the late 1980s. The majority of these patients were elderly with significant underlying diseases, notably malignancies, and 56% of all episodes were nosocomially acquired. Enterobacteriaceae have remained the most common organisms, though the frequency of gram-positive cocci isolated has increased compared to older studies. Gastrointestinal, genitourinary, and skin and soft-tissue sources were the most common, although the incidence of infections due to central venous catheters appeared to be increasing. The source of 25% of bacteremia was not identified despite newer diagnostic techniques. By univariate analysis, mortality, which was 36% overall, correlated with thrombocytopenia, respiratory failure, disseminated intravascular coagulation, encephalopathy, severity of underlying disease, hemolysis, adult respiratory distress syndrome, use of steroids, renal insufficiency, institution, presence of central lines, and nosocomial acquisition. Using stepwise logistic regression analysis, mortality was predicted by respiratory failure, severity of underlying disease, and hemolysis. We conclude that polymicrobial bacteremia remains an important entity in the present-day hospitalized population, with an increasing frequency of gram-positive organisms and catheter sources, and a large proportion of undiagnosed etiologies.