Presence Of Central Venous Catheter Research Articles

Clinical Characteristics and Outcomes of Candidemia Caused by Meyerozyma guilliermondii Complex in Cancer Patients Undergoing Surgery.

Although Meyerozyma guilliermondii complex is an uncommon cause of invasive candidiasis worldwide, reported cases, mainly regarding bloodstream infections, increased over years, and patients with cancer who have undergone recent surgery are most commonly affected. However, the clinical characteristics and outcomes of candidemia caused by M. guilliermondii complex remain poorly understood. A retrospective case-control study was conducted to evaluate the clinical characteristics and mortality of candidemia caused by M. guilliermondii complex in cancer patients undergoing surgery. Demographic and clinical data were collected from the hospital medical records system with a standardized data collection form and were analyzed with SPSS 20.0. Sixty-six cancer patients who have undergone recent surgery and were diagnosed with candidemia caused by M. guilliermondii complex were included in the study. Regarding the clinical manifestations, most patients' body temperatures ranged from 38 to 40°C, with a median fever duration of 4 (IQR: 3-6) days. Multivariate analysis indicated that the presence of central venous catheter (OR: 6.68; 95% CI 2.80-15.94) and gastric tube (OR: 3.55; 95% CI 1.22-10.34) were independent risk factors for M. guilliermondii complex fungemia. The 30-day crude mortality of candidemia caused by M. guilliermondii complex was 12.1%, twice that of the control group. Moreover, increased WBC count, age ≥ 60years, septic shock, and ICU admission were identified as predictors of mortality through univariate analysis. These findings will provide a foundation for the clinical management of candidemia caused by M. guilliermondii complex in post-surgical cancer patients.

Enterobacterales Infection after Intestinal Dominance in Hospitalized Patients.

The Enterobacterales order of Gram-negative bacteria includes the common nosocomial pathogens Klebsiella pneumoniae, Escherichia coli, Serratia marcescens, and Enterobacter species. Intestinal domination by some colonizing bacterial taxa is associated with subsequent infection, but 16S rRNA gene sequencing is too costly and slow to be used in a clinical setting. The objectives of this study were to develop a PCR-based assay that can measure Enterobacterales density, validate it against 16S rRNA gene sequencing, and measure the association between Enterobacterales dominance and subsequent infection. Two quantitative PCR (qPCR) assays that were developed to quantify the absolute and relative abundance of Enterobacterales had good correlation with 16S rRNA sequence analysis (P < 0.0001). Using both PCR assays and 16S sequencing, a matched case-control study was performed comparing rectal swabs from hospitalized patients who later developed bloodstream, urinary tract, or respiratory Enterobacterales infections (n = 95) to swabs from patients who remained uninfected (n = 189). Enterobacterales abundance measured by sequencing was high in both cases and controls (means, 31.1% and 27.5%, respectively; P = 0.322). We observed an increased risk of infection that depended on both the absolute and relative abundance of Enterobacterales as measured by qPCR assay A (P = 0.012). After adjustment for albumin levels, central venous catheter presence, and use of cephalosporins at the time of swab collection, this association still approached significance (P = 0.061). These results demonstrate that using qPCR to measure intestinal colonization dominance is feasible, indicate that hospitalized patients have high levels of Enterobacterales colonization, and suggest that both relative and absolute abundance may be associated with subsequent infection.IMPORTANCE Increasing antibiotic resistance has resulted in infections that are life-threatening and difficult to treat. Interventions that prevent these infections, particularly without using antibiotics, could save lives. Intestinal colonization by pathogens, including vancomycin-resistant Enterococcus and carbapenem-resistant Enterobacteriaceae (part of the order Enterobacterales) is associated with subsequent infection, and increased colonization density is associated with increased infection risk. Therefore, colonization offers a window of opportunity for infection prevention if (i) there are rapid and inexpensive assays to detect colonization, (ii) there are safe and effective interventions, and (iii) the risk of infection outweighs the risk of the treatment. Fecal transplants are proof of principle that manipulating the microbiome can reduce such colonization and prevent infections. This study demonstrates the feasibility of implementing rapid and inexpensive assays to quantify colonization and measures the strength of association between Enterobacterales dominance and subsequent infection. The approach described here could be a valuable tool in the prevention of antibiotic-resistant infections.

Prospective multi-center evaluation on risk factors, clinical characteristics and outcomes due to carbapenem resistance in Acinetobacter baumannii complex bacteraemia: experience from the Chinese Antimicrobial Resistance Surveillance of Nosocomial Infections (CARES) Network.

Introduction. Increasing evidence demonstrates unfavourable outcomes in bloodstream infections (BSI) due to the carbapenem-resistant Acinetobacter baumannii complex (CRAB).Aim. To investigate the differences in risk factors, clinical characteristics and outcomes in patients with A. baumannii complex BSI stratified by carbapenem resistance, a prospective multi-center study was conducted.Methodology. Information was collected in a predefined form. A total of 317 cases was included for comparison between CRAB BSI vs. carbapenem-susceptible A. baumannii complex (CSAB) BSI. Among these cases, 229 cases were defined as CRAB BSI and 88 cases as CSAB BSI.Results. Univariable analysis showed that male gender, underlying neurologic disease, prior carbapenems exposure, intensive care unit (ICU) stay, presence of central venous catheter, endotracheal intubation, tracheotomy, Foley catheter, nasogastric intubation, lower respiratory tract infections and catheter-related infections were more prevalent in CRAB BSI. Only male gender, prior carbapenems exposure and presence of endotracheal intubation persisted as independent risk factors for acquiring CRAB BSI. Patients with CRAB BSI displayed unfavourable outcomes characterized by failure of pathogen clearance, continuous fever, disease aggravation and higher incidence of 30-day all-cause mortality. Multivariate analysis demonstrated carbapenem resistance as an independent risk factor for 30-day all-cause mortality.Conclusion. Our findings reveal the epidemiological differences between CRAB BSI and CSAB BSI in a Chinese cohort. Our data suggest that carbapenem resistance has a significant impact on mortality for patients with A. baumannii complex BSI, further strengthening the importance of active prevention and control strategies for the spread of CRAB in Chinese hospitals.

P1316PREDICTORS OF ARTERIO-VENOUS FISTULA FAILURE: A POST-HOC ANALYSIS OF THE FAVOURED STUDY

Abstract Background and Aims An autologous arteriovenous fistula (AVF) is the preferred haemodialysis vascular access but successful creation is hampered by high rates of AVF failure. This study aimed to evaluate patient and surgical factors associated with AVF failure to improve vascular access selection and outcomes. Method This is a post-hoc analysis of all participants of FAVOURED, a multi-centre, double-blind, multinational, randomized placebo-controlled trial evaluating the effect of fish oil and/or aspirin in preventing AVF failure in patients receiving haemodialysis. The primary outcome of AVF failure was a composite of fistula thrombosis and/or abandonment and/or cannulation failure at 12 months post AVF creation and secondary outcomes included individual outcome components. Patient data (demographics, comorbidities, medications and laboratory data) and surgical factors (surgical expertise, anaesthetic, intraoperative heparin use) were examined using multivariable logistic regression analyses to evaluate associations with AVF failure. Results Of 536 participants, 253 patients (47%) experienced AVF failure during the study period. The mean age was 55 ± 14.4 years, 64% were male, 45% were diabetic and 4% had peripheral vascular disease. Factors associated with AVF failure included female sex (odds ratio [OR] 1.78, 95% confidence interval [CI] 1.20-2.67), lower diastolic blood pressure (DBP; OR for higher DBP 0.98, 95% CI 0.97-0.99), presence of central venous catheter (OR 1.50, 95% CI 1.02-2.20, p=0.04) and aspirin requirement (OR 1.61, 95% CI 1.01-2.57). Conclusion Female sex, requirement for aspirin therapy, requiring haemodialysis via a central venous catheter and lower diastolic blood pressure were factors associated with higher odds of AVF failure. These associations have potential implications for vascular access planning and warrant further studies.

A clinical approach to non-neutropenic fever in children with cancer.

There are a limited number of studies that address non-neutropenic fever episodes in children with cancer, and no standard approach exists. We opt to retrospectively analyze the efficacy of the current clinical approach for management of non-neutropenic fever episodes and the associated risk factors among children with cancer at the Princess Noorah Oncology Center from May 2016 through December 2017. A total of 480 non-neutropenic fever episodes were identified in 131 children, of which 62 episodes were triaged as high-risk non-neutropenic fever and 418 as low-risk non-neutropenic fever. Of those 480 non-neutropenic fever, 361 episodes (75.2%) were associated with the presence of central venous catheters. The overall failure rate of ceftriaxone mono-therapy was observed in 75.6% (11.7% in high-risk non-neutropenic fever with a mean C-reactive protein level of 21.1 (±23.2) mmol/L and 63.9% in low-risk non-neutropenic fever with a mean C-reactive protein level of 17.6 (±53.9) mmol/L). The overall bacteremia rate was 14.4%. The type of organisms isolated was mainly high-risk organisms in 59 non-neutropenic fever episodes (85.5%), OR 1.78 (95% CI: 0.45-7.04) p = 0.41. Of note, all bacteremia were associated with the presence of central venous catheter (100%). Of all the examined risk factors of outpatient treatment failure in low-risk non-neutropenic fever, only prolonged fever of more than three days were significantly associated with bacteremia OR 8.107 [95% CI: 1.744-37.691], p = 0.008. Noteworthy is that almost 43% of non-neutropenic fever episodes were associated with respiratory symptoms. This study provides a baseline for future prospective research assessing the pattern of non-neutropenic fever by focusing on associated risk factors.

Risk factors associated to infectious complications in children with febrile neutropenia induced by chemotherapy: A cohort study.

e22535 Background: Children cancer is the second cause of mortality, most of deaths are related to infectious complications due to immunosuppression provoked by chemotherapy. Febrile neutropenia is one of the most common issues in oncological patients and it’s considered an emergency. Studies have tried risk predicting models implementation, although they still need to be validated, updated and reproducible in different scenarios. The aim of this study was the early identification of conditioning factors to severe infectious complications in patients with febrile neutropenia that would allow taking decisions for diagnosis and treatment. Methods: We present a prospective cohort study that estimated the risk associated to clinical and paraclinical factors and the development of infectious complications in pediatric patients with febrile neutropenia induced by chemotherapy on their admission of an emergency room (ER). The clinical features analyzed were: age, type of cancer, chemotherapy regime, time between chemotherapy administration and ER admission, use of colony-stimulating factors, presence of central venous catheter, highest temperature registered, tachycardia, polypnea, hypoxemia and hypotension. The paraclinical features included were leucocyte, neutrophil and monocyte count, and C-reactive protein levels. Results: From 186 febrile neutropenia events, 101 cases reported infectious complications (54%). Clinical infection was the most frequent issue (38%). On the multivariate analysis we found that the features independently associated to infectious complication were tachycardia (OR1.07, CI95% 1.70-6.99) and highest temperature level reported in the ER (OR1.07, CI95% 1.00-1.13). Conclusions: Febrile neutropenia is the most common complication in pediatric oncological patients and it is related to life-threatening infections and high mortality rate. Risk prediction during the initial assessment in the ER is important to stratify patients and offer target therapy to decrease complications and prolonged hospitalization.

Risk factors for candidaemia in hospitalized patients with liver cirrhosis: a multicentre case–control–control study

ObjectivesThe aim of this study was to evaluate the risk factors for candidaemia in patients with liver cirrhosis. MethodsThis was a case–control–control (1:2:2) study performed in four Italian tertiary centres from 2006 to 2015. Cases were patients with liver cirrhosis developing candidaemia. For every case of candidaemia we enrolled two additional patients undergoing blood cultures for suspected infection yielding isolation of a bacterial pathogen (control A) and two additional patients undergoing blood cultures for suspected infection yielding negative results (control B). Patients were matched according to age, sex and model for end stage liver disease at hospital admission. ResultsDuring the study period 90 cases, 180 controls A and 180 controls B were included. At multivariate analysis assessed by means of multinomial conditional regression models, factors independently associated with candidaemia were previous (<30 days) acute-on-chronic liver failure (relative risk ratio (RRR) 2.22 (95% confidence interval (CI) 1.09–4.54), p = 0.046), previous(<30 days) gastrointestinal endoscopy (RRR 2.38 (95% CI 1.19–4.78) p = 0.014), previous(<30 days) antibiotic treatment for at least 7 days (RRR 2.74 (95% CI 1.00–7.48), p = 0.049), presence of central venous catheter (RRR 2.77 (95% CI 1.26–6.09, p = 0.011), total parenteral nutrition (RRR 3.90 (95% CI 1.62–9.40), p = 0.002) at infection onset and length of in-hospital stay >15 days (RRR 4.63 (95% CI 2.11–10.18), p <0.001] Conversely, rifaximin treatment was associated with lower rate of candidaemia (RRR 0.38 (95% CI 0.19–0.77), p = 0.007). Multivariable analysis for 30-day mortality showed that patients with isolation of Candida spp. from blood cultures had worse outcome when compared with controls even though the difference did not reach a statistical significance (hazard ratio 1.64 (95% 0.97–2.75) p = 0.06). ConclusionsWe identified previous antibiotic use, gastrointestinal endoscopy or acute-on-chronic liver failure and presence of central venous catheter especially for parenteral nutrition as independent factors associated with candidaemia. Surprisingly, chronic rifaximin use was a protective factor.

Invasive central venous monitoring during hepatic resection: unnecessary for most patients

BackgroundLow central venous pressure (LCVP) anesthesia reduces blood loss during hepatic resection and historically has required a central venous catheter (CVC) for intra-operative monitoring. The aim of this study was to assess the effect of an evolution of practice to CVP monitoring without CVC on the perioperative outcomes after liver resection. MethodsA retrospective study of partial hepatectomy patients from 2007 to 2016 who were over 18 years of age was performed. ResultsOf 3903 patients having partial hepatectomy, 2445 (62%) met inclusion criteria, and 404 (16%) had a CVC. Overall morbidity (33% non-CVC vs 38% CVC P = 0.076), major morbidity (16% vs 20% P = 0.067), and infective complications (superficial wound infection) 3% vs 4% P = 0.429; deep wound infection (5% vs 6% P = 0.720) did not differ between the two groups. In multivariate analysis, superficial wound infection, deep wound infection, and major complications were not associated with the presence of a CVC. All-cause mortality at 90 days was associated with CVC presence (OR 3.45, CI 1.74–6.85, P = 0.001) and age (OR 1.05, CI 1.02–1.08, P < 0.001). ConclusionSince the adoption of non-invasive CVP monitoring, there has been no increase in adverse peri-operative outcomes.

Persistent vs non-persistent candidaemia in adult patients in 2007-2016: A retrospective cohort study.

Persistent candidaemia (PC) is a recognised complication of candidaemia. Our objective was to evaluate risk factors and clinical significance of PC in adult patients. This is a retrospective, cohort study. We compared PC with non-PC. All patients with blood cultures positive for Candida species were identified from a microbiological database in the hospital district of Helsinki and Uusimaa from 2007 to 2016. PC was defined as an isolation of the same Candida species from positive blood culture for ≥5days. PC criteria were fulfilled by 75/350 patients (21.4%). No significant difference emerged between persistent and non-persistent cases caused by non-albicans Candida species (37.3% vs 35.1%, P=.742). The length of hospital stay before onset of candidaemia was longer before PC (hospital stay>7days; 73.3% vs 59.6%, P=.043). No significant impact on 30-day mortality was observed (20.0% vs 15.5%, P=.422). Using multivariable regression analysis, we found the presence of central venous catheter (CVC) (OR=2.71, 95% CI 1.31-5.59), metastatic infection foci (OR 3.60, 95% CI 1.66-7.79) and ineffective empirical treatment (OR=3.31, 95% CI 1.43-7.65) to be independent risk factors for PC. In subgroup analysis, early source control was identified as a protective factor against PC (30.5% vs 57.7%, P=.002). The presence of CVC, metastatic infection foci and ineffective empirical treatment were independently associated with PC in adult patients. Active search for and treatment of metastatic infection foci and removal of CVC are key elements for preventing PC.

Nutrition therapy in intensive care unit setting: what can be learned from a 6 months survey in a large academic hospital?

Malnutrition in Intensive Care Unit patients has been associated with worse clinical outcomes such as mortality and length of stay (LOS) in Intensive Care Unit (ICU), and nutritional status of Intensive Care Unit patients in particular seemed to be a significant predictor of mortality. Promptness of clinical nutrition administration is a key of nutritional support whenever volitional intake is unfeasible. Early enteral nutrition is associated with better clinical outcomes (reduced complications, LOS in ICU and in Hospital). The aim of this study is to investigate the nutrition therapy management in a large Academic Hospital, evaluating its effects on mortality and LOS in ICU and in the Hospital. Data were collected retrospectively from clinical records. Six physicians were trained on the data collection protocol and they reviewed every clinical record of patients included in the survey. Data of 426 patients admitted to ICUs between November 2016, 1st and April 2017, 30th were collected. A multivariate logistic adjusted regression, with backward variables selection method, was performed in order to identify predictors of enteral and parenteral nutrition conducted within 48 hours after admission to the ICU. The relation between medical nutrition therapy, mortality and LOS in ICU and in the Hospital were also evaluated. Patients were given prompt parenteral and enteral nutrition in 25.12% and 27.46% of cases, respectively. No association was found between medical nutrition therapy and ICU or hospital mortality. Predictors of early enteral nutrition were type of admission and surgery before admission; early parenteral nutrition predictors were gender, ICU (A vs B), impaired immunity status and Central Venous Catheter presence at admission. Our study stresses the need of monitoring nutrition prescribing behaviors in acute hospitals in order to better set up tailored interventions to standardize clinicians' practices and to focus on specific training targets.

Abstract 155: Elevated Risk of Venous Thromboembolism in Patients Undergoing Targeted Temperature Management After Cardiac Arrest

Introduction: Therapeutic hypothermia (TH) reduces mortality and improves neurological outcomes after cardiac arrest. Cardiac arrest is considered a pro-thrombotic state. Endovascular cooling catheters may increase the risk of thrombosis. Therapeutic hypothermia (TH), however, increases fibrinolysis. These opposing effects may expose patients to both bleeding and venous thromboembolic risk during and after therapeutic hypothermia. The net effect in these patientsremains largely unexplored. Moreover, the exact rate of venous thromboembolism (VTE) is uncertain in these patients. We sought to determine the incidence and potential predictors of VTE in patients undergoing TH after cardiac arrest and compare it to a control group with similar risk of VTE. Methods: Single center retrospective analysis. Participants were age ≥18 years old, admitted to Hartford Hospital with out-of-hospital or in-hospital cardiac arrest, underwent TH between January 1, 2007 and April 30, 2019 with endovascular cooling catheter. A total of 562 patients who underwent TH (Study group) were compared to 304 matchedpatientstreated in the medical ICU with a diagnosis of ARDS (control group). This control group was based on presumed similarities in factors affecting VTE: intensive care setting, immobility, length of stay and likely presence of central venous catheters. Results: Patients who underwent TH had a significantly higher rate of VTE (6.6% vs 4.6%, p=0.006) and deep vein thrombosis (DVT) (2.3% vs 1.3%, p=0.011) when compared to control group. The rate of pulmonary embolism was higher in the TH group, but this was not statistically significant (2.5% and 1.0%, p=0.128). In multivariate analysis age, gender, race and hospital length of stay were not associated with development of VTE in the study group. Conclusion: Patients undergoing TH after cardiac arrest have statistically higher incidence of VTE and DVT compared to patients with ARDS. This risk is independent of age, gender, race or length of stay. Further research into additional independent predictors of VTE and DVT in this population may eventually guide the management and potential future interventions.

Risk Factors for Pediatric Cerebral Sinovenous Thrombosis: A Case-Control Study with Pediatric Neuroradiologist Case Validation

BACKGROUND: Cerebral sinovenous thrombosis (CSVT) is a rare but serious disease process among all patients, with a slightly higher prevalence in pediatric patients. Despite its low frequency, CSVT represents the second most common type of venous thromboembolism (VTE) in children, next to deep vein thrombosis (DVT) of the limbs. Current literature lacks robust evidence on risk factors for CSVT, especially in the pediatric population. We sought to determine risk factors of CSVT in pediatric patients, via a single-institutional case-control study. METHODS: A case-control study was conducted at Johns Hopkins All Children's Hospital from patients admitted between March 31st 2006 and April 1st 2018. Cases were identified based on ICD-9 and ICD-10 codes and confirmed via electronic medical record (EMR) review and neuroradiologist confirmation of radiologic testing. Two controls were then randomly selected for each CSVT case, matched by month and year of admission. Clinical and demographic parameters were collected via abstraction from the EMR, including: age at admission, prior history of VTE, previous hospitalization within 30 days, head/neck surgery, other major surgery, congenital or acquired heart disease, dehydration, cancer, serious infection (included meningitis, sepsis, pneumonia, osteomyelitis, fungemia, pyelonephritis, head/neck infection, abscess involving anatomic sites other than skin or head/neck), prematurity, mechanical ventilation, chronic inflammatory disease, cystic fibrosis, nephrotic syndrome, obesity, and head/neck trauma. Associations between CSVT and putative risk factors were evaluated via logistic regression, using odds ratios (ORs) and 95% confidence intervals (95%CIs). Those risk factors with P-values &lt;0.1 in univariate logistic regression were included in adjusted (multivariate) logistic regression modeling; results of the latter employed a threshold of P&lt;0.05 for statistical significance. RESULTS: A total of 60 CSVT cases and 120 controls were identified. Median (and interquartile range in) age was 4.79 years (0.02-13.56 years) for cases and 5.58 years (1.16-10.78 years) for controls. Factors putatively associated with CSVT in unadjusted analyses were: presence of central venous catheter; serious infection; mechanical ventilation; chronic inflammatory disease; and head/neck trauma. In the multivariate model, mechanical ventilation (OR=9.01, 95%CI=2.19-37.02) and head/neck trauma (OR=11.52, 95% CI=2.63-50.41) remained independent, statistically-significant risk factors for CSVT. CONCLUSIONS: This single-institutional case-control study reveals that mechanical ventilation and head/neck trauma are independent risk factors for pediatric CSVT. These findings will be further investigated via the multicenter Children's Hospital-Acquired Thrombosis (CHAT) registry dataset, by which a risk model for CSVT in children will be further developed and validated, in order to inform future preventive strategies in pediatric patients at heightened risk of CSVT. Table Disclosures Goldenberg: NIH: Other: research support and salary support.

Risk Factors And Clinical Outcomes Of Hospital-Acquired MRSA Infections In Chongqing, China.

BackgroundMethicillin-resistant Staphylococcus aureus (MRSA) is a common pathogen of hospital infection with multi-drug resistant characteristics. Its spread and epidemic pose great challenges to nosocomial infection control. This study was aimed to identify risk factors for hospital-acquired MRSA (HA-MRSA) infections and investigate its clinical outcome, developing infection control strategies and improving patient outcomes.MethodsA retrospective case-case-control study was conducted to compare patients in Southwest Hospital, Chongqing, People's Republic of China from January 2018 to December 2018 with control patients. In this study, 251 patients with MRSA nosocomial infection, 339 patients with methicillin-sensitive Staphylococcus aureus strains (MSSA) nosocomial infection, and 300 patients with non-Staphylococcus aureus infection were included.ResultsMultivariate analysis showed that presence of central venous catheters (odds ratio [OR], 1.932; 95% confidence interval [CI], 1.074–3.477; P=0.028), sputum suction (OR, 2.887; 95% CI, 1.591–5.240; p<0.001), and total hospital stays more than 30 days (OR, 3.067; 95% CI, 2.063–4.559; P<0.001) were independent risk factors for HA-MRSA. Renal insufficiency (OR, 2.744; 95% CI, 1.089–6.914; P=0.032) and receipt of immunosuppressors (OR, 3.140; 95% CI, 1.284–7.678; P=0.012) were independent predictors of poor prognosis of MRSA nosocomial infection. Moreover, empirical use of antibiotics (OR, 0.514; 95% CI, 0.282–0.935; P=0.029) was a protective factor for poor prognosis of MRSA nosocomial infection. In-hospital mortality in the MRSA group was not statistically significant compared with the other two groups; however, the rate of poor prognosis in the MRSA group was higher than that of the MSSA group (27.5% vs 17.1%, χ2=9.200, P=0.002) and the control group (27.5% vs 16.0%, χ2=19.190, P=0.001).ConclusionOur results have shown presence of central venous catheters, sputum suction, and total hospital stays more than 30 days were associated with nosocomial MRSA infection. Patients with renal insufficiency and immunosuppressive therapy were more likely to cause poor prognosis with MRSA infection, and the empirical use of antibiotics can effectively reduce the adverse clinical outcomes caused by MRSA infection. Based on above findings, strategies to control MRSA infection should emphasize more attention to these patients and appropriate empirical use of antibiotics.

178. Evaluation of Oral Antibiotic Stepdown Therapy for the Management of Gram-Negative Rod Bacteremia in a Tertiary Care Medical Center

BackgroundTreatment strategies surrounding bacteremia are constantly changing as new data emerges. Transition from intravenous (IV) to oral (PO) antibiotics in patients with Gram-negative rod bloodstream infections (GNR BSI) remains controversial. The objective of this study was to characterize clinical outcomes in patients who received early (≤72 hours) vs. late (>72 hours) stepdown therapy (ES vs. LS, respectively) for GNR BSIs.MethodsA single-center, retrospective cohort study was conducted including adults with GNR BSIs admitted to a 610-bed tertiary care academic medical center between January 1, 2016 and December 31, 2017 who were transitioned from IV to PO antibiotics. Patients with severe renal impairment, inadequate source control, prolonged antibiotic course, HIV/AIDS, and pregnancy were excluded. The primary endpoint was clinical failure and secondary endpoints were 30- and 90-day all-cause mortality, duration of bacteremia, and adverse events.Results164 patients (ES = 61; NS = 103) were included. Population median age was 63 years, 56% were male, and 19% were immunocompromised. Genitourinary source was most common (48.7%), while the most common organism isolated was Escherichia coli (52.4%). Most infections were community-acquired (70.1%) and the most common step-down therapy choice was ciprofloxacin in 75% of patients. There were no major differences in baseline demographic and clinical characteristics between groups except for the greater presence of central venous catheters (16.4% vs. 35.9%; P = 0.006) in the LS group. Overall clinical failure was 9.8% vs. 13.6% between the ES and LS groups, respectively. The LS group had a higher rate of clinical failure defined by escalation from PO to IV antibiotics (1.6% vs. 10.7%; P = 0.03). Patients who failed therapy tended to be immunocompromised and/or have an intra-abdominal source of infection. Secondary endpoints did not differ between groups.ConclusionHigher clinical failure rates in the LS group indicate that these patients may have underlying clinical characteristics not amenable to stepdown therapy. Choice of step-down therapy was not driven by the source of infection or patient acuity. Further analysis and studies are needed to determine optimal time and population for stepdown.Disclosures All authors: No reported disclosures.

1688. Invasive Ocular Candidiasis: Who Is Really at Risk?

BackgroundThe Infectious Disease Society of America recommends that all patients with candidemia undergo a dilated retinal examination to exclude invasive ocular candidiasis. However, it remains unclear whether there are patients with candidemia who do not warrant routine surveillance because the risk of ocular infection is low.MethodsWe conducted a retrospective cohort study of all patients with candidemia diagnosed at three academic medical centers (Duke, University of North Carolina and University of Virginia) from 2012 to 2017. We collected risk factors for invasive ocular candidiasis based on previous literature and compared them between patients with and without invasive ocular candidiasis. We then built a multivariate logistic regression model to assess which risk factors were significant for developing invasive ocular candidiasis.ResultsOverall, 942 patients were diagnosed with candidemia over the study period. The mean age was 55.9 years, 56% were men, 25% were non-White. Among these patients, 120 (13%) were also diagnosed with invasive ocular candidiasis, 10% with chorioretinitis and 3% with vitreous involvement. In our logistic regression analysis, central venous catheter presence [OR 8.35 (3.53, 19.77)], intravenous drug use [OR 5.02 (2.63, 9.58)], immunosuppression [OR 2.40 (1.55, 3.70)], total parenteral nutrition [OR 2.28 (1.42, 3.66)], non-White race [OR 1.65 (1.07, 2.55)], older age [OR 1.02 (1.01, 1.03)],and female gender [OR 0.57 (0.37, 0.89)] were risk factors for developing invasive ocular candidiasis. In addition, we found that persons with candidemia due to C. albicans were more likely to have invasive ocular candidiasis [OR 1.86 (1.22, 2.85)].ConclusionThis cohort represents the largest study of patients with candidemia who developed invasive ocular candidiasis to date. Based on our findings, clinicians should develop targeted and cost-effective strategies for endophthalmitis screening. Disclosures All authors: No reported disclosures.

Ventilator associated pneumonia due to carbapenem resistant microorganisms in children.

Infections due to carbapenem resistant pathogens have become a major health threat especially for hospitalized patients. Acinetobacter baumanii (AB) and Pseudomonas aeruginosa (PA) are important pathogens causing ventilator-associated pneumonia (VAP) with a trend of high resistance to carbapenems. The aim of this study is to investigate the risk factors for VAP due to carbapenem resistant Acinetobacter baumanii (CRAB) and Pseudomonas aeruginosa (CRPA) in children. Between 2009 and 2013, an active, prospective observational study was conducted in Gazi University Hospital. Patients from Pediatric Intensive Care Unit (PICU), between 1 month and 12 years of age with VAP due to AB and PA were included. During this period, 74 children experienced 126 VAP episodes due to Acinetobacter baumanii (N.=58) and Pseudomonas aeruginosa (N.=68). Among these, 93.1% (N.=54) of AB and 51.5% (N.=35) of PA were carbapenem resistant. In univariate analysis, length of stay in PICU until the diagnosis of VAP, presence of central venous catheters, prior use of cefepime, ciprofloxacin, colistin, and teicoplanin were associated with VAP due to CRPA (P=0.02, P=0.02, P=0.006, P=0.01, P=0.001, and P=0.009 respectively). Significant association was not found between the development of VAP due to CRAB and the investigated risk factors. Regression analyses revealed previous use of cefepime (OR, 2.11; 95% CI, 0.016-0.595, P=0.039) and colistin (OR: 2.33; 95% CI: 0.061-0.789, P=0.023) to be independently associated with VAP due to CRPA. This study suggests that broad spectrum antibiotic usage was the most important risk factor for the development of VAP due to CRPA.

Eritrocitosis excesiva y trombosis venosa profunda de extremidad superior derecha: a propósito de un caso

La trombosis venosa profunda de extremidades superiores (TVPES) es unaentidad clínica infrecuente. Las causas secundarias asociadas con mayorfrecuencia son: la presencia de catéter venoso central y el padecer de cáncer.Se reporta un caso de TVPES que estuvo relacionado a la caída sufrida conprobable traumatismo de la vena subclavia y a la eritrocitosis excesivaque padecía. El diagnostico se realizó con ecografía duplex. El tratamientoanticoagulante empleado fue con heparina de bajo peso molecular al inicioy posteriormente con warfarina. El paciente evolucionó favorablemente. Enpersonas que habitan en altura, y que desarrollan eritrocitosis excesiva, estapudiera ser un factor importante en la génesis de la TVPES.

Invasive central venous monitoring during hepatic resection: unnecessary for most cases

Background: Low central venous pressure (LCVP) improves outcome after hepatic resection and is the standard anesthetic management technique. Historically, this approach required a central venous catheter (CVC), but non-invasive assessment of CVP has evolved and is now routine. This study evaluates the impact of this change in practice and patient outcome after liver resection. Methods: A non-randomized, retrospective, cohort design was conducted using a prospectively maintained database of hepatic resections at our institution from 2007–2016. Infection, major morbidity, and 90-day mortality were compared between the group that received CVC and the group without CVC. Multivariable logistic regression was used for each outcome. CVC was forced into each model to assess association while controlling for other significant factors. Results: During the study period, 2518 hepatic resections were assessed and analyzed over three time periods (2007–2010, 2011–2013 and 2014–2016). CVCs were placed in 16.3% of the patients. The use of CVC was significant for 90-day mortality, 3.40% with CVC verses 1.0% without CVC (p 0.008). Presence of CVC was not significantly related to superficial wound infections (p 0.644), deep wound infections (p 0.389), or major complications (p 0.166) while controlling for other significant factors in the multivariable analysis. In patients submitted to a major resection (≥3 segments), CVC was not used in 75.8% of the cases. The results remained constant over the three time periods analyzed. Conclusion: The evolution to non-invasive assessment of fluid management for patients undergoing partial hepatectomy has not resulted in adverse outcomes.

The correlation between nursing workload and bloodstream infection from central venous catheter in ICU

Introduction: Bloodstream infection associated with the presence of central venous catheters is the second most common hospital infection in the Intensive Care Unit (ICU). The nursing stuff is an essential part of the human resources of the ICU which contributes substantially to provide holistic and effective care to critically ill patients. The level of the nursing workload and its possible influence on the clinical course and outcome of critically ill ICU patients has been systematically studied in recent years. Mainly, was studied the connection with the care quality indicators such as mortality and infections Aim: The purpose of this study was to estimate the nursing workload in the ICU and to investigate the impact of bloodstream infection from Central Venous Catheter (CLABSI). Methods: The study sample consisted of 39 patients who were hospitalized in a multidisciplinary ICU in a 3 month period. For the detection of bloodstream infections we used the surveillance definition of CDC/NHSN for in vitro confirmed bloodstream infection (CLABSI). Measurement of nursing workload was via the NAS scale and the calculation was performed for each patient once existed or entering the ICU from baseline and constantly on a daily basis. A comparison of the quantitative variables was done with the statistical criterion Pearson’s x 2 , to compare the bisectors qualitative variables selected quantitative variables was used the t-test analysis and MannWhitney test. Results: Of the total sample, 74,4% (n = 29) were male, with a mean age 59 ± 21 years. The duration of ICU stay was 24 ± 23 days and mortality was 41%. The duration of hospitalization was 28 ± 24 days and the corresponding mortality of 46.2%. All correlations presented no statistically significant difference than the first day’s NAS in which appears the biggest difference between the values (p=0,046) but the NAS of the patients who did not develop bacteremia be more increased over those experienced. Conclusions: The nursing workload in our study did not prove as a risk factor for the occurrence of bloodstream infection in the ICU.

Septic shock due to Candida famata (Debaryomyces hansenii) candidemia in an ICU immunocompetent trauma-patient

Sepsis related to Candida famata (C. famata) fungemia is extremely rare in immunocompetent patients. Moreover, septic shock has not been reported due to this yeast.A previously healthy young multi-trauma male, presented septic shock from C. famata, after he had been admitted in the Intensive Care Unit (ICU) due to haemorrhagic shock. Risk factors for candidemia in ICU patients are the presence of a central venous catheter (CVC), Total Parenteral Nutrition (TPN), use of broad-spectrum antimicrobials, immunosuppression and the length of ICU stay. The presence of CVCs, prior use of antibiotics, prolonged hospitalization, disruption of skin flora and immunocompromised states have been identified as predisposing risk factors for C. famata fungemia. It is worth noting that the present case concerns a non-immunocompromised patient, but long ICU stay and brain injury may indicate a state of immunoparalysis.Identification of the yeast was performed by partial amplification and sequencing of the 26S ribosomal DNA gene [hypervariable region D1/D2; partial sequencing of the act1 gene confirmed the identity of the strain as Debaryomyces hansenii (GenBank submission ID: 1688297)]The patient quickly recovered from sepsis after initiation of amphotericin B and was discharged on the 60th day.