Presence Of Central Venous Catheter Research Articles

Indwelling medical devices and skin microorganisms on ICU patients bathed with chlorhexidine gluconate

Background: Bathing ICU patients with chlorhexidine gluconate (CHG) decreases bloodstream infections and multidrug-resistant organism transmission. The efficacy of CHG bathing on skin microorganism reduction may be influenced by patient-level clinical factors. We assessed the impact of clinical factors on the recovery of microorganisms from the skin of patients admitted to an ICU who were receiving routine CHG bathing. Methods: We analyzed data obtained from 6 single-day point-prevalence surveys of adult ICU patients between January and October 2018 at 1 medical ICU, in the context of a CHG bathing quality initiative. Demographics and covariates were collected at the bedside and by chart review. Skin swabs were collected from neck, axilla, and inguinal regions and were plated to selective and nonselective media. Standard microbiologic methods were used for species identification and susceptibilities. Multivariable models included patients who received a CHG bath and accounted for clustering of body sites within patients. Results: Across all time points, 144 patients participated, yielding 429 skin swab samples. Mean age was 57 years (SD, 17); 49% were male; 44% had a central venous catheter; and 15% had a tracheostomy Also, 140 patients (97%) had >1 CHG bath prior to skin swab collection, with a median of 9 hours since their last CHG bath (IQR, 6–13 hours). Gram-positive bacteria were more commonly recovered than gram-negative or Candida spp across all skin sites (Table 1). Variation by body site was detected only for gram-positive bacteria, with recovery more common from the neck compared to axilla or groin sites. On multivariate logistic regression (Table 2), presence of central venous catheter was associated with lower odds of gram-positive bacteria recovery among those who received a CHG bath. Presence of tracheostomy was associated with a significantly higher odds of gram-negative bacteria detection on skin. No clinical factors were independently associated with recovery of Candida spp. Conclusions: Central venous catheter presence was associated with lower odds of gram-positive bacteria detection on skin, suggesting the possibility of higher quality CHG bathing among such patients. Tracheostomy presence was associated with greater odds of gram-negative bacteria detection, suggesting that it may be a potential reservoir for skin contamination or colonization. Indwelling medical devices may influence CHG bathing effectiveness in reducing microorganism burden on skin.Funding: NoneDisclosures: None

Invasive Mold Infections in Patients with Hematologic Malignities: The Effects of Environmental Factors

Invasive fungal infections (IFI) continue to be an important cause of morbidity and mortality in patients with hematological malignancies. Candida and Aspergillus species constitute most of the IFI in these patients.. It has been reported that most of the invasive aspergillosis epidemics are related to the construction works in the hospital. In this study, we aimed to investigate the frequency of IFI in the old and the new hospital building after relocation in patients with hematological malignancies. Of 8042 patients who were hospitalized in the Department of Hematology, Ondokuz Mayıs University Faculty of Medicine between January 2015 and September 2019, 412 patients who were initiated antifungal therapy were included in the study. The patients in the hematology clinic, which were moved to the new oncology hospital building in January 2018, were grouped as prior and after relocation, and their demographical data, hematological diagnosis, chemotherapy regimens, mortality, IFI, focus of infection, presence of central venous catheter, antifungal prophylaxis and treatment, galactomannan level, fungal culture and computed tomography (CT) findings were evaluated retrospectively. It was determined that 55% of the patients were male and the median age was 58 (range:18-93). The rate of IFI development was 5.12% (n= 412) and the rate of invasive mold infection was 1.2% (n= 145). The most common hematological disease for which antifungal treatment initiated was acute myeloid leukemia (AML) with a rate of 50% (n= 206/412). Of patients, 73% received induction chemotherapy (42%, first induction, 31% reinduction), 13.4% received consolidation therapy. Invasive mold infection was diagnosed as 40% possible, 59% probable, 1% proven. While patients had similar characteristics such as age, gender, hematological disease, chemotherapy regimens and antifungal prophylaxis prior and after transportation, the rate of development of invasive mold infection was 2.1%, 2.06 / 1000 patient days, before transportation, 1.37% (p= 0.009), 1.15/1000 patient days (p<0.001) after transportation, and it was statistically significantly lower after transportation. The median value of galactomannan antigen was detected as 0.17 (0.02-5.9). Blood cultures revealed 10.3% fungal growth and the most common growth was Candida albicans with 54.8% and Mucor spp. as mold with 3.2%. Large-scale construction works such as renovation, extension and demolition works in old hospital buildings are a permanent condition in different units. Clinicians should be aware of that infections due to opportunistic fungi can be seen in immunosuppressive patients close to such construction sites, and even cause epidemics. It should be kept in mind that these infections, which can progress with serious morbidity and mortality are difficult to treat but can be prevented by infection control measures.

Invasive Trichosporonosis in Neonates and Pediatric Patients with Malignancies or Hematologic Disorders.

(1) Background: Trichosporon species have emerged as important opportunistic fungal pathogens, with Trichosporon asahii being the leading and most frequent cause of invasive disease. (2) Methods: We performed a global review focused on invasive trichosporonosis in neonates and pediatric patients with malignancies or hematologic disorders. We reviewed case reports and case series of trichosporonosis due to T. asahii published since 1994, the year of the revised taxonomic classification. (3) Results: Twenty-four cases of invasive trichosporonosis were identified in neonates with the presence of central venous catheter and use of broad-spectrum antibiotics recognized as the main predisposing factors. Thirty-two cases were identified in children with malignancies or hematologic disorders, predominantly with severe neutropenia. Trichosporon asahii was isolated from blood in 24/32 (75%) pediatric cases. Cutaneous involvement was frequently observed in invasive trichosporonosis. Micafungin was the most commonly used prophylactic agent (9/22; 41%). Ten patients receiving prophylactic echinocandins were identified with breakthrough infections. A favorable outcome was reported in 12/16 (75%) pediatric patients receiving targeted monotherapy with voriconazole or combined with liposomal amphotericin B. Overall mortality in neonates and children with malignancy was 67% and 60%, respectively. (4) Conclusions: Voriconazole is advocated for the treatment of invasive trichosporonosis given the intrinsic resistance to echinocandins and poor susceptibility to polyenes.

A complete clinico-epidemiological and microbiological profile of candidemia cases in a tertiary-care hospital in Western India.

To identify different Candida spp along with antifungal susceptibility pattern and risk factors associated with candidemia. This retrospective observational study was conducted in a tertiary-care academic hospital in Jaipur, Western India, for 3 years (July 2017-June 2020). Blood cultures were performed according to standard microbiological methods, and only 1 isolate per patient was included in the study. Isolates of Candida spp were identified using a VITEK-2 automated system and matrix-assisted laser desorption ionization-time of flight mass spectrometry. Antifungal susceptibility tests were performed using the broth microdilution assay according to the Clinical and Laboratory Standards Institute guidelines. Of 3,443 blood cultures received from suspected sepsis cases, candidemia was identified in 95 (2.8%). In addition to Candida tropicalis (n = 36; 38%) and Candida parapsilosis (n = 17; 18%), 10 isolates of Candida auris comprised the fourth most common cause of candidemia. Presence of central venous catheter and diabetes were statistically significant risk factors for development of candidemia by NAC. Resistance to fluconazole was 36%, resistance to voriconazole was 20%, resistance to 5-flucytosine was 4%, and resistance to amphotericin-B was 7%. C. auris isolates were more resistant than other NAC spp. We detected no resistance among the echinocandins. The emergence of highly resistant isolates like C. auris emphasizes the need for constant monitoring of candidemia cases for species identification and routine antifungal susceptibility so that appropriate measures can be taken to reduce the related morbidity and mortality.

Epidemiology, risk factors, species distribution, and antifungal susceptibility of candidemia among hospitalized patients with COVID-19.

Background and Purpose: The pandemic of COVID-19 has caused a worldwide health crisis. Candidemia is a potentially lethal condition that has not yet been enough discussed in patients with COVID‐19. The current study aimed to investigate the prevalence of candidemia among Iranian COVID‐19 patients and characterize its causative agents and the antifungal susceptibility patternMaterials and Methods: The present cross-sectional survey was carried out from March 2020 to March 2021 at Imam Khomeini Hospital, Tehran, Iran. Blood specimens were obtained from patients with confirmed coronavirus infection who also had criteria for candidemia and were examined for any Candida species by conventional and molecular techniques. Susceptibility of isolates to amphotericin B, voriconazole, itraconazole, fluconazole, caspofungin, and 5-flucytosine was tested using the CLSI broth dilution technique.Results: In total, 153 patients with COVID-19 were included and candidemia was confirmed in 12 (7.8 %) of them. The majority of patients were ≥ 50 years of age (n=9) and female (n=8). Moreover, 6 out of the 12 patients were diabetic. The presence of central venous catheters, broad-spectrum antibiotic therapy, ICU admission, and mechanical ventilation was observed in all patients. The C. albicans (n=7, 58.3 %) and C. dubliniensis (n=2, 16.7%) were the most common isolated species. Amphotericin B and 5-flucytosine were the most active drugs. Despite antifungal treatment, 4 out of 12 patients (33.3 %) died.Conclusion: Due to the high mortality, the early diagnosis and proper treatment of candidemia are essential requirements for optimal clinical outcomes in COVID-19 patients.

Risk Factors in Cancer Patients

Numerous studies in recent years have proven that the oncological process is an independent risk factor for thrombosis. For a long period of time and at the moment, research is continuing on the pathogenesis of a prothrombotic state in cancer patients. It was shown that the degree of risk is influenced by such indicators as the histological type of tumor, the stage of development of the disease, surgery, duration and type of anesthesia, chemotherapy, hormonal therapy, age, the presence of central venous catheters, immobilization, thrombophilia, history of thrombosis, infections. Thrombosis in cancer patients is triggered by thrombogenic factors associated with the tumor, patient-associated factors and environmental factors. The tumor cell affects the balance of hemostasis by releasing procoagulant substances, profibrinolytic, proproteolytic and proaggregant activity, expression of adhesion molecules, secretion of proinflammatory and proangiogenic cytokines; new participants in the process have also been identified. Studies have confirmed the fact that inflammation and thrombosis are inextricably linked with each other and play an important role in the progression of the disease and metastasis. All this opens up new horizons for the development of modern innovative strategies for treating cancer patients and increasing survival.

Abstract 13962: Understanding Hospital-Acquired Venous Thromboembolisms in Pediatric Cardiology Patients

Objective: This study set out to determine risk factors for hospital-acquired venous thromboembolisms (VTEs) in pediatric cardiology patients in the setting of the 2016 Solutions for Patient Safety prevention guidelines. Methods: This retrospective cohort study considered all hospitalized patients discharged between 1/1/2019 and 12/31/2020, inclusive, in an university-affiliated children’s hospital. Demographic data for all patients, including service, presence of central venous catheters, administered intravenous medications, and initial Braden QD scores were included. Hospital-acquired VTEs as defined by the National Healthcare Safety Network were included. Standard descriptive statistics were utilized. Univariate analyses were conducted using the appropriate test as appropriate based on data distribution. Regularized regression using elastic net was performed to ascertain significant risk factors with p&lt;0.05. Results: Over the study period, 28,409 patients were included. Contemporary guidelines for VTE prevention in pediatric patients only include patients greater than 12 years of age and only prevent VTEs not related to central venous catheters. However, of the 143 hospital-acquired VTEs within the study period, 67.8% occurred in patients younger than 12 years of age and 66.0% were related to a central venous catheter. The majority (54.5%) of hospital-acquired VTEs occurred in patients on the cardiology service. In a subsequent multivariable regression analysis performed on pediatric cardiology patients, risk factors for hospital-acquired VTEs included having two or more central lines simultaneously (OR 4.46, p=0.03) and treatment with IV antidiuretics (OR 3.08, p=0.04). Total Braden QD score and Braden QD subscores were not associated with hospital-acquired VTEs. (OR 1.02, p=0.99 and OR 1.37, p=0.53, respectively). Conclusion: We found that the current prevention guidelines for hospital-acquired VTEs are not applicable to the majority of pediatric cardiology patients who develop hospital-acquired VTEs. A better understanding of risk factors for hospital-acquired VTEs is needed to inform future interventions.

Predictors of Venous Thromboembolism in Patients with Acute Myeloid Leukemia or Acute Lymphoblastic Leukemia

Introduction: The association of malignancy, largely solid tumors, with venous thromboembolism (VTE) is well-known and a widely validated score, Khorana score, guides prophylactic anticoagulation in high-risk patients. However, increasing albeit scarce evidence suggests a high incidence of VTE in patients with hematologic malignancies, which are comparable to high-risk solid tumors. In this study, we sought to explore the incidence and predictors of VTE (including the variables in the Khorana score) in patients with acute myeloid leukemia (AML) or acute lymphoblastic leukemia (ALL) from a large database.Methods: We performed a retrospective cohort study of patients diagnosed with AML or ALL using an aggregated de-identified data from electronic medical record of >300 major hospitals in US (IBM Watson Explorys). Patients aged 20 to 79 years, diagnosed with AML or ALL within the past 5 years were included. The primary endpoint was the incidence of cancer associated VTE defined as deep vein thrombosis, pulmonary embolism or superficial vein thrombosis within 1 year of AML/ ALL diagnosis. Baseline characteristics including age, sex, race, body mass index (BMI), prothrombotic mutations (Factor V Leiden, prothrombin gene 20210A mutation), smoking status, prior history of VTE, presence of central venous catheter (CVC), antineoplastic agent use, erythropoietin (EPO) and pegylated asparaginase (PegA) use as well as baseline laboratory values (as included in Khorana score) were compared between acute leukemia patients with cancer associated VTE within 1 year to those without. Fibrinogen and D-dimer were not available to be explored. A univariate analysis was performed using two-sided chi-square test to study these baseline variables. A p-value <0.05 was considered statistically significant. All statistical analyses were performed using GraphPad Prism version 9.0 (GraphPad Software, San Diego, CA, USA).Results: A total of 19,050 adult patients with a diagnosis of AML or ALL in the last 5 years were included. Of these, 1,550 patients had VTE within 1 year of acute leukemia diagnosis, with an overall incidence of 8.14%. Baseline characteristics of patients with acute leukemia with and without cancer associated VTE within 1 year were compared (Table 1). On univariate analysis, age>60, Caucasian or African American race, obesity, remote or current smoking status, Factor V Leiden, prior history of VTE, presence of CVC, anemia, leukocytosis, antineoplastic agent/EPO or PegA use were all associated with an increased risk of cancer associated VTE. Interestingly, both low platelet counts (<50 x 10 9/L) and high platelet counts (>350 x 10 9/L) were associated with increased cancer associated VTE. Among these, prior history of VTE had the strongest association (OR 7.46). Younger age (20-39) and Asian race were in fact inversely associated with VTE. A multivariable analysis is currently underway to assess the significance of these risk factors independently towards cancer associated VTE in this AML/ALL population.Conclusions: Our study highlights and reiterates a high risk of VTE within one year of diagnosis of AML/ALL in what we believe is the largest cohort studied to date. Older age, Caucasian or African American race, smoking, prior VTE, presence of CVC, Factor V Leiden, antineoplastic agent or PegA use were associated with increased risk. Among the Khorana score variables, obesity, anemia, EPO use and leukocytosis stood out as potential risk factors for VTE in this population. Risk of VTE was however increased regardless of platelet counts, which emphasizes the need to consider surveillance or thromboprophylaxis strategies in AML/ALL patients with thrombocytopenia with presumed high bleeding risk. Lastly, young age and Asian ethnicity seem to confer some protection against thrombosis in this population. Our ongoing efforts include a multivariable analysis and examining the effect of the Khorana score risk stratification in our large cohort of AML/ALL patients. Finally, further studies will be fundamental to meet the unmet need for a specific risk stratification system(s) for patients with AML/ALL. [Display omitted] DisclosuresNayak: BioChip Labs: Current Employment.

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.

Surveillance of Candidemia in Connecticut: An Epidemiological Comparison Between Two Periods

Background: Candidemia is the fourth most common bloodstream infection in hospitalized patients in the United States, with an attributable mortality rate between 30% and 50%. Understanding the epidemiology of candidemia is critical due to its prevalence and association with extended hospital stays, high treatment cost, and significant morbidity and mortality. In 2019 the Connecticut Department of Public Health deemed candidemia a mandatory reportable condition and began state-wide surveillance in conjunction with the CDC’s Emerging Infections Program (EIP). Previously, the EIP had conducted population-based statewide surveillance of candidemia in Connecticut from 1998 to 2000, allowing an opportunity to assess how the epidemiology of candidemia has evolved. The goal of this study is to compare state-wide Connecticut EIP candidemia data from 2 periods (1998–2000 and 2019) to identify trends in infections and incidence, providing insight for potential improvements to current prevention measures and treatments. Methods: The sample population included all Connecticut residents aged ≥20 who tested positive for a candidemia infection during 1998–2000 and 2019. Patients who had positive blood cultures for Candida spp but were &lt; 20 years old or were not Connecticut residents were excluded. Connecticut EIP candidemia case report forms from each time period were compared and matching fields were chosen as variables for univariate analysis to search for statistically significant differences. Selected variables include: Candida species present in blood culture, patient demographics, previous exposures to healthcare settings, length of stay, presence of central venous catheter (CVC), and location of the patient at diagnosis (community vs. hospital onset). De-identified patient-level information was provided by the EIP. Results: In total, 381 candidemia episodes from 1998–2000 were compared to 247 episodes in 2019. The proportion of C. albicans species in 1998–2000 was 49.9% and declined to 40.5% of cases in 2019 (P = .02). Outcomes improved as well, with 65.2% of patients in 2019 having survived compared to 51.4% in 1998–2000 (P = .001). Other findings indicate that patients with candidemia in 2019 were less likely to have a central venous catheter, less likely to have undergone a recent surgery, and were more likely to have community-onset infection (all p &lt; 0.05). Conclusions: The epidemiology of candidemia has changed over the past 20 years, with significant improvements in patient survival and a shift toward community-onset infections and non-Albicans spp. These findings have important implications in designing prevention strategies and optimizing candidemia management, particularly in the community setting where increased intravenous drug use and the availability of home healthcare may be important factors.Funding: NoDisclosures: None

Validation of the Peds Clot Clinical Decision Rule [PCDR] in Hospital-Acquired Venous Thromboembolism

Background: Venous thromboembolism (VTE) in critically ill children is associated with increased morbidity and mortality. Therefore, significant efforts to identify children with a predisposition to VTE are being made so that prevention strategies can be implemented. To identify these children a priori, our group developed the Peds Clot Clinical Decision Rule based on exposure to known VTE risk factors (Sharathkumar et al Journal of Thrombosis and Haemostasis, 10: 1326-1334). Since this decision rule was developed using a retrospective case-control study design, we performed prospective validation of the PCDR utilizing the automatic data-collection tool available via our institution's Computer Data Warehouse (CDW). The interim analysis(Prospective Validation of the Peds Clot Clinical Decision Rule [Pdcr] in Hospital-Acquired Venous Thromboembolism: An Interim Analysis Blood 2016 128:3812) showed that three of the six variables, immobility, blood stream infection (BSI), and oral contraceptive pill (OCP) use, required manual entry. To capture immobility objectively, we took advantage of a recent initiative to record immobility of patients 13 and older at Lurie Children's Hospital. This report summarizes the analysis of this ongoing validation effort.Objective: 1. To validate the Peds Clot Clinical Decision Rule [PCDR] utilizing automatic data collection at Lurie Children's hospital; 2. To evaluate whether the sensitivity and specificity of PDCR improves after objective assessment of immobility.Methods: The Computer data warehouse (CDW) facility was used to directly import relevant variables into the database for our study period of 03/01/16-03/31/17. Inclusion criteria for the study were Intensive Care Unit (Pediatric, Cardiac, Neonatal) stay for at least 48 hours or more. The following demographic and clinical variables were included in the dataset: age, sex, ethnicity, date of admission and discharge, central venous catheter (CVC), BSI, immobility (defined as being incapable of ambulating without assistance), OCP use, mechanical ventilation, and length of hospitalization (LOH). Risk factors were scored as per PCDR rule1. Chi-square tests were used to examine the association between the potential risk factors and VTE. Risk factors with an association to VTE in univariate analysis were included in multivariate logistic regression model. PCDR model performance was evaluated by reporting the sensitivity and specificity. Additional independent multivariate analysis was performed to explore the role of other variables in the development of VTE.Results: A total of 2836 children were eligible for analysis. The demographic and clinical features are detailed in Table 1. Of 2836 patients, 141 (4.9%) were identified as having VTE and 881 (31%) had a CVC. LOH, presence of CVC, and BSI continued to be significantly associated with a VTE event. There was an association between VTE and immobility, but it did not reach statistical significance. The model performance showed that at the cutoff point of 3, the specificity and sensitivity of the PDCR in predicting VTE is 62% and 70% respectively. This is an improvement from our interim analysis report which had a specificity of 75% but a very low sensitivity (37%). Presence of a CVC was independently associated with VTE risk (AOR=4.33; 95% CI=2.88, 6.52). Caucasian race emerged to be associated with VTE and but did not retain its significance in multivariate analysis. Interestingly, other variables (immobility, length of stay, OCP) did not show an association with VTE in the multivariable analysis.Conclusions: Our study confirms that automatic data collection is feasible with electronic medical records and data-ware house facility. Diligent efforts to collect standardized data for immobility resulted in only a minor improvement in the performance of the PCDR. This suggests that unlike in the general hospital population, underlying disease processes may be more important determinants of a procoagulant phenotype in critically ill patients. We plan to assess these processes in our next analysis. It is noteworthy that prospective data-collection improved the sensitivity of PCDR. This will help clinicians closely monitor this population and reduce or avoid exposure to risk factors for VTE. [Display omitted] DisclosuresSharathkumar:Shire: Consultancy; CSL Behring: Consultancy.

Venous Thromboembolism among Noncritically Ill Hospitalized Children: Key Considerations for the Pediatric Hospital Medicine Specialist.

Venous thromboembolism (VTE) is a leading cause of morbidity and preventable harm among noncritically ill hospitalized children. Several clinical factors relevant to the noncritically ill hospitalized child significantly increase the risk of VTE including the presence of central venous catheters, systemic inflammation, and prolonged immobilization. Although risk mitigation strategies have been described, the diagnosis, treatment, and prevention of VTE require standardization of institutional practices combined with multidisciplinary collaboration among pediatric hospitalists, hematologists, and other care providers. In this narrative review, we summarize the epidemiology of VTE, risk models identifying high-risk conditions associated with VTE, and prevention and treatment strategies. We further describe successful quality improvement efforts implementing institutional VTE risk stratification and thromboprophylaxis procedures. Finally, we highlight unique challenges facing pediatric hospital medicine specialists in the era of the COVID-19 pandemic, including caring for adults admitted to pediatric hospital units, and describe future research opportunities for VTE in the noncritically ill hospitalized child.

Elevated risk of venous thromboembolism in patients undergoing therapeutic hypothermia after cardiac arrest

IntroductionTargeted Temperature Management (TTM) 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. Targeted Temperature Management, however, increases fibrinolysis. The net outcome of these opposing effects remains 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 TTM. MethodsSingle center retrospective analysis. Participants were age ≥18 years old, admitted with out-of-hospital or in-hospital cardiac arrest, underwent TTM between January 1, 2007 and April 30, 2019 with endovascular cooling catheter. A total of 562 patients who underwent TTM (Study group) were compared to 562 patients treated for 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. ResultsPatients who underwent TTM had a significantly higher rate of VTE (6.6% vs 2.3%, p = 0.006) and deep vein thrombosis (DVT) (4.6% vs 1.3%, p = 0.011) when compared to control group. In multivariate analysis age, gender, race and hospital length of stay were not associated with development of VTE in the study group. ConclusionPatients undergoing TTM 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.

Venous Thromboembolism in Pediatric Inflammatory Bowel Disease: A Case-Control Study.

Inflammatory bowel disease (IBD) is associated with increased risk of venous thromboembolism (VTE). Despite this recognized risk, there are limited data and no anticoagulation guidelines for hospitalized pediatric IBD patients. The objectives of this study were to characterize pediatric IBD patients with VTE and determine risk factors. This was a nested case-control study comparing hospitalized children with IBD diagnosed with VTE to those without VTE over a decade at a large referral center. Standard descriptive statistics were used to describe the VTE group. Multivariable conditional logistic regression was used to assess risk factors. Twenty-three cases were identified. Central venous catheter (CVC) presence (odds ratio [OR] 77.9; 95% confidence interval [CI]: 6.9--880.6; P < 0.001) and steroid use (OR 12.7; 95% CI: 1.3--126.4; P = 0.012) were independent risk factors. Median age at VTE was 17 years (interquartile range [IQR] 13.5--18.2), and in 48%, VTE was the indication for admission. Median duration of anticoagulation was 3.8 months (IQR 2.3--7.6), and there were no major bleeding events for patients on anticoagulation. There were no patients with known sequelae from VTE, though 22% had severe VTE that required interventions. Pediatric patients with IBD are at risk for VTE, although the absolute risk remains relatively low. The safety and efficacy of pharmacologic thromboprophylaxis needs to be further evaluated in this population with attention to risk factors, such as steroid use and presence of CVC.

Incidence and risk factors of venous thrombotic events in pediatric patients with CNS tumors compared with non-CNS cancer: A population-based cohort study

BackgroundVenous thromboembolism (VTE) is a well-recognized complication in pediatric cancer patients. It has been demonstrated that the incidence of VTE in pediatric patients with central nervous system (CNS) tumors is lower than that of patients with other cancers. Risk factors for developing cancer-related thrombosis are numerous and can include patient, disease, or treatment-related influences. The present study was designed to assess the VTE incidence in a pediatric oncology population, and to investigate whether intensity of treatment has similar associated with risk of VTE development in patients with and without CNS tumors. MethodsA retrospective population-based cohort study of pediatric oncology patients in Atlantic Canada was conducted. Data collected from medical records included demographics, cancer type, treatment, presence of central venous catheters (CVC), and presence of thrombosis. Treatment intensity was assessed using the intensity of treatment rating scale (ITR-3). Study period was from January 2000 to December 2017. SPSS version 24 was used for statistical analysis. ResultsOf 1262 patients with pediatric cancer, 247 (19.6%) had CNS tumors. VTE occurred in significantly fewer (n = 5, 2%) patients with CNS tumors compared with patients with non-CNS cancers (n = 79, 7.8%) (p = 0.001). The ITR-3 scores did not differ significantly between the CNS and non-CNS groups (p = 0.638). In a multivariate logistic regression analysis, ITR-3 score was associated with VTE (odds ratio [OR]: 1.48, 95% CI: 1.2–1.9), while presence of CNS tumor was protective (OR: 0.26, 95% CI: 0.1–0.6). ConclusionsWe demonstrate that pediatric patients with CNS tumors experience a significantly lower incidence of VTE compared with patients with non-CNS cancer. An increase in the ITR-3 rating significantly increased the odds of developing VTE.

Risk factors of multidrug-resistant pyogenic spondylitis in thoraco-lumbar spine: A retrospective study of 122 cases

BackgroundThe number of spinal infections has been increasing in developed countries due to the increase of aged or immunosuppressed patients. Spondylitis caused by multidrug-resistant (MDR) bacterial infection often become intractable and require long-term antibiotic therapy and multiple surgeries. Therefore, it is of great importance to understand risk factors for MDR spinal infections. The aim of this study was to elucidate the risk factors for MDR bacterial spondylitis. MethodsA total of 122 patients (82 men, 40 women; average age: 63.8 y) with thoracic/lumbar spondylitis who underwent posterolateral full-endoscopic debridement and irrigation were included. The organisms detected by this endoscopic procedure were investigated, and the incidence and risk factors for MDR bacterial infection were retrospectively analyzed. ResultsCultures of specimens obtained by endoscopic procedures were positive in 78 patients (63.9%). Among 68 isolated bacteria, MDR bacteria accounted for 47.1%. Multivariate analysis showed that significant risk factors for MDR bacterial infection included autoimmune connective tissue disease (P = 0.03) and central venous catheter (P = 0.02). The incidence of MDR bacteria in patients who were administered a broad-spectrum antibiotic for more than 1 month preoperatively was 64.0%, which was significantly higher than in patients who were administered a broad-spectrum antibiotic for less than 1 month and patients who were administered a narrow-spectrum antibiotic (P < 0.01, P < 0.01, respectively). ConclusionsThe significant risk factors for MDR bacterial spondylitis included immunosuppressed conditions, such as autoimmune connective tissue disease, presence of central venous catheter, and longer administration periods of a broad-spectrum antibiotic. In patients with pyogenic spondylitis who could not be controlled with previous antibiotics and whose result of culture was negative, administration of anti-MRSA antibiotics would be considered when they have the risk factors identified in this study.

Endogenous Candida endophthalmitis: Who is really at risk?

ObjectivesThe Infectious Disease Society of America recommends that all patients with candidemia undergo a dilated retinal exam to exclude endogenous Candida endophthalmitis. Our objective was to determine if there are significant risk factors in candidemic patients for developing endogenous Candida endophthalmitis MethodsWe conducted a retrospective study of all candidemic patients at three academic medical centers between 2012 and 2017. We extracted risk factors for Candida endophthalmitis based on prior literature and compared them between patients with and without endophthalmitis. We then built a multivariate logistic regression model to assess which ones were significant. ResultsWe found 771 patients with candidemia. 120 (15.6%) of these patients were diagnosed with Candida endophthalmitis. In our logistic regression analysis, central venous catheter presence (OR 8.35), intravenous drug use (OR 4.76), immunosuppression (OR 2.40), total parenteral nutrition recipient (OR 2.28), race (OR 1.65), age (OR 1.02), and gender (OR 0.57) were risk factors for developing Candida endophthalmitis. Additionally, Candida albicans was more likely to result in Candida endophthalmitis (OR 1.86). ConclusionsThis cohort represents the largest study of risk factors for candidemic patients who developed endogenous Candida endophthalmitis. Based on our findings, clinicians should develop targeted and cost-effective strategies for endophthalmitis screening.

1424. Factors Associated with Failure to Clear Candidemia Infection: Surveillance Data from Eight States, 2017

BackgroundCandidemia is a bloodstream infection commonly associated with high morbidity and mortality. Failure to clear candidemia can lengthen hospitalization and treatment. Factors associated with candidemia clearance are unknown.MethodsWe analyzed 2017 candidemia surveillance data from the Centers for Disease Control and Prevention’s Emerging Infections Program. Data from eight sites (counties in California, Colorado, Georgia, Minnesota, New Mexico, New York, Oregon, and Tennessee) were included. Clearance was defined as having a blood culture negative for Candida ≤30 days after initial culture date (ICD). Cases with unknown clearance, unknown survival outcome, or death ≤30 days of ICD were excluded. Demographic and clinical factors associated with clearance were assessed with bivariate analysis using chi-square tests and multivariable logistic regression to calculate adjusted odds ratios (aOR) using backward selection (p-value< 0.10).ResultsOf 1,024 candidemia cases, 737 were included and 582 (79%) demonstrated clearance, of which 79% had evidence of clearance ≤5 days after ICD. In bivariate analysis, clearance was associated with central venous catheter (CVC) ≤2 days before ICD, CVC removal ≤7 days after ICD, and systemic antifungal medication within 14 days before ICD. Clearance was inversely associated with black race and admission from another hospital. In multivariable analysis, only race and admission from another hospital were significant predictors; age, sex, and CVC presence and subsequent removal were also retained for their clinical relevance. In the final model, clearance was less likely among black patients (aOR 0.51, 95% confidence interval [CI] 0.29-0.91) and those admitted from another hospital (aOR 0.28, 95% CI 0.11-0.75).Table 1. Bivariate associations for select variables between individuals with documented candidemia clearance and those without documented clearance in eight Emerging Infections Program surveillance sites, 2017 ConclusionWe found failure to clear candidemia infection to be associated with black race and prior hospital exposure, but not other factors previously shown to be associated (e.g., comorbidities, CVC presence). These associations could reflect illness severity, access to care, or other obstacles to effective treatment. Additional research is needed to investigate these associations further and identify other factors (e.g., treatment type and timing) to improve outcomes.Disclosures All Authors: No reported disclosures

Predictors of Arteriovenous Fistula Failure: A Post Hoc Analysis of the FAVOURED Study.

An autologous arteriovenous fistula (AVF) is the preferred hemodialysis 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. This is a post hoc analysis of all participants of FAVOURED, a multicenter, double-blind, multinational, randomized, placebo-controlled trial evaluating the effect of fish oil and/or aspirin in preventing AVF failure in patients receiving hemodialysis. 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, anesthetic, intraoperative heparin use) were examined using multivariable logistic regression analyses to evaluate associations with AVF failure. 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], 1.79; 95% confidence interval [CI], 1.20 to 2.68), lower diastolic BP (OR for higher DBP, 0.85; 95% CI, 0.74 to 0.99), presence of central venous catheter (OR, 1.49; 95% CI, 1.02 to 2.20; P=0.04), and aspirin requirement (OR, 1.60; 95% CI, 1.00 to 2.56). Female sex, requirement for aspirin therapy, requiring hemodialysis via a central venous catheter, and lower diastolic BP were factors associated with higher odds of AVF failure. These associations have potential implications for vascular access planning and warrant further studies.

NON-ALBICANS SPECIES: MAIN ACTORS OF CANDIDEMIA? SEVEN-YEAR EXPERIENCE FROM A SINGLE CENTRE

Objective: Candidemia is a major cause of mortality among healthcare-associated infections. Considering the increase in non-albicans species in recent years, it is important to define the treatment approach by identifying Candida at the species level. The aim of this study was to evaluate the epidemiological characteristics, risk factors and mortality of patients with candidemia in our hospital. Material and Method: Forty-four patients with Candida species isolated from at least one bottle of blood culture taken during hospitalization between January 2013 and October 2019 were included in the study. Patients’ demographic information, comorbidities, duration of hospitalization and ward, neutropenia, total parenteral nutrition (TPN), steroid administration and invasive device use, antimicrobial treatments used in the last month, source of candidemia, acute phase indicators, Candida species and antifungal resistance, antifungal treatment, clinical response and mortality were evaluated retrospectively. Candida species and antifungal susceptibilities were identified using the automated system VITEK®2 (bioMérieux, Marcy l’Etoile, France). Results: A total of 44 patients with candidemia participated; the median age was 57, and 27 (61.3%) were male. The median length of stay was 33.5 days. Forty-two (95.4%) of the cases were accompanied by multiple comorbidities, and the most common aetiology was malignancy (59%). Most (97.7%) of the patients had received broad-spectrum antibiotic treatment in the last month. Central venous catheters (CVCs) were used in 35 (79.5%) of the cases and 50% of them were treated with TPN. Candida albicans (54.6%) was the most common species, followed by Candida tropicalis (18.2%). Non-albicans species were observed to increase over time. Thirty-day mortality was 36.3%.Conclusion: Non-albicans candidemia was found to have increased over the years in our study. The main risk factors for candidemia were determined as the presence of comorbidities, especially malignancy, prior broad-spectrum antibiotherapy use, TPN treatment and the presence of CVC. The mortality rate in this study was also consistent with the literature.