Reduction Of Bloodstream Infections Research Articles

QAPI 20 - Bundled Approach to Reduce Blood stream infections in Patients Requiring use of Extracorporeal Membrane Oxygenation

QAPI 20 - Bundled Approach to Reduce Blood stream infections in Patients Requiring use of Extracorporeal Membrane Oxygenation

Cost-effectiveness of taurolidine-citrate in a cohort of patients with intestinal failure receiving home parenteral nutrition.

Catheter-related bloodstream infections (CRBSIs) in patients receiving home parenteral nutrition (HPN) for chronic intestinal failure (CIF) are associated with significant morbidity and financial costs. Taurolidine is associated with a reduction in bloodstream infections, with limited information on the cost-effectiveness as the primary prevention. This study aimed to determine the cost-effectiveness of using taurolidine-citrate for the primary prevention of CRBSIs within a quaternary hospital. All patients with CIF receiving HPN were identified between January 2015 and November 2022. Data were retrospectively collected regarding patient demographics, HPN use, CRBSI diagnosis, and use of taurolidine-citrate. The direct costs associated with CRBSI-associated admissions and taurolidine-citrate use were obtained from the coding department using a bottom-up approach. An incremental cost-effective analysis was performed, with a time horizon of 4 years, to compare the costs associated with primary and secondary prevention against the outcome of cost per infection avoided. Forty-four patients received HPN within this period. The CRBSI rates were 3.25 infections per 1000 catheter days before the use of taurolidine-citrate and 0.35 infections per 1000 catheter days after taurolidine-citrate use. The incremental cost-effectiveness ratio indicates primary prevention is the weakly dominant intervention, with the base case value of $27.04 per CRBSI avoided. This held with one-way sensitivity analysis. Taurolidine-citrate in the primary prevention of CRBSIs in patients with CIF receiving HPN is associated with reduced hospital costs and infection rates.

Preventing Pediatric Outpatient Hemodialysis Morbidity: Implementing the Use of Needleless Connectors and Prevention Process Measures Audits to Reduce Bloodstream Infections

Preventing Pediatric Outpatient Hemodialysis Morbidity: Implementing the Use of Needleless Connectors and Prevention Process Measures Audits to Reduce Bloodstream Infections

Central Line Associated Bloodstream Infection Reduction Efforts in a Pediatric Cardiac Intensive Care Unit: A Multifaceted Approach

Central Line Associated Bloodstream Infection Reduction Efforts in a Pediatric Cardiac Intensive Care Unit: A Multifaceted Approach

Central Line Associated Blood Stream Infection Reduction at an Academic Community Hospital During the COVID-19 Pandemic to Achieve Patient Safety

During the COVID-19 pandemic, many institutions saw an overall increase in central line associated blood stream infection (CLABSI) events. CLABSI events can be prevented by decreasing central line utilization, improving practices during central line insertion and maintenance phases, and daily surveillance for necessity. A belief that zero harm to patients is possible and development of a supportive organizational culture with visible leadership were key to reducing CLABSI events and creating long-lasting change, even during the pandemic.

Chlorhexidine bathing in a tertiary care neonatal intensive care unit: A pilot study.

Concerns regarding potential risk of dermal irritation have led to the exclusion of NICU patients from the recommendation regarding the use of 2% chlorhexidine gluconate (CHG) wash for daily skin cleansing to reduce bloodstream infections. Our aim was to assess the safety of 2% CHG bathing in NICU patients. The regulator required a stepwise study enrollment to three successive groups: term infants, followed by near-term and pre-term infants. For comparison, we used a cohort of matched controls. A propensity score-adjusted regression model was used to compare the groups. Infants were bathed thrice-weekly with 2% CHG-impregnated washcloths. Participant's skin was examined daily. Over a total of 661 days of treatment: 384,129, and 148 days for the term, near-term and pre-term groups, respectively, no skin reactions were observed. The intervention group was generally sicker, however, bloodstream infections were similar between the groups. For infants >30 weeks and >3 days old, 2% CHG bathing was safe. Large multicenter studies are urgently needed to establish the effectiveness of this practice in the NICU.

How to improve aseptic technique to reduce bloodstream infection during vascular access procedures.

Bloodstream infections associated with vascular access procedures pose a serious risk to patients that can be reduced by better standards of aseptic technique. The objectives of this roundtable of experts were to achieve a consensus on how to improve skin antisepsis in hospital, improve training, competency, compliance and consistency in skin antisepsis, review the role of devices in improving skin antisepsis, identify methods to improve skin antisepsis integrated with the Aseptic Non Touch Technique (ANTT®) approach, and identify challenges to the implementation of the panel's recommendations. Recommendations include using MHRA-licensed 2% chlorhexidine gluconate in 70% isopropyl alcohol solution with bidirectional strokes for up to 30 seconds, then leaving the skin to air dry for 30 seconds; using the ANTT Clinical Practice Framework and terminology as the standard for skin antisepsis training and practice; standardised ANTT and skin antisepsis education with 3-yearly competency assessments for all UK health professionals; and more research to address the evidence gap on transmission of infection after skin antisepsis.

Expert consensus on clinical application of multi-chamber bag for parenteral nutrition (2022)

Parenteral nutrition has become a routine clinical nutritional treatment. The guidelines at home and abroad unanimously recommend and standardize the application of "all in one" parenteral nutrition."Multi-chamber bag" parenteral nutrition encapsulates nutrients such as fat emulsion, amino acid and glucose in a non polyvinyl chloride soft bag composed of two or three cavities. When in use, the inner cavity separator is opened. The multi-chamber bag preparation has a variety of specifications and has the characteristics of reasonable prescription, strict quality standards, ready-to-use, and other characteristics, which can reduce prescription and configuration errors, reduce bloodstream infections, and meet the clinical nutritional needs of most patients. In view of the non-standard application of multi-chamber bag, the Chinese Society for Parenteral and Enteral Nutrition organized domestic experts in general surgery, critical care medicine, gastroenterology, geriatrics, nutrition, clinical pharmacy, and evidence-based medicine to write this expert consensus in accordance with the latest guidelines, expert consensus, and the latest clinical evidence. According to the improved Delphi method, 43 experts discussed and modified 23 recommendations one by one in the first round, and 219 experts voted and put forward modification suggestions in the second round. Each recommendation shall be established only when the approval rate of ≥ 90%. It is hoped that this consensus can promote the rational application of multi-chamber bag for parenteral nutrition.

Is There a Role for Targeted Antibiotic Prophylaxis in Carbapenem Resistant or Extended Spectrum Betalactamase Producers (ESBL) Enterobacterales to Reduce Bloodstream Infection in Colonized Patients at Transplant?

<h3>Purpose</h3> Carbapenem resistant (CR) or extended spectrum betalactamase producers (ESBL) <i>Enterobacterales</i> (E) associated bloodstream infections (BSIs) are a serious hazard for the patient's life, their peak incidence is within the first month after transplant, rectal colonization is a main risk factor. There are no clear effective preventive measures to prevent CRE or ESBL <i>E</i> BSIs after SOT in colonized patients. The aim of this study was to evaluate whether a targeted antibiotic prophylaxis (TAP) at lung or heart transplant could reduce ESBL or CR BSI incidence in patients with ESBL or CR rectal colonization <h3>Methods</h3> All patients with rectal swab positive for CR ESBL E from 1/1/2015 to 31/8/2021 to were included. From 1/10/2018 a TAP at heart or lung transplant for colonized patients was introduced for 48 hours and was associated to vancomicin. All BSI episodes occurring within the first-month post-transplant were recorded <h3>Results</h3> Over 126 transplanted patients, 12 (10%) were colonized and were included in the study (median age 62 ±6, 10 males). Rectal swabs was positive in 2 for <i>Klebsiella pneumonia</i> class A carbapenemase producer-KPC-, in 5 for <i>Escherichia coli</i> ESBL, in 2 for <i>Klebsiella</i> spp ESBL, in 1 for <i>Citrobacter koseri</i> VIM producer, in 1 for <i>Klebsiella pneumonia</i> New Dheli metallo beta lactamase). Targeted antimicrobial therapy was introduced for 10 patients (meropenem for ESBL producers, <i>ceftazidime/avibactam plus aztreonam</i> for metallo beta lactamase prodecers). Two patients transplanted before 1/10/2018 were colonized with KPC, none received TAP and both of them developed a KPC BSI on 1 and 7 after transplant, respectively. From 1/10/2018, one over the ten patients treated with a targeted antimicrobial prophylaxis developed a BSI due to the same bacteria in the month following transplant (on day 5 after transplant) (p=0.04). None of the patients developed Gram positive or fungal BSIs. No <i>C. difficile</i> colitis cases were registered in the follow up. One patients resulted positive in the follow up for vancomicin resistan <i>Enterococcus faecium</i> rectal swab (in an endemic situation). <h3>Conclusion</h3> Patients and graft survival are negatively affected by BSIs. The use of TAP at transplant was associated with a reduction of BSI due to CR or ESBL E in the first month after transplant.

181. Potential Benefit of Masking and other COVID-19 Infection Prevention Measures on Late-Onset Infections in the NICU

BackgroundIncidence of blood stream infections (BSI) among NICU admissions remains high, with associated mortality and morbidity. Due to COVID-19, there are increased infection prevention (IP) measures in NICUs including universal masking for all healthcare workers and families, social distancing, visitation restrictions, and increased attention to hand hygiene. These measures may also affect late-onset infection rates and offer understanding of novel interventions for prevention.MethodsWe examined infection rates during the 24 months prior to implementation of COVID-19 IP measures (PRE-period) compared to the months after implementation from April 2020 (POST-period). Late-onset infections were defined as culture-confirmed infection of the blood, urine, or identification of respiratory viral pathogens. An interrupted time series analysis of infection per 1000 patient days was performed based on a change-point Poisson regression with a lagged dependent variable and the number of patient days used as offsets. Each month was treated as independent with additional analysis using an observation-driven model to account for serial dependence.ResultsMulticenter analysis to date included all infants cared for at three centers (Level 3 and 4) from 2018-2020. Monthly BSI rates decreased in the POST-period at the three centers (Figure 1). At all centers actual BSI rate was lower than the expected rate in the POST-period (Figure 2). The combined BSI rate per 1000 patient days was 41% lower compared to the rate prior to implementation (95% CI, 0.42 to 0.84, P=0.004) (Table 1). In subgroup analysis by birthweight, infants< 1000g had a 39% reduction in BSI (P=0.023), for1000-1500g patients there was a 44% reduction (P=0.292) and in those > 1500g there was a 53% reduction (0.083). Figure 1. PRE and POST MASKING and other COVID Infection Prevention Measures and Monthly BSI Rates. Figure 2. PRE and POST MASKING and other COVID infection prevention measures and BSI Trends. At all centers actual BSI rate was lower than the expected rate for that center in the POST period. UVA and Duke showed a baseline decrease and Pennsylvania Hospital showed a downward trend in infection rates. There was an approximate decrease in expected bloodstream infection events at Pennsylvania Hospital by 7 events, at UVA by 22 events and at Duke by 23 events. Overall, all three centers saw a decrease in their expected infections after COVID-19 infection prevention measures were implemented.Table 1. Percent reduction in Bloodstream Infection at each center. ConclusionIn this preliminary analysis, we found a reduction of BSI after the implementation of COVID-19 infection prevention measures. Additionally, there were fewer viral infections, though there were a limited number of episodes. Further analyses of multicenter data and a larger number of patients will elucidate the significance of these findings and the role some of these IP measures such as universal masking may have in infection prevention in the NICU.Disclosures All Authors: No reported disclosures

Effectiveness and antimicrobial susceptibility profiles during primary antimicrobial prophylaxis for pediatric acute myeloid leukemia

Limited data are available on antimicrobials exposure and microbiology evolution in pediatric acute myeloid leukemia (AML) patients underwent antimicrobials prophylaxis. To assess the effectiveness of antimicrobials prophylaxis, antibiotic susceptibilities of bacteria, and exposure of antimicrobials during intensive chemotherapy for AML patients, 90 consecutive de novo AML patients aged 0–18 years between January 1, 1997 and March 31, 2018 were enrolled. Vancomycin, ciprofloxacin and voriconazole prophylaxis was administered from January 1, 2010. During the preprophylaxis period, January 1997 to December 2009, 62 patients experienced a total of 87 episodes of bloodstream infection (BSI) and 17 episodes of invasive fungal infection (IFI) among 502 courses of chemotherapy. In contrast, 16 episodes of BSI occurred and no IFIs were reported to occur in 28 patients who received 247 courses of chemotherapy in the prophylaxis period. Patients who received antimicrobial prophylaxis had a significant reduction of BSI, IFI, and febrile neutropenia in comparison with patients without prophylaxis. Exposure to amikacin, carbapenem, amphotericin B was reduced in the prophylaxis period. Imipenem susceptibility of Enterobacter cloacae as well as vancomycin susceptibility of Enterococcus species were reduced in the prophylaxis period. At the time of the last follow up, patients with prophylaxis had a better subsequent 5-year overall survival rate than those without prophylaxis. Prophylactic antimicrobials administration in children with AML who undergo chemotherapy can significantly reduce the rates of life-threatening infection, exposure to antimicrobials, and might result in a better outcome.

Intensive oral care can reduce bloodstream infection with coagulase-negative staphylococci after neutrophil engraftment in allogeneic hematopoietic stem-cell transplantation.

Bloodstream infection (BSI) is a major complication of allogeneic hematopoietic stem-cell transplantation (allo-SCT). There are several causes of BSI; in particular, severe oral mucositis (OM) can induce BSI due to coagulase-negative staphylococci (CoNS). The OM severity may be reduced with intensive oral care. Thus, we evaluated whether the type of oral care affects the BSI incidence eventually. We performed retrospective analysis on 206 recipients who underwent allo-SCT from 2006 to 2017 at our institute. Intensive oral care by a dental specialist was performed for 111 recipients (intensive-care group) and self-oral care was performed by 95 recipients (self-care group). Incidence of BSI was assessed by type of the oral care, before neutrophil engraftment (pre-E-BSI) and after neutrophil engraftment (post-E-BSI) period until 180days after allo-SCT. A total of 112 BSI occurred in 90 of the 206 recipients and 120 bacteria were identified, with CoNS being the most prevalent. There was no significant difference in the incidence of pre-E-BSI between the self-care and intensive-care groups (30.8% and 30.6%, respectively; P = 0.508). Meanwhile, the incidence of post-E-BSI was significantly lower in the intensive-care group than in the self-care group (14.3% and 28.6%; P = 0.008). In addition, the intensive-care group had significantly lower incidence of post-E-BSI with CoNS than the self-care group (8.5% and 21.5%, respectively; P = 0.009). Intensive oral care through the period of allo-HCT can significantly reduce the post-E-BSI occurrence, especially due to CoNS.

Evaluating a Novel Hemodialysis Central Venous Catheter Cap in Reducing Bloodstream Infections: A Quality Improvement Initiative.

PurposeCentral line-associated bloodstream infection (CLABSI) is the second leading cause of death in hemodialysis patients. Patients dialyzed via central venous catheters (CVCs) are more susceptible to vascular access-related bloodstream infection (VRBSI), sepsis, and mortality when compared to patients with other dialysis accesses.Patients and MethodsA retrospective observational data analysis was conducted from 13 outpatient dialysis clinics in the United States to compare novel chlorhexidine-coated end caps to standard needlefree connectors for differences in CLABSI rates when utilizing CVCs for hemodialysis. There were two periods in this study: in the first study period over a 5-month period (May 2018 to September 2018), data were evaluated from a group of patients undergoing hemodialysis using chlorhexidine end-caps (‘chlorhexidine group’) as well as a group using standard needlefree connectors (‘standard group’). An initial assessment found that a substantial CLABSI rate reduction was seen with use of chlorhexidine-coated end caps; therefore, most patients were switched to chlorhexidine by February 2019 and data continued to be collected till June 2019. The second study period spanned 9 months from October 2018 to June 2019.ResultsAcross 13 dialysis centers, anonymized health records of 5934 patients who were dialyzed via CVCs between May 2018 and June 2019 were analyzed. The mean age was 61.3 and 47.1% of all patients were female. Study period one included 967 patients with chlorhexidine and 1044 patients with standard end caps, while there were 3647 chlorhexidine and 276 standard patients in the second period. The combined CLABSI rate in the chlorhexidine group was 0.09/1000 CVC days versus 0.63/1000 CVC days in the standard group (p<0.0001).ConclusionChlorhexidine-coated CVC caps may provide a therapeutic improvement in CVC hemodialysis management.

Implementation of an Electronic Catheter Checklist in Outpatient Hemodialysis Facilities: Results of a Pilot Quality Improvement Project.

Performing catheter-care observations in outpatient hemodialysis facilities are one of the CDC's core interventions, which have been proven to reduce bloodstream infections. However, staff have many competing responsibilities. Efforts to increase and streamline the process of performing observations are needed. We developed an electronic catheter checklist, formatted for easy access with a mobile device, and conducted a pilot project to determine the feasibility of implementing it in outpatient dialysis facilities. The tool contained the following content: (1) patient education videos; (2) catheter-care checklists (connection, disconnection, and exit-site care); (3) prepilot and postpilot surveys; and (4) a pilot implementation guide. Participating hemodialysis facilities performed catheter-care observations on either a weekly or monthly schedule and provided feedback on implementation of the tool. The pilot data were collected from January 6 through March 12, 2020, at seven participating facilities. A total of 954 individual observations were performed. The catheter-connection, disconnection, and exit-site steps were performed correctly for most individual steps; however, areas for improvement were (1) allowing for appropriate antiseptic dry time, (2) avoiding contact after antisepsis, and (3) applying antibiotic ointment to the exit site. Postpilot feedback from staff was mostly favorable. Use of the electronic checklists facilitated patient engagement with staff and was preferred over paper checklists, because data are easily downloaded and available for use in facility Quality Assurance and Performance Improvement (QAPI) meetings. The educational video content was a unique learning opportunity for both patients and staff. Converting the CDC's existing catheter checklists to electronic forms reduced paperwork and improved the ease of collating data for use during QAPI meetings. An additional benefit was the educational content provided on the tablet, which was readily available for viewing by patients and staff while in the hemodialysis facility.

Progress in Preventing Bloodstream Infections in Hemodialysis: Data From the National Healthcare Safety Network, 2014–2018

Background: More than 450,000 patients receive outpatient hemodialysis in the United States. Patients on hemodialysis are at high risk of bloodstream infections (BSIs), which are associated with significant morbidity and mortality. National prevention efforts targeting hemodialysis facilities have resulted in widespread changes in practice, including modifications to central venous catheter (CVC) maintenance procedures. We analyzed dialysis event surveillance data submitted to the CDC NHSN to describe changes in BSI rates among hemodialysis outpatients from 2014 to 2018. Methods: Outpatient hemodialysis facilities report BSIs (ie, positive blood cultures collected in the outpatient setting or within 1 calendar day after hospital admission) and the number of hemodialysis outpatients treated during the first 2 working days of each month to the NHSN. For each BSI, the suspected source (ie, vascular access, another site, contamination, or uncertain) and vascular access type are indicated: CVC, arteriovenous fistula (AVF) or arteriovenous graft (AVG). Pooled mean rates (per 100 patient months) were calculated for BSIs, access-related BSIs (ARBSIs), and BSIs and ARBSIs were stratified by vascular access type. Annual BSI rate trends were evaluated using a negative binomial regression model, which treated patient months as an offset variable and included access type, year, and an access-year interaction variable. Results: More than 6,000 outpatient hemodialysis facilities reported 134,961 BSIs from 2014 to 2018. Of these BSIs, 102,505 (76%) were categorized as access related. CVCs were present in 63% of BSIs and 70% of ARBSIs. Pooled mean BSI rates decreased 27% from 0.64 to 0.47 per 100 patient months; rates of ARBSIs decreased 27% from 0.49 to 0.36 per 100 patient months. Significant decreases in event rates occurred across vascular access strata (Fig. 1). The reduction in BSI and ARBSI burden was most pronounced among patients with CVCs. BSI rates in patients with CVCs decreased 32% from 2.16 per 100 patient months to 1.46 (annual average decrease, 9.5%), and ARBSI rates in patients with CVCs decreased 32% from 1.83 per 100 patient months to 1.24 (annual average decrease, 9.4%). Conclusions: Substantial reductions in BSI and ARBSI rates among hemodialysis outpatients occurred during this 5-year period, and these reductions appear to be most prominent among CVC and AVF patients. Improvements in infection prevention and control practices, including CVC care, have likely contributed to these reductions. Additional efforts to increase the uptake of known prevention practices and to identify new strategies for prevention might contribute to continued decreases in infections among this highly vulnerable population.Funding: NoneDisclosures: None

Outbreaks of Healthcare-Associated Infections in Sao Paulo State, Brazil: Results From a Statewide Monitoring System

Background: Outbreaks of healthcare-associated infections (HAI) are relevant causes of morbidity and mortality. Healthcare-authorities should monitor them to allow prompt interventions, identify tendencies along the time, and develop large scale strategies to avoid new cases and clusters. According to the Brazilian legislation, any outbreak should be reported to health authorities. Sao Paulo State Health Department (Brazil) has a system in place since 2011 to monitor HAI outbreaks. This study aims at describing the 3.5 last year’s results of surveillance system for monitoring HAI outbreaks. Methods:Study design: Quantitative descriptive study. Source of information: Database from HAI outbreak reports, Division of Hospital Infection at Sao Paulo State Health Department. Reports were filled out online by professionals from healthcare settings or regional health authorities according to predefined criteria. Interventions were put in place by the health authorities based on the analysis of each situation in a timely manner. Variables analyzed: Number of reports, local, infection site, type of care unit, causative microorganisms, number of cases, and number of deaths. Results: The number of reports have been stable for 3 years: 2016 (n = 34, 34.7%), 2017 (n = 28, 28.6%), 2018 (n = 25, 25.5%) and the first semester of 2019 (n = 11, 11.2%). These reports encompassed 712 confirmed cases and 123 deaths. The reports were mainly about infection outbreaks; 6 reports were about colonization of multidrug-resistant microorganisms. The bloodstream was the most frequent infection site in the HAI outbreak reports (n = 37, 37.7%), followed by respiratory tract (n = 25, 25.5%), urinary tract (n = 10, 10.2%), and surgical wound (n = 9, 9.2%). HAI outbreaks happened more frequently in intensive care units, including neonatal, pediatric, and adult ICUs (n = 38, 38.8%), followed by clinical and general wards (n = 20, 20.4%), hemodialysis (n = 6, 6.1%), and surgical wards (n = 5, 5.1%). Among reported outbreaks, 62.2% occurred in the capital and the metropolitan region of São Paulo. Microorganisms causing the HAI outbreaks reports were mainly carbapenem resistant, both Klebsiella pneumoniae (n = 28, 28.5%) and Acinetobacter baumannii (n = 12, 12.2%), but carbapenem-susceptible Pseudomonas aeruginosa (n = 7, 7.1%) was also reported. Conclusions: HAI outbreaks reported to health authorities in Sao Paulo may represent only a minute percentage of the total outbreaks, most of which are still not being reported, despite the normative. However, the available data emphasize the importance of developing strategies for intensive care units and hemodialysis units that focus on reducing bloodstream infections caused by multidrug-resistant gram-negative organisms.Funding: NoneDisclosures: None

Healthcare worker perceptions of the implementation context surrounding an infection prevention intervention in a Zambian neonatal intensive care unit

BackgroundInfants in the neonatal intensive care unit (NICU) are particularly susceptible to healthcare-associated infections (HAIs). NICUs in low- and middle income countries face additional challenges to HAI prevention. There is a need to better understand the role of the implementation context surrounding infection prevention interventions in low- and middle income countries.AimThe aim of this study was to identify NICU healthcare worker perceptions of an intervention to reduce bloodstream infections in a large Zambian NICU.MethodsSemi-structured interviews were conducted with NICU staff during a prospective cohort study examining the impact of an infection prevention bundle on bloodstream infections. Interviews were analyzed using an integrated approach, combining inductive theme generation with an application of the Consolidated Framework for Implementation Research (CFIR).ResultsInterviews were conducted with 17 NICU staff (5 physicians and 12 nurses). Respondents believed the bundle elements were easy to use, well-designed and facilitated improved performance. Four organizational characteristics that facilitated HAI transmission were identified – (1) lack of NICU admission protocols; (2) physical crowding; (3) understaffing; and (4) equipment shortages. Respondents suggested that NICU resource constraints reflected a societal ethos that devalued the medical care of infants. Despite the challenges, respondents were highly motivated to prevent HAIs and believed this was an achievable goal. They enthusiastically welcomed the bundle but expressed serious concern about sustainability following the study.ConclusionsBy eliciting healthcare worker perceptions about the context surrounding an infection prevention intervention, our study identified key organizational and societal factors to inform implementation strategies to achieve sustained improvement.

Improving Oral Health and Modulating the Oral Microbiome to Reduce Bloodstream Infections from Oral Organisms in Pediatric and Young Adult Hematopoietic Stem Cell Transplantation Recipients: A Randomized Controlled Trial.

Bloodstream infections (BSIs) from oral organisms are a significant cause of morbidity and mortality in hematopoietic stem cell transplantation (HSCT) recipients. There are no proven strategies to decrease BSIs from oral organisms. The aim of this study was to evaluate the impact of daily xylitol wipes in improving oral health, decreasing BSI from oral organisms, and modulating the oral microbiome in pediatric HSCT recipients. This was a single-center 1:1 randomized controlled trial in pediatric HSCT recipients age >2 years. Age-matched healthy children were enrolled to compare the oral microbiome. The oral hygiene standard of care (SOC) group continued to receive the standard oral hygiene regimen. The xylitol group received daily oral xylitol wipes (with .7 g xylitol) in addition to the SOC. The intervention started from the beginning of the transplantation chemotherapy regimen and extended to 28 days following transplantation. The primary outcome was oral health at interval time points, and secondary outcomes included BSIs from oral organisms in the first 30 days following transplantation, oral microbiome abundance, and diversity and oral pathogenic organism abundance. The study was closed early due to efficacy after an interim analysis of the first 30 HSCT recipients was performed (SOC group, n=16; xylitol group, n=14). The xylitol group had a significantly lower rate of gingivitis at days 7, 14, and 28 following transplantation (P=.031, .0039, and .0005, respectively); oral plaque at days 7 and 14 (P=.045 and .0023, respectively); and oral ulcers >10 mm at day 14 (P=.049) compared with the SOC group. The xylitol group had no BSI from oral organisms compared with the SOC group, which had 4 (P=.04). The xylitol group had significantly lower abundance of potential BSI pathogens, such as Staphylococcus aureus (P=.036), Klebsiella pneumoniae (P=.033), and Streptococcus spp (P=.011) at the day after transplantation compared with the SOC group. Healthy children and young adults had significantly increased oral microbiome diversity compared with all HSCT recipients (P < .001). The addition of xylitol to standard oral care significantly improves oral health, decreases BSI from oral organisms, and decreases the abundance of pathogenic oral organisms in pediatric and young adult HSCT recipients.

Enteral nutrition protects children undergoing allogeneic hematopoietic stem cell transplantation from blood stream infections

Enteral Nutrition (EN) is recommended as first line nutritional support for patients undergoing Allogeneic Hematopoietic Stem Cell Transplantation (allo-HSCT), but only few studies exist in the literature which compare EN to Parenteral Nutrition (PN) in the paediatric population.Forty-two consecutive paediatric patients undergoing allo-HSCT at our referral centre between January 2016 and July 2019 were evaluated. Post-transplant and nutritional outcomes of patients receiving EN for more than 7 days (EN group, n = 14) were compared with those of patients receiving EN for fewer than 7 days or receiving only PN (PN group, n = 28). In the EN group, a reduced incidence of Blood Stream Infections (BSI) was observed (p = 0.02) (n = 2 vs. n = 15; 14.3% vs. 53.6%). The type of nutritional support was also the only variable independently associated with BSI in the multivariate analysis (p = 0.03). Platelet engraftment was shorter in the PN group than in the EN group for a threshold of > 20*109/L (p = 0.04) (23.1 vs 35.7 days), but this correlation was not confirmed with a threshold of > 50*109/L. The Body Mass Index (BMI) and the BMI Z-score were no different in the two groups from admission to discharge.Our results highlight that EN is a feasible and nutritionally adequate method of nutritional support for children undergoing allo-HSCT in line with the present literature. Future functional studies are needed to better address the hypothesis that greater intestinal eubyosis maintained with EN may explain the observed reduction in BSI.

782 Central Line Associated Blood Stream Infection Reduction Utilizing a Business Improvement Model: The Four Disciplines of Execution

Abstract Introduction In July of 2018, the Burn ICU had very high Central Line Associated Blood Stream Infection (CLABSI) rate, more than double national rates. Due to the high cost and mortality associated with CLABSI, the unit leadership initiated a quality improvement project to decrease CLABSI rates. Methods The process implemented is called the “Four Disciplines of Execution” (4DX) based on a book by Sean Covey. Those methods are as follows: Results The 4DX Process allowed identification of areas for all team members (MDs and RNs) to improve their practice. Over time, consistency of practice with lead measures became 100% and new lead measures had to be developed. CLABSI improvement rate exceeded expectations; in June the rate dropped to 2.29 infections per 1000 patient line days (only 1 CLABSI during intervention period). Conclusions This process allowed engagement of the whole team, allowed for MD and RN problem solving and accountability, and resulted in dramatic improvement in HAI rates in the Burn ICU. Applicability of Research to Practice This method was unique compared to typical healthcare improvement models. In addition to being effective, it helped improve overall morale and performance on the unit.