Risk Of Bloodstream Infection Research Articles

Risk factors for carbapenem-resistant Acinetobacter baumannii (CRAB) bloodstream infections and related mortality in critically ill patients with CRAB colonization.

Among MDR bacteria, carbapenem-resistant Acinetobacter baumannii (CRAB) is a major concern due to the limited therapeutic options. During the COVID-19 pandemic, a worrying increase in the spread of CRAB infections was reported. The study assessed the risk factors for CRAB bloodstream infection (BSI) in patients admitted to the ICU with CRAB colonization, and the related mortality risk factors. We conducted a single-centre, observational, prospective study; all consecutive patients with CRAB colonization admitted to the ICU of a tertiary hospital in Rome from January 2021 to September 2022 were included in the study. Univariate and multivariate analyses were performed to investigate BSI and mortality risk factors. Overall, 129 patients were included in the study; 57 (44%) out of these developed BSI. In our study population, at the multivariable analysis the Charlson comorbidity index (CCI) (P = 0.026), COVID-19 (P < 0.001), multisite colonization (P = 0.016) and the need for mechanical ventilation (P = 0.024) were risk factors independently associated with BSI development. Furthermore, age (P = 0.026), CCI (P < 0.001), septic shock (P = 0.001) and Pitt score (P < 0.001) were independently associated with mortality in the BSI patients. Instead, early appropriate therapy (P = 0.002) and clinical improvement within 72 h (P = 0.011) were shown to be protective factors. In critically ill patients colonized by CRAB, higher CCI, multisite colonization and the need for mechanical ventilation were identified as risk factors for BSI onset. These predictors could be useful to identify patients at highest risk of BSI.

Gastrointestinal barrier integrity and mucosal inflammation as risk factors of blood stream infections in children treated for acute lymphoblastic leukaemia.

Chemotherapy-induced mucositis increases the risk of blood stream infections (BSI) due to translocation of bacteria across the intestinal epithelium. Our study investigated if quantitative measures of intestinal mucositis severity, including plasma citrulline (a marker of functional enterocytes) and CCL20 (an intestinal immune homeostatic chemokine), could identify patients at risk of BSI. A total of 106 children with ALL undergoing induction treatment (NOPHO ALL 2008) were included and information regarding BSI episodes was collected from the patients' medical records. Twenty-seven patients (25%) developed BSI during induction. Patients with BSI had a larger decrease in citrulline after chemotherapy than patients without BSI, and nearly all BSI episodes (25/27) occurred in the group of patients exhibiting a drop in citrulline (OR = 6.4 [95% CI: 1.4-29.3], P = .008). Patients who developed BSI had higher plasma CCL20 levels on days 8, 15 and 22 than patients without BSI (all P < .05), and elevated CCL20 levels on day 8 increased the risk of subsequent BSI (OR = 1.57 [1.11-2.22] per doubling of CCL20 level, P = .01) in a multivariable logistic regression analysis. These findings suggest that children with ALL who develop BSI during chemotherapy are characterised by more severe intestinal mucositis, as measured by plasma citrulline and CCL20. These markers may be useful in early risk stratification to guide treatment decisions.

Etiology of Bacterial Sepsis and Isolate Resistance Patterns in Hospitalized Neonates in Zambia.

The Sepsis Prevention in Neonates in Zambia study is a prospective cohort study that evaluated an infection prevention and control (IPC) bundle in the University Teaching Hospital neonatal intensive care unit (NICU) in Lusaka, Zambia. We present here the etiologies, antimicrobial resistance profiles, and associated mortality of bloodstream infections (BSI) in this cohort. Venous blood was collected from neonates with clinically suspected sepsis and cultured with an automated blood culture system. Organism identification and susceptibility testing were done using the Vitek II system. We used the CDC National Health Safety Network criteria to define pathogens and commensals. There were 1120 blood cultures performed for 1060 neonates with suspected sepsis. Overall, 38% (424/1120) of cultures were positive of which 72% (306/424) grew pathogens. Blood cultures obtained after, as compared to before, 2 days of hospitalization were more likely to yield a pathogen (77% vs. 65%; P < 0.001). Klebsiella pneumoniae was the most prevalent organism, accounting for 74% (225/306) of all pathogens . K. pneumoniae isolates were highly resistant: 98% (221/225) were extended-spectrum beta-lactamase (ESBL)-positive, while 81% were resistant to gentamicin (182/225) and fluoroquinolones (177/219). Only one isolate was carbapenem resistant. Observed mortality rate was 32% (122/380); 61% (75/122) of the deaths was related to Klebsiella BSI. Multidrug-resistant ESBL-producing Klebsiella species were the main organisms responsible for BSI and were associated with increased mortality. BSI risk increased with prolonged hospitalization, underscoring the importance of IPC measures in the NICU.

Relationship between COVID-19 and ICU-Acquired Bloodstream Infections Related to Multidrug-Resistant Bacteria.

A bloodstream infection (BSI) is a severe ICU-acquired infection. A growing proportion is caused by multidrug-resistant bacteria (MDRB). COVID-19 was reported to be associated with a high rate of secondary infections. However, there is a lack of data on the relationship between COVID-19 and the incidence of MDRB ICU-acquired BSI. The aim of this study was to evaluate the relationship between COVID-19 and ICU-acquired BSI related to MDRB. This retrospective study was conducted in a single-center ICU during a one-year period. All adult patients admitted for more than 48 h were included. The cumulative incidence of ICU-acquired BSI related to MDRB was estimated using the Kalbfleisch and Prentice method. The association of COVID-19 status with the risk of ICU-acquired BSI related to MDRB was assessed using cause-specific Cox's proportional hazard model. Among the 1320 patients included in the analysis, 497 (37.65%) had COVID-19. ICU-acquired BSI related to MDRB occurred in 50 patients (36 COVID patients (7%) and 14 non-COVID patients (1.6%)). Extended-spectrum beta-lactamase Enterobacteriacae (46%) and carbapenem-resistant Acinetobacter baumannii (30%) were the most commonly isolated MDRB. COVID-19 was significantly associated with a higher risk of MDRB ICU-acquired BSI (adjusted cHR 2.65 (1.25 to 5.59) for the whole study period). However, this relationship was only significant for the period starting at day 15 after ICU admission. ICU-acquired BSI related to MDRB was significantly associated with ICU mortality (HR (95%CI) 1.73 (1-3)), although COVID-19 had no significant impact on this association (p het 0.94). COVID-19 is significantly associated with an increased risk of ICU-acquired BSI related to MDRB, mainly during the period starting at day 15 after ICU admission.

Risk of catheter-associated bloodstream infection by catheter type in a neonatal intensive care unit: a large cohort study of more than 1100 intravascular catheters

The aim of this study was to evaluate the risk of catheter-associated bloodstream infection (CABSI) among different catheter types using a large prospective database in the neonatal intensive care unit (NICU) of a tertiary care centre in Switzerland. We included all neonates admitted to the NICU with at least one central intravascular catheter inserted between January 2017 and December 2020. We used marginal Cox model to determine the risk of CABSI among different catheter types. A total of 574 neonates and 1103 intravascular catheters were included in the study: 581 venous umbilical catheters, 198 arterial umbilical catheters and 324 peripherally inserted central catheters (PICCs). We identified 17, four and four CABSIs in neonates with venous umbilical catheters, arterial umbilical catheters and PICCs, respectively. The risk of CABSI increased after two days of umbilical catheter maintenance. Using univariable Cox models, and adjusting for sex and gestational age, we observed a similar CABSI risk between venous and arterial umbilical catheters (HR 0.57; 95% CI 0.16e2.08). Birth weight was associated with CABSI, with higher weight being protective (HR 0.37, 95% CI 0.16e0.81). Strategies aimed at reducing umbilical catheter dwell time, particularly in low and very low birth weight neonates, may be effective in decreasing the incidence of CABSI in this population.

Prolonged cardiopulmonary bypass time as predictive factor for bloodstream infection

ObjectivesTo evaluate the correlation between patient characteristics, operative variables and the risk of blood stream infection as well as the association of primary blood stream infection and adverse outcomes. MethodsClinical records of 6500 adult patients who underwent open heart surgery between February 2008 and October 2020 were analyzed. The microbiological pattern of the primary BSI and its association with adverse events, such as mortality and major cardiovascular events, were evaluated. ResultsPrimary bloodstream infection was diagnosed in 1.7% (n = 108) of patients following cardiac surgery with the application of cardiopulmonary bypass. Most isolated bacteria were gram-negative bacillus groups, such as the Enterobacteriaceae family with Serrata marcescens in 26.26%, followed by the Enterococcaceae family with the Enterococcus faecalis in 7.39% and Enterococcus faecium in 9.14% as the most frequently identified bacteria. The postprocedural mortality, stroke rate p < 0.001, the incidence of postoperative new renal failure p < 0.001, and the renal replacement therapy p < 0.001 were significantly higher in the primary BSI group. Aortic cross-clamp time >120 min, OR 2.31 95%CI 1.34 to 3.98, perfusion time >120 min, OR 2.45 95%CI 1.63 to 3.67, and duration of the intervention >300min, OR 2.78 95%CI 1.47 to 5.28, were significantly related to the primary BSI. ConclusionThe gram-negative bacillus was the most common microorganism identified in BSI after cardiovascular operations using cardiopulmonary bypass. Patients on dialysis prior to cardiac surgery are at higher risk for having BSI. Enteric bacterial translocation after prolonged cardiopulmonary bypass is a possible mechanism of early primary bloodstream infection in these patients. In patients at high risk, prophylactic use of an antibiotic regimen with broader gram-negative bacteria coverage should be considered, especially in those with prolonged cardiopulmonary bypass and intervention time.

A phase 1b study to evaluate the efficacy, safety, and pharmacokinetics of an investigational microbiome therapeutic, SER-155, in adults undergoing hematopoietic stem cell transplantation.

TPS7080 Background: In patients undergoing allogeneic hematopoietic cell transplantation (HCT), loss of gastrointestinal microbial diversity is associated with risk of bloodstream infections (BSI), acute graft-versus-host disease (aGvHD), and death. SER-155 is a rationally designed investigational cultivated microbiome therapeutic, hypothesized to improve clinical outcomes in HCT by restoring colonization resistance to potential pathogens, promoting epithelial barrier integrity, and reducing colonic inflammation. SER-155-001 is a Phase 1b study evaluating the efficacy, safety, and pharmacokinetics (PK) of SER-155 in adults undergoing HCT. Methods: This study will enroll approximately 70 subjects ≥18 years in an open-label Cohort 1 (n = 10) followed by a double-blind, placebo-controlled Cohort 2 (n = 60) randomized 1:1 to SER-155 or placebo. A variety of conditioning regimens, donor types, and GVHD-prophylaxis regimens are included. Exclusion criteria include history of severe colitis or active inflammatory bowel disease or total colectomy, umbilical cord blood or ex vivo T-cell depletion, exposure to fecal microbiota transplant or any live microbial therapeutic within 3 months prior to screening, and evidence of relapse or progression of hematologic malignancy (minimal residual disease is allowed). Following screening, participants in both cohorts receive 2 treatment courses (one before and one after HCT), each comprised of microbiome conditioning with oral vancomycin or placebo followed by SER-155 or placebo, plus a conditional 3rd treatment course if the subject receives antibiotics. Safety outcomes are followed through 52 weeks post HCT. The primary endpoint is the incidence and severity of adverse events, serious adverse events, and adverse events of special interest. Secondary endpoints include rates of BSI, gastrointestinal infections, aGvHD, febrile neutropenia and overall survival. Microbiome related endpoints include engraftment of SER-155 bacterial strains in the gastrointestinal tract (PK endpoint) and fecal microbiome diversity, composition and metabolites. Results: Cohort 1 enrollment is complete, with 13 participants receiving SER-155. In December 2022, the Data and Safety Monitoring Committee supported continuation to Cohort 2 enrollment following review of safety data from Cohort 1. Enrollment in Cohort 2 is underway. Conclusions: This Phase 1b study is designed to assess the safety, and clinical efficacy of SER-155 in allogeneic HCT, expanding the clinical experience of microbiome- directed interventions in allogeneic HCT recipients. Clinical trial information: NCT04995653 .

Effectiveness of Disinfecting Caps for Intravenous Access Points in Reducing Central Line-Associated Bloodstream Infections, Clinical Utilization, and Cost of Care During COVID-19.

Intravenous (IV) access point protectors, serving as passive disinfection devices and a cover between line accesses, are available to help reduce the risk of central line-associated bloodstream infections (CLABSIs). This low-maintenance disinfection solution is particularly valuable in situations with excessive workloads. This study examined the effect of a disinfecting cap for an IV access point on CLABSI rates, hospital length of stay, and cost of care in an inpatient setting during the coronavirus disease 2019 (COVID-19) pandemic. The study utilized data from the Premier Healthcare Database, focusing on 200,411 hospitalizations involving central venous catheters between January 2020 and September 2020. Among these cases, 7423 patients received a disinfecting cap, while 192,988 patients did not use any disinfecting caps and followed the standard practice of hub scrubbing. The two cohorts, Disinfecting Cap and No-Disinfecting Cap groups, were compared in terms of CLABSI rates, hospital length of stay (LOS), and hospitalization costs. The analysis accounted for baseline group differences and random clustering effects by employing a 34-variable propensity score and mixed-effect multiple regression, respectively. The findings demonstrated a significant 73% decrease in CLABSI rates (p= 0.0013) in the Disinfecting Cap group, with an adjusted CLABSI rate of 0.3% compared to 1.1% in the No-Disinfecting Cap group. Additionally, the Disinfecting Cap group exhibited a 0.5-day reduction in hospital stay (9.2 days versus 9.7 days; p = 0.0169) and cost savings of $6703 ($35,604 versus $42,307; p = 0.0063) per hospital stay compared to the No-Disinfecting Cap group. This study provides real-world evidence that implementing a disinfecting cap to protect IV access points effectively reduces the risk of CLABSIs in hospitalized patients compared to standard care, ultimately optimizing the utilization of healthcare resources, particularly in situations where the healthcare system is under significant strain or overloaded.

Relative risk of primary bloodstream infection in patients with mechanical circulatory support devices

Background: Patients requiring mechanical circulatory support (MCS) during episodes of cardiogenic shock are at risk for hospital-acquired bloodstream infection (HABSI). Clinically MCS devices include extracorporeal membrane oxygenation (ECMO) devices, durable and temporary left ventricular-assist devices (VADs), and intra-aortic balloon pumps (IABPs). However, the MCS exclusion to the NHSN central-line–associated bloodstream infection (CLABSI) surveillance rules in 2018 did not include IABP as a qualifying device. We have described utilization and incidence of primary HABSI (pHABSI) in our patients requiring MCS. Methods: The setting for this study was 9 cardiothoracic and heart failure intensive care units with 131 total beds at the Cleveland Clinic Main Campus. Surveillance for HABSI to include determination of CLABSI was performed prospectively. MCS-associated pHABSI were patients who had ECMO, LVAD, or IABP present for &gt;2 calendar days with device in place on the date of infection or removed the day before. A patient with 2 device types at time of infection was counted as a pHABSI for both groups. Patient, device, and MCS days were extracted from an electronic database. Non-MCS patient days were calculated as the difference between total patient days and total MCS days. The incidence of ECMO-, VAD-, and IABP-associated pHABSI were compared to each other and to non–MCS-associated pHABSI using OpenEpi version 3.01 software. Results: Surveillance results are shown in Table 1. During the observation period, there were 221 pHABSIs and 139,013 patient days. Moreover, 67 pHABSIs were associated with an MCS device over 17,044 total MCS days: 43 ECMO days, 18 VAD days, and 13 IABP days. Also, 9 patients had &gt;1 type of eligible device and 7 (39%) of the IABP-associated pHABSIs were CLABSIs.The cumulative incidences of pHABSI associated with ECMO, VAD, and IABP were 5.68, 4.59, and 2.34 per 1,000 MCS days, respectively. The incidence of IABP pHABSI was not significantly different from VAD pHABSI (P = .06), but it was different from ECMO pHABSI (P &lt; .01). The pHABSI rate for non-MCS days was 1.26 per 1,000 patient days. Conclusions: In our patients requiring MCS, the risk of pHABSI associated with IABP was significantly greater than in patients without MCS and was similar to patients with VAD. MCS of all types should be considered a risk for HABSI in patients with cardiogenic shock beyond the presence of a central line. Protocols to further prevent HABSI morbidity in IABP patients are needed.Disclosure: None

End-of-life care and hospital-acquired bloodstream infection

Background: All critically ill patients are at risk for hospital-acquired bloodstream infection (HABSI). At any time, however, there is heterogeneity among patients in the ICU; some patients have the added complexity of end-of-life discussions. We sought to better understand the patients in our medical intensive care unit (MICU) with HABSIs that do and do not meet the NHSN definition for a central-line–associated bloodstream infection (CLABSI) event by evaluating for the presence of a do-not-resuscitate (DNR) order. Methods: The study was conducted at our 66-bed MICU at the Cleveland Clinic Main Campus between January 2021 and September 2022. Surveillance for HABSI to include determination of CLABSI is performed prospectively according to the NSHN definition. The electronic health record was queried for each patient with a HABSI for the presence of a DNR order. DNR orders were categorized as follows: prevalent (DNR orders present at the time of admission to the MICU), incident (orders entered after admission to the MICU), or no DNR (for patients without an order at any time during their MICU stay). For incident orders, time from order to HABSI was recorded. Time to event was calculated as days between ICU admission to HABSI. Results: During the observation period there were 36,477 MICU patient days and 4,815 admissions. There were 112 HABSIs, of which 48 (43%) were CLABSIs. Overall, 65 patients were categorized as incident DNR, 7 were categorized as prevalent DNR, and 40 were categorized as no DNR. For patients with an incident DNR order, 50 HABSIs occurred on the date of or before the order and 15 occurred after the order. In patients in whom HABSI occurred after the incident DNR order, the median number of days between DNR order and HABSI was 11 days (range, 1–69). Discussion: In our MICU, &gt;50% of HABSIs and 60% of CLABSIs occurred in patients with a DNR order incident to their MICU stay. Interventions to prevent hospital-acquired bloodstream infection and the analysis of the events are inextricably linked to issues of end-of-life care for critically ill patients. Further exploration of patient characteristics easily obtainable from the EHR, such as DNR orders, is necessary to inform best practices for prevention and risk adjustment of bloodstream infection rates.Disclosures: None

Probiotic-Associated Central Venous Catheter Bloodstream Infections Lead to Increased Mortality in the ICU.

To determine the occurrence rate and impact on patient outcomes of probiotic-associated central venous catheter bloodstream infections in the ICU. Retrospective observational cohort study. The cohort was gathered using HCA Healthcare's data warehouse. Adult patients with central venous catheters in the ICU. None. Blood culture data were used to determine whether an infection had occurred with an organism contained in an administered probiotic. Eighty-six probiotic-associated central venous catheter bloodstream infections were identified among the 23,015 patient cohort who received probiotics (0.37%). The number needed to harm was 270. Zero infections were found in the cohort that did not receive probiotics. Patients who contracted a probiotic infection had increased mortality (odds ratio, 2.23; 1.30-3.71; p < 0.01). Powder formulations had an increased rate of infection compared with nonpowder formulations (0.76% vs 0.33%; odds ratio, 2.03; 1.05-3.95; p = 0.04). Probiotic administration is associated with a substantial rate of probiotic-associated bloodstream infection in ICU patients with central venous catheters in place. Probiotic-associated bloodstream infections result in significantly increased mortality. Powder formulations cause bloodstream infections more frequently than nonpowder formulations. In ICU patients with central venous catheters, the risks of probiotic-associated central venous catheter bloodstream infection and death outweigh any potential benefits of probiotic administration.

Estimating racial differences in risk for CLABSI in a large urban healthcare system

Background: Socioeconomic barriers or divergent implementation of prevention measures may impact risk of healthcare-associated infections by racial groups. We utilized a previously studied cohort of patients to quantify disparities in central-line–associated bloodstream infection (CLABSI) risk by race accounting for inherent differences in risk related to device utilization. Methods: In a retrospective cohort of adult patients at 4 hospitals (range, 110–733 beds) from 2012 to 2017, we linked central-line data to patient encounter data: race, age, comorbidities, total parenteral nutrition (TPN), chemotherapy, CLABSI. Analysis was limited to patients with &gt;2 central-line days and &lt;3 concurrent central lines. Patient exposures were calculated for each central-line episode (defined by insertion and removal dates); analysis of central-line episode-specific risk of CLABSI among Black versus White patients adjusted for clinical factors, duration of central-line episode, and central-line risk category (ie, low: single port, dialysis or PICC; medium: single temporary or nontunneled; or high: any concurrent central-lines) in Cox proportional hazards regression of time to CLABSI. Results: In total, 526 CLABSIs occurred a median of 14 days after insertion among 57,642 central-line episodes in 32,925 patients. CLABSIs occurred in similar frequency across racial groups: 217 (1.7%) among Black patients, 256 (1.6%) among White patients, and 11 (1.6%) among Hispanic patients (also 42 among unknown or other race). Duration of central-line episode was similar between racial groups (median, 5 days). Black patients were less likely to have medium-risk central lines (34%) compared to white patients (RR, 0.82; 95% CI, 0.79–0.84), but they had a similar frequency of high-risk central lines (21%; RR, 1.0; 95% CI, 1.0–1.1). Compared with low-risk central lines, risk of CLABSI was increased among medium-risk central lines (RR, 1.3; 95% CI, 1.0–1.7) and high-risk central lines (RR, 2.2; 95% CI, 1.8–2.7). CLABSIs were more likely in TPN central lines (RR, 2.3; 95% CI, 1.9–2.7) than others, but they were not more likely among Black patients than White patients (RR, 0.9; 95% CI, 0.1–1.1). In survival analysis, there were 24,700 central-line episodes among Black patients compared to 26,648 episodes among White patients; adjusting for central-line risk and TPN, the risk of CLABSI was similar during the first 21 days of central-line use (adjusted hazard ratio, 1.08; 95% CI, 0.88–01.32) (Fig. 1). Conclusions: After accounting for central-line configuration, Black patients did not have a higher risk of CLABSI within 21 central-line days. Further evaluation is warranted to assess racial disparities in risks of other healthcare-associated infections and to determine whether a lack of CLABSI-specific racial disparities can be replicated in other regions and healthcare systems.Disclosures: None

Bloodstream infection burden among cancer clinic patients with PICC Lines: A prospective, observational study

Background: Oncology patients are at high risk for bloodstream infection (BSI) due to immunosuppression and frequent use of central venous catheters. Surveillance in this population is largely relegated to inpatient settings and limited data are available describing community burden. We evaluated rates of BSI, clinic or emergency department (ED) visits, and hospitalizations in a large cohort of oncology outpatients with peripherally inserted central catheters (PICCs). Methods: In this prospective, observational study, we followed a convenience sample of adults (age&gt;18) with PICCs at a large academic outpatient oncology clinic for 35 months between July 2015 and November 2018. We assessed demographics, malignancy type, PICC insertion and removal dates, history of prior PICC, and line duration. Outcomes included BSI events (defined as &gt;1 positive blood cultures or &gt;2 positive blood cultures if coagulase-negative Staphylococcus), ED visits (without hospitalization), and unplanned hospitalizations (excluding scheduled chemotherapy hospitalizations). We used χ2 analyses to compare the frequency of categorical outcomes, and we used unpaired t tests to assess differences in means of continuous variable in hematologic versus solid-tumor malignancy patients. We used generalized linear mixed-effects models to assess differences in BSI (clustered by patient) separately for gram-positive and gram-negative BSI outcomes. Results: Among 478 patients with 658 unique PICC lines and 64,190 line days, 271 patients (413 lines) had hematologic malignancy and 207 patients (232 lines) had solid-tumor malignancy. Cohort characteristics and outcomes stratified by malignancy type are shown in Table 1. Compared to those with hematologic malignancy, solid-tumor patients were older, had 47% fewer clinic visits, and had 32% lower frequency of prior PICC lines. Overall, there were 75 BSI events (12%; 1.2 per 1,000 catheter days). We detected no significant difference in BSI rates when comparing solid-tumor versus hematologic malignancies (P = 0.20); BSIs with gram-positive pathogen were 69% higher in patients with solid tumors. Gram-negative BSIs were 41% higher in patients with hematologic malignancy. Solid-tumor malignancy was associated with 4.5-fold higher odds of developing BSI with gram-positive pathogen (OR, 4.48; 95% CI, 1.60–12.60; P = .005) compared to those with hematologic malignancy, after adjusting for age, sex, history of prior PICC, and line duration. Differences in gram-negative BSI were not significant on multivariate analysis. Conclusions: The burden of all-cause BSIs in cancer clinic adults with PICC lines was 12% or 1.2 per 1,000 catheter days, as high as nationally reported inpatient BSI rates. Higher risk of gram-positive BSIs in solid-tumor patients suggests the need for targeted infection prevention activities in this population, such as improvements in central-line monitoring, outpatient care, and maintenance of lines and/or dressings, as well as chlorhexidine bathing to reduce skin bioburden.Disclosures: None

Bloodstream Infection and Colorectal Cancer Risk in Queensland Australia, 2000-2019

BackgroundBloodstream infections may occur as a complication of colorectal cancer or be a marker for its occult presence. The objectives of this study were to quantify the overall and etiology-specific risks for incident colorectal cancer-associated bloodstream infection. MethodsPopulation-based surveillance for community-onset bloodstream infection was conducted among adults aged 20 years and older in Queensland, Australia between 2000 and 2019. Statewide databases were used to identify patients with incident colorectal cancer and collect clinical and outcome information. ResultsAfter exclusion of 1794 patients with prior colorectal cancer, a cohort of 84,754 patients was assembled, of which 1030 had colorectal cancer-associated bloodstream infection and 83,724 had no colorectal cancer. Bloodstream infection was associated with a 16-fold annualized increased risk for diagnosis of colorectal cancer (incidence rate ratio 16.1; 95% confidence interval [CI], 15.1-17.1) in the adult population. Patients who had colorectal cancer-associated bloodstream infection were more likely to be older and male, have hospital-onset and polymicrobial infections, and have fewer non-cancer-related comorbidities. The organisms associated with highest risk for colorectal cancer included Clostridium species (relative risk [RR] 6.1; 95% CI, 4.7-7.9); especially C. septicum (RR 25.0; 95% CI, 16.9-35.7), Bacteroides species (RR 4.7; 95% CI, 3.8-5.8); especially B. ovatus (RR 11.8; 95% CI, 2.4-34.5), Gemella species (RR 6.5; 95% CI, 3.0-12.5), Streptococcus bovis group (RR 4.4; 95% CI, 2.7-6.8); especially S. infantarius subsp. coli (RR 10.6; 95% CI, 2.9-27.3), Streptococcus anginosus group (RR 1.9; 95% CI, 1.3-2.7), and Enterococcus species (RR 1.4; 95% CI, 1.1-1.8). ConclusionAlthough much attention has been afforded to S. bovis group over the past decades, there are many other isolates associated with higher risk for colorectal cancer-associated bloodstream infections.

Central Line-Associated Bloodstream Infection in Patients With Hematologic Malignancy Receiving Parenteral Nutrition.

Parenteral nutrition (PN) has been shown to be a safe method of feeding in the intensive care unit with modern infection prevention practices, but similar analysis in the hematology-oncology setting is lacking. A retrospective analysis of 1,617 patients with hematologic malignancies admitted and discharged from the Hospital of the University of Pennsylvania during 3,629 encounters from 2017 to 2019 was undertaken to evaluate the association of PN administration with risk of central line-associated bloodstream infection (CLABSI). Proportions of mucosal barrier injury (MBI)-CLABSI and non-MBI-CLABSI were also compared between groups. Risk of CLABSI was associated with cancer type and duration of neutropenia but not with PN administration (odds ratio, 1.015; 95% CI, 0.986 to 1.045; P = .305) in a multivariable analysis. MBI-CLABSI comprised 73% of CLABSI in patients exposed to and 70% in patients not exposed to PN, and there was no significant difference between groups (χ2 = 0.06, P = .800). PN was not associated with increased risk of CLABSI in a sample of patients with hematologic malignancy with central venous catheters when adjusting for cancer type, duration of neutropenia, and catheter days. The high proportion of MBI-CLABSI highlights the effect of gut permeability within this population.

Dilemmas in establishing preterm enteral feeding: where do we start and how fast do we go?

Beginning and achieving full enteral nutrition is a key step in the care of preterm infants, particularly very low birth weight (VLBW) infants. As is true for many organ system-specific complications of prematurity, the gastrointestinal tract must complete in utero development ex utero while concurrently serving a physiologic role reserved for after completion of full term development. The preterm gut must assume the placental function of the interface between a source of energy, precursors for anabolism, and micronutrients, and the developing infant-through digestion and absorption of milk, instead of directly from the mother via the uteroplacental interface. The benefits of enteral nourishment in preterm infants are counterbalanced by gastrointestinal complications of prematurity: dysmotility leading to difficulty establishing and advancing feeds, and the risk of necrotizing enterocolitis (NEC). Concern for these complications can prolong the need for parenteral nutrition with an associated increase in risk for central line-associated bloodstream infection (CLABSI) and parenteral nutrition (PN)-associated cholestasis or liver disease (PNALD). Thus, a daily issue facing neonatologists caring for preterm infants is how to optimally begin, advance, and reach full enteral nutrition sufficient to satisfy the nutrient, energy, and fluid requirements of VLBW infants while minimizing risk. In this perspective, we provide an overview of the approaches and supporting data for starting and advancing enteral feeds in preterm infants, particularly very low birth weight infants, and we discuss the significant gaps in knowledge that accompany current approaches. This framework recognizes the dilemmas of preterm feeding initiation andadvancement and identifies areas of opportunity for further investigation.

Time-series prediction and detection of potential pathogens in bloodstream infection using mcfDNA sequencing.

Next-generation sequencing of microbial cell free DNA (mcfDNA-seq) has emerged as a promising diagnostic method for blood stream infection (BSI) and offers the potential to detect pathogens before blood culture. However, its application is limited by a lack of clinical validation. We conducted sequential mcfDNA-seq on blood samples from ICU participants at high risk of BSI due to pneumonia, or intravascular catheterization; and explored whether mcfDNA-seq could diagnose and detect pathogens in advance of blood culture positivity. Blood culture results were used as evaluation criteria. A total of 111 blood samples were collected during the seven days preceding and on the day of onset of 16 BSI episodes from 13 participants. The diagnostic and total predictive sensitivity of mcfDNA-seq were 90% and 87.5%, respectively. The proportion of pathogenic bacteria was relatively high in terms of both diagnosis and prediction. The reads per million of etiologic agents trended upwards in the days approaching the onset of BSI. Our work found that mcfDNA-seq has high diagnostic sensitivity and could be used to identify pathogens before the onset of BSI, which could help expand the clinical application of mcfDNA-seq.

Multinational prospective cohort study of incidence and risk factors for central line-associated bloodstream infections over 18 years in 281 ICUs of 9 Asian countries.

Our objective was to identify central line (CL)-associated bloodstream infections (CLABSI) rates and risk factors (RF) in Asia. From 03/27/2004 to 02/11/2022, we conducted a multinational multicenter prospective cohort study in 281 ICUs of 95 hospitals in 44 cities in 9 Asian countries (China, India, Malaysia, Mongolia, Nepal, Pakistan, Philippines, Sri Lanka, Thailand, and Vietnam). For estimation of CLABSI rate we used CL-days as denominator and number of CLABSI as numerator. To estimate CLABSI RF for we analyzed the data using multiple logistic regression, and outcomes are shown as adjusted odds ratios (aOR). A total of 150,142 patients, hospitalized 853,604 days, acquired 1514 CLABSIs. Pooled CLABSI rate per 1000 CL-days was 5.08; per type of catheter were: femoral: 6.23; temporary hemodialysis: 4.08; jugular: 4.01; arterial: 3.14; PICC: 2.47; subclavian: 2.02. The highest rates were femoral, temporary for hemodialysis, and jugular, and the lowest PICC and subclavian. We analyzed following variables: Gender, age, length of stay (LOS) before CLABSI acquisition, CL-days before CLABSI acquisition, CL-device utilization ratio, CL-type, tracheostomy use, hospitalization type, ICU type, facility ownership and World Bank classifications by income level. Following were independently associated with CLABSI: LOS before CLABSI acquisition, rising risk 4% daily (aOR = 1.04; 95% CI = 1.03-1.04; p < 0.0001); number of CL-days before CLABSI acquisition, rising risk 5% per CL-day (aOR = 1.05; 95% CI 1.05-1.06; p < 0.0001); medical hospitalization (aOR = 1.21; 95% CI 1.04-1.39; p = 0.01); tracheostomy use (aOR = 2.02;95% CI 1.43-2.86; p < 0.0001); publicly-owned facility (aOR = 3.63; 95% CI 2.54-5.18; p < 0.0001); lower-middle-income country (aOR = 1.87; 95% CI 1.41-2.47; p < 0.0001). ICU with highest risk was pediatric (aOR = 2.86; 95% CI 1.71-4.82; p < 0.0001), followed by medical-surgical (aOR = 2.46; 95% CI 1.62-3.75; p < 0.0001). CL with the highest risk were internal-jugular (aOR = 3.32; 95% CI 2.84-3.88; p < 0.0001), and femoral (aOR = 3.13; 95% CI 2.48-3.95; p < 0.0001), and subclavian (aOR = 1.78; 95% CI 1.47-2.15; p < 0.0001) showed the lowest risk. The following CLABSI RFs are unlikely to change: country income level, facility-ownership, hospitalization type, and ICU type. Based on these findings it is suggested to focus on reducing LOS, CL-days, and tracheostomy; using subclavian or PICC instead of internal-jugular or femoral; and implementing evidence-based CLABSI prevention recommendations.

Bloodstream Infections in Infants and Children With Congenital Heart Disease Undergoing Cardiac Surgery

Children with congenital heart disease undergoing cardiac surgery are at risk for laboratory-confirmed bloodstream infections (LCBIs). These infections can lead to morbidity, mortality, and increased health care costs. The role of mucosal barrier injury in causing LCBIs is unknown. To describe characteristics of LCBIs in patients admitted to cardiac intensive care and step-down units and to assess frequencies of National Healthcare Safety Network infection types and associations with organism classification, patient clinical factors, and infection outcomes. A retrospective cohort analysis using manual electronic medical record data abstraction included children with congenital heart disease who developed an LCBI while receiving inpatient cardiac care between August 2011 and November 2018 at one institution. Demographic, clinical, laboratory, and outcome variables were collected and analyzed with descriptive and inferential statistics. Eighty-seven patients with congenital heart disease developed 103 LCBIs during the study time frame. The most common causative microorganisms were gram-positive bacteria, including Enterococcus faecalis and Staphylococcus epidermidis. Sixty-three percent of causative organisms were characterized as originating from mucosal barrier injury, although no infections met National Healthcare Safety Network criteria for mucosal barrier injury LCBIs. Translocation of bacteria through injured gut mucosa may cause bloodstream infections in children with congenital heart disease. Further investigation is warranted to understand microbiome changes that adversely select pathogenic gut organisms. Preventive care to maintain intact gut function and a healthy microbiome should be explored for this patient population.

Vital Signs: Health Disparities in Hemodialysis-Associated Staphylococcus aureus Bloodstream Infections — United States, 2017–2020

IntroductionRacial and ethnic minorities are disproportionately affected by end-stage kidney disease (ESKD). ESKD patients on dialysis are at increased risk for Staphylococcus aureus bloodstream infections, but racial, ethnic, and socioeconomic disparities associated with this outcome are not well described. MethodsSurveillance data from the 2020 National Healthcare Safety Network (NHSN) and the 2017–2020 Emerging Infections Program (EIP) were used to describe bloodstream infections among patients on hemodialysis (hemodialysis patients) and were linked to population-based data sources (CDC/Agency for Toxic Substances and Disease Registry [ATSDR] Social Vulnerability Index [SVI], United States Renal Data System [USRDS], and U.S. Census Bureau) to examine associations with race, ethnicity, and social determinants of health. ResultsIn 2020, 4,840 dialysis facilities reported 14,822 bloodstream infections to NHSN; 34.2% were attributable to S. aureus . Among seven EIP sites, the S. aureus bloodstream infection rate during 2017–2020 was 100 times higher among hemodialysis patients (4,248 of 100,000 person-years) than among adults not on hemodialysis (42 of 100,000 person-years). Unadjusted S. aureus bloodstream infection rates were highest among non-Hispanic Black or African American (Black) and Hispanic or Latino (Hispanic) hemodialysis patients. Vascular access via central venous catheter was strongly associated with S. aureus bloodstream infections (NHSN: adjusted rate ratio [aRR] = 6.2; 95% CI = 5.7–6.7 versus fistula; EIP: aRR = 4.3; 95% CI = 3.9–4.8 versus fistula or graft). Adjusting for EIP site of residence, sex, and vascular access type, S. aureus bloodstream infection risk in EIP was highest in Hispanic patients (aRR = 1.4; 95% CI = 1.2–1.7 versus non-Hispanic White [White] patients), and patients aged 18–49 years (aRR = 1.7; 95% CI = 1.5–1.9 versus patients aged ≥65 years). Areas with higher poverty levels, crowding, and lower education levels accounted for disproportionately higher proportions of hemodialysis-associated S. aureus bloodstream infections. Conclusions and implications for public health practiceDisparities exist in hemodialysis-associated S. aureus infections. Health care providers and public health professionals should prioritize prevention and optimized treatment of ESKD, identify and address barriers to lower-risk vascular access placement, and implement established best practices to prevent bloodstream infections.