Central Venous Catheter Salvage Research Articles

Catheter salvage from central line-related bloodstream infections in pediatric intestinal failure.

Patients with intestinal failure require central venous access which puts them at risk for central line-associated bloodstream infections (CLABSI). Maintaining vascular patency is critical for this population to receive nutrition support. When CLABSIs occur line salvage can help maintain vascular access. The aim of this study is to assess factors associated with safe and successful central venous catheter salvage. Retrospective cohort study of patients with intestinal failure at two tertiary care institutions between 2012 and 2020. The study examined the rates of attempted salvage, factors associated with successful salvage, and complications associated with salvage attempts. Over the study period, 76 patients with intestinal failure were include while central venous access was in place. There were a total of 94 CLABSIs. Salvage was more likely to be attempted when patients were under the direct care of an intestinal rehabilitation service (95% vs. 68%, p = 0.04). The overall successful salvage rate was 91.6% (n = 77). Gram-positive, Gram-negative, and polymicrobial infections had successful salvage rates of 97%, 92%, and 94% respectively. The successful salvage rate for fungal infections was 40%. There was no difference in 30-day complication rates for hospital readmission, intensive care unit admission, and death between patients who underwent salvage attempt and those who did not. Central line salvage can be safely attempted for many infections in patients with intestinal failure, leading to vascular access preservation.

Central Venous Catheter-related Bloodstream Infections Caused by Enterobacterales in Pediatric Oncology Patients: Catheter Salvage or Removal.

The aim was to determine whether salvage treatment with systemic antibiotics is a safe and effective strategy for Enterobacterales bloodstream infections (BSI) in pediatric oncology patients with a central venous catheter (CVC). A retrospective study was performed on oncology and stem cell recipient patients with a CVC and blood culture with Enterobacterales, at the Princess Máxima Centre for Pediatric Oncology, Utrecht, the Netherlands. Analyses were performed for all BSI and for episodes meeting central line-associated bloodstream infection (CLABSI) criteria. The cumulative incidence of an event (ie, removal, intensive care admission or death) was estimated after blood culture collection for episodes primarily treated with antibiotics. The effect of prognostic factors on the hazard of the event of interest was assessed by estimating a Cox proportional hazard regression model. In total, 95 CVC-related Enterobacterales BSIs in 82 patients were included; 12 (13%) BSIs required immediate CVC removal and for 83 (87%) BSIs CVC salvage was attempted. The cumulative incidence of events at 60 days was 53.0% [95% confidence interval (CI): 41.7-63.1] for BSIs (n = 83), and 64.4% (95% CI: 48.3-76.7) for CLABSIs (n = 45). The events occurred after a median of 6 (Q1-Q3: 2-15) and 6 (Q1-Q3: 2-20) days for BSIs and CLABSIs, respectively. Intensive care admission after salvage treatment was required in 16% of the BSIs and CLABSIs, resulting in death in 5% and 2% of cases, respectively. No significant association between risk factors and events was found. The cumulative incidence of an event at 60 days after salvage treatment for Enterobacterales CLABSIs and BSIs in pediatric oncology patients is high. Immediate CVC removal appears recommendable for this patient group.

Effectiveness of salvage catheters in home parenteral nutrition: A single-center study and systematic literature review

There are sparse data regarding the rate of catheter salvage and long-term effectiveness of antibiotic lock treatment outcome after central line-associated bloodstream infections (CLABSI). Objectives were to analyze the effectiveness of central venous catheter (CVC) rescue strategy and its impact on catheter lifespan. Secondary objective included effectiveness of taurolidine+4% citrate in primary prevention, compared to a secondary prevention strategy, by analyzing infection incidence during two successive periods. Real-life 5-year observational study assessing CLABSI occurrence and CVC salvage outcomes in adult patients requiring Home Parenteral Nutrition (HPN) managed in a single-center Intestinal Failure Unit. Over the 5-year period, there were 106 confirmed infections (63/143 patients (44%)). Infection incidence was 0.92/1000 catheter-days. Incidence was 1.02/1000 catheter-days during the taurolidine+4% citrate period while lower at 0.84/1000 catheter-days (p=0.034) during the systematic taurolidine lock period. Of the total number of infections, 89 CVCs were immediately removed and 17 were salvaged. The success rate of catheter salvage with antibiotic lock was 82.4%, with 53% remaining CLABSI-free at one year. The salvage strategy extended catheter lifespan by a median 165 days (IQR 50-214). However, the rate of new infection was significantly higher in instances of salvage (71.4%) vs. removal (36%). Parenteral Nutrition (PN) ≥12 months (p=0.002), PN (vs. hydroelectrolytic support) (p=0.028) and self-management by patients (p=0.049) were independent risk factors of CLABSI. Catheter salvage appears to be an effective long-term strategy with >50% of CVCs remaining CLABSI-free at one year and a prolonged catheter life, although may expose to a more frequent and earlier infection recurrence. Cohort approved by the French CNIL (National Committee for Data Protection, authorization number CNIL 2015-25). referred to as "observational research", "non-interventional", or«non-RIPH ».

Catheter-related bloodstream infection management in patients receiving home parenteral nutrition: An observational cohort study

Patients with intestinal failure receiving home parenteral nutrition (HPN) are susceptible to central-line associated bloodstream infections (CLABSIs), with crucial roles for adequate (empiric) antimicrobial therapy and effective catheter management strategies. Our aim was to link recent epidemiologic CLABSI data with clinical outcomes and to identify risk factors for therapeutic failure to decide on the safest and most accurate CLABSI management in patients receiving HPN. A retrospective observational cohort study was conducted. All data on CLABSIs (period 2010-2020) in adult patients receiving HPN were retrieved. The efficacy of attempted catheter salvage and empiric antimicrobial treatment (β-lactam antibiotics) in our center, with a low prevalence of methicillin-resistant staphylococci, was investigated. Multivariate cox-regression analysis was performed to identify risk factors for recurrent CLABSI. 389 CLABSIs occurred in 149 patients. The overall infection rate was 0.64 per 1000 central venous catheter (CVC) days. Most CLABSIs were caused by Coagulase-negative staphylococci (37%). Attempted CVC salvage was successful in 70% of the cases. Empiric antimicrobial therapy was found to be adequate in only 47% of cases, mainly because of insufficient Coagulase-negative staphylococci coverage. According to the Cox model, patients with a replaced CVC had a 50% lower risk of a new CLABSI than patients with a retained (salvaged) CVC during follow-up (HR 0.50; 95% CI 0.35-0.72, P<0.001). CVC salvage can be achieved in most CLABSI cases but seems associated with a shorter CLABSI-free survival. Importantly, based on our findings, a glycopeptide containing antibiotic treatment regimen will increase the likelihood of adequate empiric coverage.

Management of home parenteral nutrition catheter-related bloodstream infections in hospitals outside of a specialized intestinal failure center.

Catheter-related bloodstream infections (CRBSIs) remain the commonest complication associated with home parenteral nutrition (HPN). Although the management outcomes of CRBSIs have been extensively reported by specialized intestinal failure (IF) centers, there are minimal data reporting CRBSI outcomes for HPN-dependent patients admitted to nonspecialized hospitals. This was an observational study from a prospectively maintained database of CRBSIs in HPN-dependent patients managed outside of a specialized IF center. Three hundred and six patients from a total cohort of 1066 HPN-dependent patients suffered from 489 CRBSI events from 2003 to 2021; after 2017, 71 of these events were managed at the patient's local, nonspecialized hospital and the remainder at the specialized IF center. From 2017 to 2021, salvage of the central venous catheter (CVC) with antimicrobial therapy was attempted in 32 out of 71 (45.1%) patients admitted to the nonspecialized hospital, with successful salvage recorded in 23 (71.8%) cases. Notably, CVC salvage was attempted more commonly (77 out of 103 [74.8%]; P = 0.004 vs nonspecialized hospital), with a better salvage success rate (64 out of 77 [83.1%] P = 0.01 vs nonspecialized hospital) in patients who were admitted to the specialized IF center. In some instances, CRBSIs can be effectively managed when patients presenting to a nonspecialized hospital; however, overall salvage is more likely to be successful in the specialized setting. Further development of clinical and educational networks between IF centers and patients' local hospitals aimed at standardizing care may lead to improved CRBSI outcomes.

Evaluation of central line salvage for mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) management practices in patients with hematologic malignancies

Patients with underlying hematologic malignancy (HM) and/or allogeneic hematopoietic stem cell transplant (HCT) recipients are at risk for mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) secondary to bacterial translocation. There is sparse data comparing MBI-LCBI management practices, in particular central venous catheter (CVC) salvage versus removal. We created a 22-item poll of Infectious Disease specialists at major US cancer centers on management controversies. Response rate was 44% (31/70). CVC salvage was a common practice among 87.5%. This was followed by a single center retrospective study (2017–2019) comparing outcomes related to CVC practices. We identified 115 patients, 52% (60/115) admitted for chemotherapy and 33% (38/115) for allogeneic HCT. The majority of patients (78%, 90/115) had their CVC removed. There was no difference in 72 h defervescence, microbiological clearance, in-hospital mortality, and 90-day recurrent infection between CVC salvage versus removal. CVC salvage is a safe approach in certain clinical scenarios.

Central Venous Catheter Salvage in Ambulatory Central Line-Associated Bloodstream Infections.

Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.

Comparing success rates in central venous catheter salvage for catheter-related bloodstream infections in adult patients on home parenteral nutrition: a systematic review and meta-analysis

ABSTRACTBackgroundCatheter-related bloodstream infection (CRBSI) is a life-threatening complication of parenteral nutrition. Therefore, optimal management, ideally with catheter salvage, is required to maintain long-term venous access.ObjectivesWe aimed to evaluate successful catheter salvage rates in patients on home parenteral nutrition (HPN).MethodsStudies were retrieved from medical databases, conference proceedings, and article reference lists. Data were collected relating to clinical outcomes of 3 treatments: systemic antibiotics, antimicrobial lock therapy (ALT), and catheter exchange. ORs and 95% CIs were calculated from a mixed logistic effects model.ResultsFrom 10,036 identified publications, 28 met the inclusion criteria (22 cohort studies, 5 case-control studies, and 1 randomized clinical trial), resulting in a total of 4911 CRBSIs. To achieve successful catheter salvage, the addition of an antimicrobial lock solution was superior to systemic antibiotics alone (OR: 1.75; 95% CI: 1.21, 2.53; P = 0.003). Recurrence of infection was less common in studies that used ALT than in those that used systemic antibiotics alone (OR: 0.26; 95% CI: 0.11, 0.61; P = 0.002). The catheter exchange group was excluded from multilevel regression analysis because only 1 included study applied this treatment. Successful salvage rates were highest for coagulase-negative staphylococci, followed by Gram-negative rods and Staphylococcus aureus .ConclusionsThe addition of an antimicrobial lock solution seems beneficial for successful catheter salvage in HPN-dependent patients with a CRBSI. Future prospective randomized studies should identify the most effective and pathogen-specific strategy.This review was registered at www.crd.york.ac.uk/PROSPERO as CRD42018102959.

P-51: Successful Central Venous Catheter Salvage after Central Line Associated Blood Stream Infections(CLABSI) in Children on Long-term Home Parenteral Nutrition(PN)

P-51: Successful Central Venous Catheter Salvage after Central Line Associated Blood Stream Infections(CLABSI) in Children on Long-term Home Parenteral Nutrition(PN)

Predicting outcomes in central venous catheter salvage in pediatric central line-associated bloodstream infection.

Central line-associated bloodstream infections (CLABSIs) are a common, costly, and hazardous healthcare-associated infection in children. In children in whom continued access is critical, salvage of infected central venous catheters (CVCs) with antimicrobial lock therapy is an alternative to removal and replacement of the CVC. However, the success of CVC salvage is uncertain, and when it fails the catheter has to be removed and replaced. We describe a machine learning approach to predict individual outcomes in CVC salvage that can aid the clinician in the decision to attempt salvage. Over a 14-year period, 969 pediatric CLABSIs were identified in electronic health records. We used 164 potential predictors to derive 4 types of machine learning models to predict 2 failed salvage outcomes, infection recurrence and CVC removal, at 10 time points between 7 days and 1 year from infection onset. The area under the receiver-operating characteristic curve varied from 0.56 to 0.83, and key predictors varied over time. The infection recurrence model performed better than the CVC removal model did. Machine learning-based outcome prediction can inform clinical decision making for children. We developed and evaluated several models to predict clinically relevant outcomes in the context of CVC salvage in pediatric CLABSI and illustrate the variability of predictors over time.

Prevalence of central venous catheter salvage in newborn with staphylococcal bloodstream infection

to establish the prevalence of salvage of central venous catheters in newborns with bloodstream infection caused by coagulase-negative staphylococci. retrospective cross-sectional study with 136 newborns admitted to the Neonatal Intensive Care Unit between 2011 and 2017. The total of 143 infection events undergoing antibiotic therapy were evaluated. among the 143 infection events, 39 catheters in which antibiotic therapy was used were saved and in 69 cases, the device was removed. Positive central blood culture and single lumen catheter were factors associated with salvage failure. The probability of salvage decreased with infections diagnosed from 15 days of using the catheter. Negative blood culture raised the chance of salvage by fourfold. the use of antibiotic therapy in the treatment of infections resulted in a low prevalence of salvage of the central venous catheter. The probability of salvage was associated with variables of the device.

Central venous catheter salvage following a catheter related bloodstream infection in patients on home parenteral nutrition

Rationale: Catheter related bloodstream infection (CRBSI) is a serious complication of home parenteral nutrition (HPN). Central venous catheter (CVC) salvage with antibiotics is usually performed1 but recurrence rates are not described.

Central Venous Catheter Management in High-risk Children With Bloodstream Infections.

National guidelines recommend removal of central venous catheters (CVCs) for central line-associated bloodstream infections (CLABSIs) caused by Staphylococcus aureus, Pseudomonas aeruginosa, and fungi. Data regarding guideline compliance and rates of associated treatment failures in pediatric patients with attempted CVC salvage are limited. We performed a retrospective analysis of high-risk children (age ≤ 21 years) hospitalized from 1/2009 to 12/2015 with a long-term CVC and CLABSI due to S. aureus, Pseudomonas spp., and Candida spp. Enterococcus spp. was included given differing management recommendations between short and long-term CVCs. Compliance with national guideline recommendations, as well as treatment failures including infection relapse, recurrence, and death were evaluated in relation to CVC retention or removal. Multivariate logistic regression modeling was performed to account for confounders impacting treatment failure. Fifty-three children had 108 CLABSI episodes requiring 84 hospitalizations. CVCs were removed in 36 (33%) CLABSI episodes per guideline recommendations. Optimal antimicrobial management, including targeted agent and adequate duration was provided in 54 (50%) of 106 treated episodes; no significant difference in treatment failure rates were noted compared with episodes with suboptimal management. The treatment failure rate was significantly higher in patients with CVC retention compared those with CVC removal within 7 days of the first positive blood culture (31% vs. 6%, P = 0.003). Despite pathogen-specific guideline recommendations for CVC removal, compliance with national guidelines was poor. CVC salvage was attempted in the majority of CLABSI episodes in our cohort and resulted in a significantly higher treatment failure rate.

579. Machine-Learning Based Models for Prediction of Recurrence-free Catheter Retention After ALT Treatment of CLABSI in a Pediatric Population

BackgroundDeciding whether to attempt salvage of an infected central venous catheter (CVC) can be challenging. While line removal is the definitive treatment for central-line associated bloodstream infection (CLABSI), salvage may be attempted with systemic antibiotics and antibiotic lock therapy (ALT). Weighing risk and benefit of CVC salvage is limited by uncertainty in the future viability of salvaged CVCs. If a CVC is likely to require subsequent removal (e.g., due to recurrent infection) salvage may not be beneficial, whereas discarding a viable CVC is also not desirable. Here we describe a machine learning approach to predicting outcomes in CVC salvage.MethodsEpisodes of pediatric CLABSI cleared with ALT were identified by retrospective record review between January 1, 2008 and December 31, 2018 and were defined by a single positive central blood culture of a known pathogen or two matching cultures of a possible contaminant. Clearance was defined as 48-hours of negative cultures and relapse was defined as a matching positive blood culture after clearance. Predictive models [logistic regression (LR), random forest (RF), support vector machine (SVM) and an ensemble combining the three] were used to predict recurrence-free CVC retention (RFCR) at various time points using a training and test set approach.ResultsOverall, 712 instances CLABSI cleared with ALT were identified. Demographic and microbiological data are summarized in Tables 1 and 2. Few (8%) instances recurred in the first 28 days. 58% recurred at any time within the study period. Rates of RFCR were 75%, 43%, 22% and 10% at 28, 91, 182 and 365 days. Machine learning (ML) models varied in their ability to predict RFCR (Table 3). RF models performed best overall, although no model performed well at 91 days.ConclusionML models provide an opportunity to augment clinical decision making by learning patterns from data. In this case, estimating the likelihood of useful line retention in the future could help guide informed decisions on salvage vs. removal of infected CVCs. Limitations include the heterogeneity of clinical data and the use of an outcome capturing both clinical decision making (line removal) and infection recurrence. With further model development and prospective validation, practical machine learning models may prove useful to clinicians. Disclosures All authors: No reported disclosures.

Innovations in Quality Improvement of Intravascular Catheter-Related Bloodstream Infections

Significant reductions in catheter-related bloodstream infections (CRBSI) have occurred in the United States. Reductions in CRBSIs are attributed to the widespread implementation of the practice-based measures and innovations in the diagnosis, treatment, and prevention of CRBSI. Diagnosis of CRBSI historically required removal of the central venous catheter (CVC) for catheter tip culture. Removing the CVC for CRBSI diagnosis predisposes many patients to potential life-threatening complications. Advances in diagnostic techniques such as culturing catheter hubs, catheter entry site cultures, applying differential time to positivity, molecular diagnostics, biomarkers, and innovative approaches like biosensors on the CVC lumen may provide an alternative to CVC removal. Removal of the CVC is common for the treatment of CRBSI; however, antimicrobial lock therapy is increasingly used as a CVC salvage method. Implementation of newer technology such as antimicrobial coated catheters, chlorhexidine-impregnated dressings, and antiseptic port protectors are crucial for the prevention of CRBSIs. Increasing evidence also support newer sutureless CVC securement devices prevent CRBSIs. CRBSI remains a significant clinical problem despite advances made in the diagnosis, management, and prevention. Molecular techniques are increasingly being used for pathogen identification in CRBSI, but the optimal diagnostic test remains debatable. Increasing experience is being gained with antimicrobial lock therapy for CRBSI treatment with catheter salvage. Use and adherence to practice-based measures and technological innovations has significantly reduced CRBSIs. Continued efforts are required to develop a cost-effective and targeted approach for CRBSI prevention.

Management of Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infections (MBI-LCBIs) in Stem Cell Transplant Recipients: A National Survey of Cancer Centers Practices

Background Patients with hematologic malignancies receiving chemotherapy and those undergoing stem cell transplantation (SCT) are at risk for mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBIs). Our comprehensive cancer center, which performs over 300 SCTs per year, has historically removed central venous catheters (CVCs) for the majority of transient MBI- LCBI cases in SCT recipients. However, given the lack of evidence-based guidelines for removal or salvage, we created a national survey to gauge current clinical practice of MBI-LCBI and CVC management among U.S. cancer centers. Methods We created a 22-item online anonymous survey via Qualtrics software. The survey was performed in August and September of 2018 and open for a total of 30 days. The questionnaire consisted of three parts: respondents' characteristics, MBI-LCBI and CVC clinical practice questions, and two clinical vignettes. In parallel, a quality improvement project is ongoing to evaluate outcomes following catheter salvage versus removal in MBI-LCBI cases of SCT recipients. Results The survey was distributed to seventy Infectious Diseases consultants at cancer centers in the United States. The response rate was 44%. 70% of respondents had > 5 years of clinical experience. The majority (75%) responded that MBI-LCBI does not implicate the CVC as the source of bacteremia. 61% of respondents salvage CVCs in SCT patients unless contraindicated. In patients with salvaged CVCs, 37.5% of responders do not use adjunct lock therapy and 46% deem repeat end of therapy surveillance blood culture as unnecessary. 62.5% of responders do not routinely recommend other procedures such as venous duplex ultrasound and transthoracic echocardiogram for MBI-LCBI cases unless clinically indicated. Among 90% of respondents deemed fluoroquinolone step down oral therapy for susceptible Enterobacteriaceae MBI-LCBI as acceptable. Conclusion Management of MBI-LCBIs in hematologic malignancies and SCT patients is variable but CVC salvage is considered by a majority of survey respondents as a safe approach. Data comparing outcomes of catheter salvage strategies are lacking. Results of our ongoing quality improvement project will provide further guidance.

Catheter-related infections in patients with acute type II intestinal failure admitted to a national centre: Incidence and outcomes

The management of intestinal failure (IF) requires safe and sustained delivery of parenteral nutrition (PN). The long-term maintenance of central venous catheter (CVC) access is therefore vital, with meticulous catheter care and salvage of infected CVCs being of prime importance. CVC-related infection and loss of intravenous access are important causes of morbidity and mortality in IF. Avoidance, prompt recognition and appropriate management of CVC-related infections are crucial components of IF care. However, there are few, if any, data on the occurrence of CVC-related infections in patients with acute, type 2, IF managed on a dedicated IF unit and no data on the salvage outcomes of infected CVCs in this group of patients. This is a retrospective observational study conducted between January 2011 and July 2017. All patients with acute, type 2 IF newly admitted to a national U.K. IF unit (IFU) during these dates were included. All patients admitted to the unit with a CVC in place underwent immediate 'screening' paired central and peripheral blood cultures on arrival before the CVC was used for any infusate. A prospectively maintained database was used to record all confirmed catheter-related blood stream infections (BSI)/colonisations, demographic and clinical data. Diagnosis of catheter-related BSI/colonisation was based on quantitative and qualitative analysis of paired central and peripheral blood cultures. A standardized 10-14-day catheter salvage treatment protocol involving antibiotic and urokinase CVC locks and systemic antibiotic administration was used to salvage any infected or colonised CVCs, as appropriate. The CVC was not used for PN until successful salvage had been confirmed by negative blood cultures drawn 48h after antibiotic completion. The development of a subsequent catheter-related BSI was recorded for all patients, both during the remaining in-patient stay on the IFU and after discharge home on PN. Of the 509 patients with type 2 IF admitted to the IFU during the study period, 341 (54% female; mean age 54.6 (range 16-86 years)) had an indwelling CVC that had been placed in the referring hospital. Surgical complications and mesenteric ischaemia were the most common underlying disease aetiologies. Sixty-five of 341 (19.1%) patients had an infected/colonised CVC on the initial screening set of blood cultures. A successful CVC salvage rate of 91% was achieved in this cohort after antibiotic therapy. The subsequent in-patient catheter-related BSI rate for those admitted with a CVC (n=341) on the IFU was 0.042 per 1000 catheter days, over a total of 23,548 in-patient catheter days. Two hundred and seventy nine of 341 patients were discharged on home PN (HPN); with a subsequent catheter-related BSI rate on HPN of 0.22 per 1000 catheter days (mean duration of HPN=778 catheter days (range:)) over a follow-up period of 216,944 out-patient catheter days. There was no increased risk of HPN-related catheter-related BSI (p=0.09) or mortality (p=0.4) in those admitted with an infected CVC. This is the first study to report catheter-related BSI/colonisation rates and salvage outcomes in patients with type 2 IF newly admitted to a dedicated IF Unit. We report that nearly one-fifth of all patients were referred with evidence of a catheter related BSI/colonisation; despite this, successful catheter salvage is possible and, with stringent CVC care, an extremely low subsequent catheter related BSI rates can be achieved and maintained during in-patient stay on a dedicated IF Unit and after discharge on HPN. These data provide novel evidence to support ESPEN recommendations that patients with type 2 IF are managed on a dedicated IF Unit.

Assessing the impact of quality improvement measures on catheter related blood stream infections and catheter salvage: Experience from a national intestinal failure unit

Prevention of catheter related blood stream infections (CRBSI) and salvage of infected central venous catheters (CVC) are vital to maintaining long term venous access in patients needing home parenteral nutrition (HPN). It remains unclear as to whether patients are best trained for catheter care at home or in hospital or whether CRBSIs are lower if the patient self-cares for the CVC. Furthermore, there is minimal data on the longer term outcome following salvage of infected catheter and limited consensus on agreed protocols for catheter salvage. We conducted a retrospective 5-year evaluation of CRBSI occurrence and CVC salvage outcomes in adult patients requiring HPN managed at a national UK Intestinal Failure Unit from 2012 to 2016. Prior to 2012, patients were primarily trained to administer PN in hospital; thereafter, patients underwent training at home. A total of 134 CRBSI were recorded in 92 patients (62 patients with a single CRBSI and 30 patients with more than 1 CRBSI) in a cohort of 559 HPN patients, with a total of 1163 HPN years. The overall CRBSI rate was 0.31 per 1000 catheter days. CNS were the most common isolates (41/134 (30.5%)), followed by polymicrobial infections (14/134 (10.4%)), Klebsiella spp. (16/134 (11.9%)) and methicillin - sensitive Staphylococcus aureus (MSSA) 5/134 ((3.7%)). Salvage was not attempted in 34 cases due to methicillin - resistant (MRSA) infection (1/34), fungal infection (13/34) or clinical instability due to sepsis (20/34). Of the 100 cases where salvage was attempted, 67% were successful. 82.8% of CNS salvage attempts were successful; there was no difference in salvage rates between CNS CRBSIs salvaged with a 10-day (22/26) or 14-day protocol (7/9) (p=0.4). CRBSI rate, in those cared for by trained home care nurses was the lowest at 0.270 (self care: 0.342 and non-medical carer (e.g. family member): 0.320) (p=0.03). We previously reported a sustained very low CRBSI rate in a large cohort of HPN patients in a national unit; we now further report that this is not influenced by training patients at home rather than in hospital but is influenced by the individual managing the catheter at home. CNS remains the primary cause of CRBSIs and can be successfully salvaged with a reduced duration of antibiotic therapy compared to our previous experience.

Central venous catheter salvage in children with Staphylococcus aureus central line-associated bloodstream infection.

Prompt central venous catheter (CVC) removal is currently recommended in children with Staphylococcus aureus central line-associated bloodstream infection (CLABSI). Our objective was to examine the outcome of attempted line salvage in children with S. aureus CLABSI and assess predictors of success. A single-institution, retrospective cohort study was performed of all children with S. aureus CLABSI between 2012 and 2015. Patients with and without immediate CVC removal (≤ 2days after first positive culture) were compared. The primary outcome was failed CVC salvage (removal after 3+days). Seventy-seven children met criteria for S. aureus CLABSI. Immediate CVC removal was performed in 27.3% of patients. Among the 72.7% patients in whom CVC salvage was attempted, 78.6% were successful and 21.4% required delayed CVC removal. Malignancy, short gut syndrome, neutropenia, methicillin-resistant S. aureus, and line type were not associated with salvage failure. No associated morbidity or mortality occurred in patients with a failed salvage attempt. New or recurrent bacteremia occurred in five patients, but three were successfully salvaged a second time. CVC salvage was feasible in the majority of children with S. aureus CLABSI and was not associated with significant complications or attributable mortality as reported in adults.

Central Venous Catheter Salvage in Home Parenteral Nutrition Catheter-Related Bloodstream Infections: Long-Term Safety and Efficacy Data.

Catheter-related bloodstream infections (CRBSIs) are a serious complication in the provision of home parenteral nutrition (HPN). Antibiotic salvage of central venous catheters (CVCs) in CRBSI is recommended; however, this is based on limited reports. We assessed the efficacy of antibiotic salvage of CRBSIs in HPN patients. All confirmed CRBSIs occurring in patients receiving HPN in a national intestinal failure unit (IFU), between 1993 and 2011, were analyzed. A standardized protocol involving antibiotic and urokinase CVC locks and systemic antibiotics was used. In total, 588 patients were identified with a total of 2134 HPN years, and 297 CRBSIs occurred in 137 patients (65 single and 72 multiple CRBSIs). The overall rate of CRBSI in all patients was 0.38 per 1000 catheter days. Most (87.9%) infections were attributable to a single microorganism. In total, 72.5% (180/248) of CRBSIs were salvaged when attempted (coagulase-negative staphylococcus, 79.8% [103/129], Staphylococcus aureus, 56.7% [17/30]; polymicrobial infections, 67.7% [21/30]; and miscellaneous, 66.1% [39/59]). CVC salvage was not attempted in 49 episodes because of life-threatening sepsis (n = 18), fungal infection (n = 7), catheter problems (n = 20), and CVC tunnel infection (n = 4). Overall, the CVC was removed in 33.7% (100/297) of cases. There were 5 deaths in patients admitted to the IFU for management of the CRBSI (2 severe sepsis at presentation, 3 metastatic infection). This is the largest reported series of catheter salvage in CRBSIs and demonstrates successful catheter salvage in most cases when using a standardized protocol.