Urgent Initiation Research Articles

Urgent-start peritoneal dialysis versus haemodialysis for people with chronic kidney disease

Patients with chronic kidney disease (CKD) who require urgent initiation of dialysis but without having a permanent dialysis access have traditionally commenced haemodialysis (HD) using a central venous catheter (CVC). However, several studies have reported that urgent initiation of peritoneal dialysis (PD) is a viable alternative option for such patients. This review aimed to examine the benefits and harms of urgent-start PD compared to HD initiated using a CVC in adults and children with CKD requiring long-term kidney replacement therapy. We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 for randomised controlled trials through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 11 February 2020) and EMBASE (OVID) (1980 to 11 February 2020) were searched. All randomised controlled trials (RCTs), quasi-RCTs and non-RCTs comparing urgent-start PD to HD initiated using a CVC. Two authors extracted data and assessed the quality of studies independently. Additional information was obtained from the primary investigators. The estimates of effect were analysed using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI). The GRADE framework was used to make judgments regarding certainty of the evidence for each outcome. Overall, seven observational studies (991 participants) were included: three prospective cohort studies and four retrospective cohort studies. All the outcomes except one (bacteraemia) were graded as very low certainty of evidence given that all included studies were observational studies and few events resulting in imprecision, and inconsistent findings. Urgent-start PD may reduce the incidence of catheter-related bacteraemia compared with HD initiated with a CVC (2 studies, 301 participants: RR 0.13, 95% CI 0.04 to 0.41; I2 = 0%; low certainty evidence), which translated into 131 fewer bacteraemia episodes per 1000 (95% CI 89 to 145 fewer). Urgent-start PD has uncertain effects on peritonitis risk (2 studies, 301 participants: RR 1.78, 95% CI 0.23 to 13.62; I2 = 0%; very low certainty evidence), exit-site/tunnel infection (1 study, 419 participants: RR 3.99, 95% CI 1.2 to 12.05; very low certainty evidence), exit-site bleeding (1 study, 178 participants: RR 0.12, 95% CI 0.01 to 2.33; very low certainty evidence), catheter malfunction (2 studies; 597 participants: RR 0.26, 95% CI: 0.07 to 0.91; I2 = 66%; very low certainty evidence), catheter re-adjustment (2 studies, 225 participants: RR: 0.13; 95% CI 0.00 to 18.61; I2 = 92%; very low certainty evidence), technique survival (1 study, 123 participants: RR: 1.18, 95% CI 0.87 to 1.61; very low certainty evidence), or patient survival (5 studies, 820 participants; RR 0.68, 95% CI 0.44 to 1.07; I2 = 0%; very low certainty evidence) compared with HD initiated using a CVC. Two studies using different methods of measurements for hospitalisation reported that hospitalisation was similar although one study reported higher hospitalisation rates in HD initiated using a catheter compared with urgent-start PD. Compared with HD initiated using a CVC, urgent-start PD may reduce the risk of bacteraemia and had uncertain effects on other complications of dialysis and technique and patient survival. In summary, there are very few studies directly comparing the outcomes of urgent-start PD and HD initiated using a CVC for patients with CKD who need to commence dialysis urgently. This evidence gap needs to be addressed in future studies.

Is Tunneled Cuffed Catheter a Viable Link to AV Fistula? An Experience from a Tertiary Care Centre

Introduction: The Tunneled Cuffed Catheter (TCC) is used as a bridge access for haemodialysis. Non-availability of fluoroscopy for insertion of TCC results in unnecessary waiting times and inappropriate use of non-tunneled catheters. Recently, ultrasound guidance is being used widely in developed countries for TCC insertions for urgent haemodialysis initiation. Aim: The aim of the present study was to look at whether ultrasound guided TCC is a useful bridge to Arteriovenous Fistula (AVF) in haemodialysis patients and also to look at the incidence of catheter insertion complications, infective and bleeding complications and have data on catheter longevity. Materials and Methods: The present study was a prospective observational study. 106 TCC insertion procedures were performed between July 2017 and December 2018 in Nephrology interventional suite at St Johns MedicalCollege and Hospital, Bengaluru, Karnataka, India, using ultrasound guidance for accessing Internal Jugular Vein (IJV) by Nephrologist. Fluoroscopy was used in none. The success rate, insertion complications, infections and other catheter outcomes like bleeding, catheter blocks and catheter longevity of TCC inserted using ultrasound guidance alone were studied. Further, the patients were followed-up for a minimum period of nine months. Data was recorded in the predesigned Epi info version 7.0 proforma and analysed by SPSS software version 24. Results: There was 100% success rate for uncomplicated insertions of right IJV. No increase in major/minor bleeding complications was noted. Of the 106 insertions, only a single patient had a catheter kink. Mean blood flow was 230.3 ml/min. Cather Related Blood Stream Infecton (CRBSI) rate was 1.65 per 1000 catheter days. On follow-up, 59 of 72 patients underwent AVF creation, five underwent renal transplant and another five were converted to Continuous Ambulatory Peritoneal Dialysis (CAPD) and three patients with Acute Kidney Injury (AKI) requiring prolonged dialysis had renal recovery. Conclusion: TCCs for haemodialysis initiation can be safely placed by using ultrasound guidance. It can be used for longer period and is a useful bridge to AV fistula. There is 100% success rate for right-sided jugular TCC insertions using ultrasound alone. There are very less infective and bleeding complications with TCC usage.

Acute Tubulointerstitial Nephritis in a Patient on Anti-Programmed Death-Ligand 1 Triggered by COVID-19: A Case Report.

Rationale:Immune checkpoint inhibitors are monoclonal antibodies used in the treatment of various types of cancers. The downside of using such molecules is the potential risk of developing immune-related adverse events. Factors that trigger these autoimmune side effects are yet to be elucidated. Although any organ can potentially be affected, kidney involvement is usually rare. In this case report, we describe the first known instance of a patient being treated with an inhibitor of programmed death-ligand 1 (anti-PD-L1, a checkpoint inhibitor) who develops acute tubulointerstitial nephritis after contracting the severe acute respiratory syndrome coronavirus 2.Presenting concerns of the patient:A 62-year-old patient, on immunotherapy treatment for stage 4 squamous cell carcinoma, presents to the emergency department with symptoms of lower respiratory tract infection. Severe acute kidney injury is discovered with electrolyte imbalances requiring urgent dialysis initiation. Further testing reveals that the patient has contracted the severe acute respiratory syndrome coronavirus 2.Diagnosis:A kidney biopsy was performed and was compatible with acute tubulointerstitial nephritis.Interventions:The patient was treated with high dose corticosteroid therapy followed by progressive tapering.Outcomes:Rapid and sustained normalization of kidney function was achieved after completion of the steroid course.Novel findings:We hypothesize that the viral infection along with checkpoint inhibitor use has created a proinflammatory environment which led to a loss of self-tolerance to renal parenchyma. Viruses may play a more important role in the pathogenesis of autoimmunity in this patient population than was previously thought.

Investigating the missing heritability of fetal haemoglobin level in Africa.

Investigating the missing heritability of fetal haemoglobin level in Africa.

How To Build a Successful Urgent-Start Peritoneal Dialysis Program.

In-center hemodialysis (HD) remains the predominant dialysis therapy in patients with ESKD. Many patients with ESKD present in late stage, requiring urgent dialysis initiation, and the majority start HD with central venous catheters (CVCs), which are associated with poor outcomes and high cost of care. Peritoneal dialysis (PD) catheters can be safely placed in such patients with late-presenting ESKD, obviating the need for CVCs. PD can begin almost immediately in the recumbent position, using low fill volumes. Such PD initiations, commencing within 2 weeks of the catheter placement, are termed urgent-start PD (USPD). Most patients with an intact peritoneal cavity and stable home situation are eligible for USPD. Although there is a small risk of PD catheter-related mechanical complications, most can be managed conservatively. Moreover, overall outcomes of USPD are comparable to those with planned PD initiations, in contrast to the high rate of catheter-related infections and bacteremia associated with urgent-start HD. The ongoing coronavirus disease 2019 pandemic has further exposed the vulnerability of patients with ESKD getting in-center HD. PD can mitigate the risk of infection by reducing environmental exposure to the virus. Thus, USPD is a safe and cost-effective option for unplanned dialysis initiation in patients with late-presenting ESKD. To develop a successful USPD program, a strong infrastructure with clear pathways is essential. Coordination of care between nephrologists, surgeons or interventionalists, and hospital and PD center staff is imperative so that patient education, home visits, PD catheter placements, and urgent PD initiations are accomplished expeditiously. Implementation of urgent-start PD will help to increase PD use, reduce cost, and improve patient outcomes, and will be a step forward in fostering the goal set by the Advancing American Kidney Health initiative.

Impact on survival of urgent dialysis initiation in patients with end-stage renal disease: a case-control study.

Outcomes of patients with end-stage renal disease at urgent dialysis initiation are varied, but evidence of their long-term prognosis is limited. We aimed to characterize patients undergoing urgent dialysis initiation and analyse its effect on survival outcome. We retrospectively identified 208 patients who began haemodialysis from 1 January 2012 to 31 December 2018 at our hospital. In this observational case-control study, the case group comprised patients starting urgent dialysis, and the control group comprised patients starting planned dialysis. We analysed laboratory data, sex, age, smoking history, comorbidities and presence of vascular access and nephrology care that potentially affected the outcome. Data were analysed with Kaplan-Meier curves of early and late period (3years after dialysis initiation) survival and log-rank tests and with Cox regression analysis. Median age (range) at dialysis initiation was 73 (28-90) years, with 50 (24%) patients in the urgent initiation group. Five (10%) patients in this group had vascular access at dialysis initiation, whereas 21 (42%) had not received adequate pre-dialysis nephrology care. The estimated median overall survival rates of the urgent group and planned initiation group were 42months and not reached, respectively (P = 0.0011). Multivariable analysis found urgent dialysis initiation to be an independent risk factor for survival (HR 2.36; 95% CI 1.36-4.00; P = 0.02). Survival was not significantly different between the groups for patients who continued chronic dialysis for > 3years from dialysis initiation (P = 0.1339). The prognosis of patients starting dialysis in an urgent condition was poor compared with those who started planned dialysis.

De-escalation of empiric broad spectrum antibiotics in hematopoietic stem cell transplant recipients with febrile neutropenia

Febrile neutropenia (FN) is a common serious complication in patients undergoing hematopoietic stem cell transplantation (HSCT) requiring urgent evaluation and initiation of empiric broad spectrum antibiotics (BSA). The appropriate duration of BSA for FN in patients with negative cultures and no identifiable infection remains undefined. We retrospectively analyzed allogenic and autologous HSCT patients with FN and negative infectious work-up at our facility from 2012 to 2018. The early de-escalation group (EDG) included those who had BSA de-escalation to fluoroquinolone prophylaxis at least 24 h prior to absolute neutrophil count (ANC) recovery after the patient was fever-free for at least 48 h. Among 297 patients undergoing their first HSCT who experienced FN with negative infectious work-up, 83 patients were de-escalated early with the remaining 214 in the standard of care group (SCG) whose BSA were continued until ANC was > 500. Duration of broad-spectrum antibiotics was shorter in EDG compared to SCG (3.86 days vs. 4.62 days, p = 0.03). Rates of mortality, new infections, and clinical decompensation requiring intensive care unit transfer and/or pressor use within 30 days were all similar between the two groups (0% vs. 0.4% p = 1.00, 0% vs. 1.4% p = 0.56, 13.2% vs. 8.4% p = 0.27). This indicates that it is safe to de-escalate antibiotics prior to ANC recovery, leading to less BSA exposure.

Urgent-start peritoneal dialysis in chronic kidney disease patients: A systematic review and meta-analysis compared with planned peritoneal dialysis and with urgent-start hemodialysis

An increasing number of studies have focused on whether peritoneal dialysis (PD) can be used for the urgent initiation of dialysis in patients with chronic kidney disease (CKD). We performed this systematic review and meta-analysis to evaluate the feasibility and safety of urgent-start PD compared with those of planned PD and urgent-start hemodialysis (HD) in this population. PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), clinicaltrials.gov, and China National Knowledge Infrastructure (CNKI) were searched for relevant studies. Conference abstracts were also searched in relevant websites. The meta-analysis was performed using RevMan 5.3 software. A total of 15 trials involving 2426 participants were identified. The quality of the included studies was fair, but the quality of evidence was very low. Unadjusted meta-analysis showed that urgent-start PD had significantly higher mortality than planned PD, while adjusted meta-analysis did not show a significant difference. Higher incident of leakage and catheter mechanical dysfunction were observed in urgent-start PD. However, peritonitis, exit-site infection, or PD technique survival were comparable between urgent-start and planned PD. The all-cause mortality was comparable in urgent-start PD and urgent-start HD. Bacteremia was significantly lower in the urgent-start PD group than with urgent-start HD. Based on limited evidences, PD may be a viable alternative to HD for CKD patients requiring urgent-start dialysis. Because of the inconsistent results and the low quality of evidence, a definitive conclusion could not be drawn for whether urgent-start PD was comparable with planned PD. Therefore, high-quality and large-scale studies are needed in the future.

SAT-215 INCIDENCE AND RISK FACTORS OF NON TUNNELED HEMODIALYSIS CATHETER INFECTIONS: A FOLLOW UP STUDY IN TWO HEMODIALYSIS CENTERS IN CAMEROON

Non-tunneled central venous catheter (NTCVC) are useful for urgent initiation of acute and chronic dialysis. However they are associated with a high risk of infection limiting the duration of their use to less than 3 weeks for jugular and one week for femoral catheters. Nevertheless, in many sub-Saharan African countries, NTCVC are used for longer periods even for chronic dialysis due to limited access to tunneled catheters and vascular surgery for arteriovenous fistulas. We sought to identify risk factors for NTCVC infections in patients on hemodialysis We prospectively followed up for 6 weeks, all consenting incident and prevalent patients using NTCVC for hemodialysis through a NTCVC in the two public hemodialysis units in Yaounde. We excluded prevalent catheters with a history of infection. The study variables of interest were: the profile of physician inserting central venous catheter(CVC), respect of asepsis during CVC manipulation by health personnel, frequency of catheter repositioning during dialysis, patient hygiene of catheter exit site, and occurrence of non-catheter-related bacterial infection. The outcome of interest was the occurrence of CVC infection defined as a body temperature >37.5˚C or <36.˚C in the presence of a purulent discharge at the catheter exit site with or without a positive catheter/blood culture. The study was approved by the ethics board of the hospitals. We followed up a total of 131 NTCVC in 131(65.6% male) participants. Most catheters(n=129; 98.5%) were placed by nephrology fellows, and the remainder by nephrologists. Reasons for catheter insertion were: urgent start of chronic dialysis for ESKD (n=67; 51.1%), AKI (n=41; 31.3%), and failed AV fistula (n=23; 17.6%). In all, there were (n=97;74%) incident and (n=34;26%) prevalent catheters. The sites of catheter insertion were: right internal jugular, (n=77;58.8% ), right femoral, (n=52;39.7% ), and left femoral,(n= 21.5%). The median [IQR] follow-up duration of the NTCVC was 36.0 [11.0-42.0] days and was significantly longer for prevalent catheters (42.0 [16-42] versus 29[11-42]; p=0.02). The median [IQR] follow-up duration of was 12.5 [8.0-40.0] days for femoral, and 42 [21.0-42.0] for jugular catheters. The overall incidence of catheter infection was 6.9 cases per 1000 catheter days. The incidence was significantly higher for femoral compared to jugular catheters (11.5 versus 4.8 per 1000 catheter days; p=0.02), and non-significantly higher for incident compared to prevalent catheters (7.4 versus 5.4 cases per 1000 catheter days; p=0.48). Poor patient hygiene of exit site (RR=21.4, [5.7 – 80.3] p= 0.00) and occurrence of non-catheter related bacterial infection (RR=4.9, [1.1 – 20.9] p=0.03) were independent risk factors of non-tunneled catheter infection. Our results suggest a need for improved patient education on care of the catheter exit site area, and limiting the use of the femoral site. The catheter infection risk associated with the presence of non-catheter bacterial infections requires further studies. There is an urgent need to reduce the duration of use of these catheters through patient education and cost containment of tunneled catheters and fistula surgery.

Indications for early plasma transfusion and its optimal use following trauma.

This study aimed to evaluate the effect of plasma transfusion before urgent hemostasis initiation on in-hospital mortality in hemodynamically unstable patients with severe trauma. This retrospective observational study of patients admitted to hospital between January 2011 and January 2019 grouped patients according to whether plasma transfusion was initiated before (Before group) or after (After group) hemostasis initiation. Patients with severe trauma who were unable to wait for plasma transfusion and had started hemostasis before the plasma infusion were excluded. We used multivariable logistic regression analysis to determine the effect of plasma transfusion before the initiation of urgent hemostasis on in-hospital mortality. We included 47 and 73 patients in the Before and After groups, respectively. Blunt trauma was more common, and the D-dimer levels and Injury Severity Score were significantly higher in the Before group than in the After group (median D-dimer, 57.5 versus 38.1μg/mL; P=0.040; median Injury Severity Score, 50 versus 34; P<0.001). Plasma given before hemostasis initiation was associated with significantly lower in-hospital mortality (adjusted odds ratio, 0.27; 95% confidence interval, 0.078-0.900; P=0.033) in contrast with the total plasma volume given in the first 6 or 24h. Plasma transfusion before hemostasis initiation could be an important factor for improving outcomes in hemodynamically unstable patients with blunt trauma, high D-dimer levels, or a high Injury Severity Score.

Dialysis Catheter Insertion with Extended Ultrasound Monitoring

Introduction: Dialysis catheter insertion is a routine procedure performed when there is necessity of urgent renal replacement therapy initiation. Due to limited access, higher costs, and long waiting times for fluoroscopy, alternative visualization methods are introduced into clinical practice. One of the most promising is transthoracic echocardiographic monitoring of guide-wire introduction. Objective: The feasibility of the technique was verified by nephrologists inserting dialysis catheters. Methods: A single center prospective trial was performed (NCT03727581). Introduction of guide-wire was monitored with ultrasound to confirm correct position of the wire in the inferior vena cava (IVC) or right atrium (RA). The study group included 30 patients, 19 males and 11 females, 25–83 years old. Results: It was possible to obtain a good picture of IVC in the majority of patients. In 20 (66.7%) cases, IVC view was excellent; in 9 (30%) cases, was fair; and in 1 (3.3%) patient, we failed to visualize IVC. The guide-wire was identified in IVC in 12 (42.8%) patients, in another 9 (32.1%) patients guide-wire was visible in IVC after withdrawing and advancing it, and in RA in 6 (21.4%) patients. Catheters were successfully placed in 29 (96.7%) patients. Conclusions: Detection of the guide-wire confirms correct course of the procedure and increases the safety of catheter insertion without fluoroscopy.

54. Binocular sight loss: uncommon, yet a devastating complication of GCA

IntroductionGCA (giant cell arteritis) affects cranial branches of the arteries from aortic arch, especially the superficial temporal artery and vessels supplying the eye. Ophthalmic manifestations of GCA are characterised by the vasculitis of the ophthalmic artery and its branches. We present a case of a patient who developed the binocular sequential permanent vision loss secondary to GCA due to the delayed diagnosis.Case descriptionA seventy-six year-old lady with a background of type two diabetes mellitus, hypertension and dyslipidemia and hemicolectomy for appendix tumour two years ago (no recurrence) was admitted with blurring of vision in the eye. She did not complain about other symptoms, however, on direct questioning she admitted six weeks history of weight loss (2.5 stones), severe tiredness and occasional night sweats, mild left sided temporal headache. She was initiated on 60mg of prednisolone. One week prior to admission she had right eye CRAO diagnosed by the ophthalmology team with preceding three weeks history of right eye blurring of vision. CRP at that time was 12 g/L and GCA was not considered likely. Following her permanent right sided vision loss, she was referred to stroke team for further management and was given aspirin. Her CT and MRI brain scans were unremarkable, USS carotid arteries revealing diffuse intimal thickening in all the arteries of the neck. On assessment in the rheumatology fast track clinic she denied any associated jaw/tongue/arms claudication and no proceeding or historical PMR symptoms. She had mild left sided temporal artery tenderness and decreased temporal artery pulses bilaterally, no vision in the right eye along with the blurring in the left eye. There were no audible bruits in carotid, axillary, femoral arteries. Her acute phase maker (CRP) was mild but persistently elevated with a maximum level of 12 g/L for one week prior the admission. USS showed features consistent with GCA with extensive non-compressible halo signs in temporal arteries and its branches bilaterally. An urgent ophthalmology review revealed AION changes in the left eye, her vision deteriorated over the next forty-eight hours despite the initiation of high dose intravenous methylprednisolone. The patient was also started on tocilizumab infusion in an attempt to reverse the sight loss.DiscussionThe ophthalmic manifestations of GCA range from AION (anterior ischaemic optic neuropathy), CRAO (anterior central retinal artery occlusion), cilioretinal artery occlusion to occipital lobe infarcts, transient monocular vision loss, photopsias or diplopia. Ophthalmic GCA is an emergency and requires urgent ophthalmological evaluations and initiation of treatment with high dose of steroids to avoid permanent loss of vision. The reported incidence of visual symptoms in GCA ranges widely from 12% to 70% of cases. GCA is often associated with constitutional symptoms such as weight loss, night sweats, fevers, systemic inflammatory response with elevated inflammatory markers. However, it had been reported that this can be very mild in ischaemic GCA.The diagnosis of GCA in this particular case was delayed for approximately six weeks due to the atypical initial presentation with mainly constitutional symptoms and unilateral vision blurring as well as mildly elevated inflammatory markers. A collaboration of three teams (namely ophthalmology, stroke and rheumatology) proved necessary to initiate high dose steroid treatment and tocilizumab. However, patient still suffered from permanent binocular vision loss. She was registered blind and will in future require extensive physical and psychological support.Key learning pointsDespite the recent advances and increased awareness with good availability of fast track GCA services, cases of bilateral blindness are still observed. This is due to a lack of awareness of atypical non-cranial symptoms that frequently accompany a GCA ischaemic presentation. Inflammatory markers are often only mildly elevated in such cases. We suggest a heightened public and professional awareness program to mitigate this irreversible disastrous complication.Conflicts of interestThe authors have declared no conflicts of interest.

The dynamic effect of direct-acting antiviral treatments on the risk of hepatocellular carcinoma in patients with cirrhosis and chronic hepatitis C.

There is still some controversy over a potentially increased short-term risk of developing hepatocellular carcinoma (HCC) after the initiation of direct-acting antiviral (DAA) therapy, even though a decreased long-term risk of HCC has been reported following a sustained virological response in patients with chronic hepatitis C virus (HCV) infection. We characterized the time-varying effect of DAAs on the risk of the occurrence of HCC in patients with cirrhosis and HCV infection. We analysed patients with cirrhosis and chronic HCV infection from the ANRS CO22 HEPATHER cohort study. We excluded patients with active HBV coinfection, liver transplantation or a past history of HCC. We used a flexible weighted effect cumulative exposure Cox model to characterize the time-varying effect of DAAs on the risk of HCC. A total of 3595 patients, mean age 59.3years old, 65% men, were eligible for the study. Median follow-up was 36.8months (IQR 24.6-47.1). DAAs were started during follow-up in 3292 patients. Three hundred and fifty-six HCCs were reported (275 treated, 81 untreated). Overall, a constant decrease in the risk of occurrence of HCC (vs untreated) was found from the start of treatment. Results were similar in patients without a history of decompensated cirrhosis (DC). Analysis of patients with a past history of DC showed a nonsignificant increase in the occurrence of HCC over the first 6months, while the HR was significantly decreased at 14months. These findings support the urgent initiation of DAAs in all patients.

Impact of Shifts to Birth Testing on Early Infant Diagnosis Program Outcomes in KwaZulu-Natal, South Africa.

South African early infant diagnosis guidelines shifted to recommending an initial HIV nucleic acid-based test (NAT) test at birth in 2015. Prior to this, initial NAT was recommended at 6 weeks of age. Here we examine parameters of early infant diagnosis performance in KwaZulu-Natal before and after this change. Data on all HIV diagnostic NAT conducted for the province between January 2013 and April 2016 were assembled and analyzed. Laboratory barcodes allowed identification of repeat tests on the same child. We evaluated coverage, positivity rates, age at testing and frequency of repeat tests across birth cohorts. In birth cohorts 2013 and 2014, 62.1% and 61.8%, respectively, of tests <16 weeks were done in children who were 6-8 weeks of age. In birth cohort 2015, 41.3% of tests <16 weeks were done earlier at <2 weeks of age. The percentage of children with a positive result who had at least 1 follow-up test increased from 11.5% and 13.1% in birth cohorts 2013 and 2014, respectively, to 24.8% in 2015. The percentage of infants with an initial nonpositive result who received at least 1 follow-up test did not appreciably change from 15.0% and 14.4% in 2013 and 2014, respectively, to 14.7% in 2015. Birth testing allows for earlier identification of HIV-infected infants who need urgent antiretroviral treatment initiation. Although follow-up testing rates may be underestimated in this data source, repeat testing rates remained low. More effort is needed to ensure infants tested at birth continue to be engaged in care and undergo follow-up testing.

Cumulative antimicrobial susceptibility data for a tertiary-level paediatric oncology unit in Johannesburg, South Africa

Background: There is global concern regarding the spread of antimicrobial resistance in bacteria and fungi. Oncology patients are at particular risk of infections with multidrug resistant organisms. These patients require urgent initiation of empiric antimicrobial therapy when presenting with neutropenic fever. Currently, piperacillin-tazobactam and amikacin with or without vancomycin is the treatment of choice in the unit.Aim: The purpose of this study was to develop a cumulative antibiogram for the paediatric oncology unit at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) to guide empiric treatment recommendations for patients presenting with suspected bacterial or fungal infection.Setting: Tertiary-level paediatric oncology unit.Methods: A retrospective observational analysis was performed of bacterial and fungal antimicrobial susceptibility data extracted from the microbiology laboratory information system for clinical specimens submitted from the paediatric oncology unit at CMJAH. Data was analysed for the period January 2015 to May 2018. In addition, analysis and comparison of two 17-month time periods was performed in order to elicit any changes over time.Results: Klebsiella pneumoniae and Escherichia coli were the most common gram-negative organisms isolated. Twenty-one percent of Enterobacteriaceae showed resistance to third generation cephalosporins and 9% to carbapenems. Rates of carbapenem-resistant isolates decreased significantly over time. Adding amikacin to piperacillin-tazobactam significantly increased bacterial coverage. Coagulase-negative staphylococci and Candida parapsilosis were the most common gram-positive and fungal isolates recovered during the study.Conclusion: The results support the continued use of piperacillin-tazobactam and amikacin for paediatric oncology patients presenting with neutropenic fever in this unit. Antibiograms are an important component of antimicrobial stewardship in conjunction with efficient infection prevention and control measures.

Contemporary use of inpatient antineoplastic (IP) treatment (Rx): Who is getting care and why?

e18015 Background: The steady trend towards outpatient antineoplastic medication delivery has been spurred by improvements in supportive care, innovations in drug delivery, and financial considerations. Despite these trends, a significant number of patients (pts) continue to receive IP Rx for both hematological (HM) and solid cancers (ST). The purpose of this study is to describe a single center’s experience with IP Rx between 01/01/2015 and 12/31/2017. Methods: All pts ( &gt; 18yo) who received IP Rx for a cancer diagnosis, exclusive of stem cell transplantation, were identified from hospital pharmacy records. Patient and disease characteristics were collected at the index (initial) admission. All pts were followed for 1 year after index admission for 30-day readmission and subsequent admissions for IP Rx. Reasons for IP Rx included: urgent/emergent initiation of Rx; high acuity inpatient management for ST (e.g., intraperitoneal, intra-arterial, intravesical therapy) or complex HM regimen; ongoing Rx; palliation. Results: A total of 266 index admissions were identified with 66.2% of pts having a HM (n = 176) and 33.8% having a ST (n = 90). IP Rx was classified as urgent for 48.1% of pts (n = 128); 70.3% (n = 90) of these admissions were new diagnoses of which 91.4% (n = 86) were HM. High acuity IP management was required for 37.5% of pts (n = 100) (47% for ST (n = 47) and 53% for HM (n = 53)). The remaining index admissions were classified as ongoing Rx for 4.5% of pts (n = 12) and palliation for 9.8% (n = 26). Pts with ST required intensive care significantly more often than pts with HM (57.8% vs. 15.9%, p &lt; 0.001) but with no difference in inpatient mortality (4.4% vs. 5.7%, p = 0.891). The 30-day readmission rate was 32.2% for ST and 25.6% for HM (p = 0.515). After the index admission, 10% of ST pts and 60.2% of HM pts had at least 1 subsequent admission for IP Rx (p &lt; 0.001). Conclusions: In this 3-year retrospective review, the vast majority of pts receiving IP Rx required either urgent initiation of care or high acuity care, currently only available in the inpatient setting. While there is little evidence of routine IP Rx or opportunity, at present, to transition further care to the outpatient setting, the high rates of 30-day readmission warrant further evaluation.

Metformin Toxicity in Acute Kidney Injury. A Rare Cause of Severe Lactic Acidosis

Metformin a biguanide derivative is the preferred initial pharmacologic agent for the treatment of type 2 diabetes mellitus per current guidelines of the American Diabetes Association. It is prescribed to an estimated 120 million people worldwide. Type B lactic acidosis is a reported but rare side effect of Metformin use. Serum Metformin level is not routinely monitored or available in most hospitals, but it can be a useful test to confirm the diagnosis and guide future use of Metformin in at risk patients. We present a case of a 78-year old African American diabetic female on prescribed dose of Metformin with no history of kidney disease who presented with acute encephalopathy and hemodynamic instability. Her laboratory data showed acute kidney injury (AKI) with severe lactic acidosis (LA). She required large amount of intravenous bicarbonate infusions and urgent initiation of Continuous Veno-Venous Hemodialysis (CVVHD) due to severe refractory metabolic acidosis. Her serum Metformin level sent 12 hours after initiation of CVVHD was still critically elevated at 19 mcg/ml. Her acidosis and AKI started to resolve after 48 hours of CVVHD with resolution of encephalopathy as well. Her renal function returned to baseline and she was eventually discharged home, but Metformin was not resumed back.

2195. Effectiveness of a Dual-Test Strategy and Software Modifications for Mitigating and Preventing Hepatitis B Virus (HBV) Exposures in a Dialysis Unit

BackgroundYearly, the number of U.S. patients needing dialysis increases by 5%. Unlike patients infected with Hepatitis C or HIV who require only standard precautions during dialysis, patients with HBV infection must be segregated. Given the prevalence of HBV, first time dialysis patients could be infected with HBV and inadvertently dialyzed in a nonsegregated setting, especially if dialysis is urgent. Following such an event, we sought to minimize subsequent exposure risk to roommates of the exposed patients if/when they seroconverted before their serology and HBV-DNA results were available. The high volume of patients needing dialysis, and limited resources, made segregating all exposed for 6 months logistically impossible. We also optimized a widely used electronic medical software program to prevent future incidents.MethodsAn exposure was defined as any non-immune patient concurrently dialyzed in the same room with the index case (horizontal; n = 4) or dialyzed on the same machine that was cleaned (but not bleached and heat treated) immediately after the index patient (vertical; n = 1). All received HBV vaccine and immunoglobulin, and all of the dialysis machines were sequestered, bleached, and heat treated after each dialysis. All patients were monitored for seroconversion (SCV) with weekly HBSAg and DNA. The dialysis position of the vertical exposure was moved to last of the day. Root causes of a patient’s serologic status escaping verification included: (1) having only a single manual verification step; (2) gaps in a popular medical software (Epic Verona, WI); (3) urgent initiation of the first dialysis session; and (4) automatic importing of lab results. A highly visible “HBV” column on the dialysis census and a”hard stop’ in electronic ordering were added.ResultsAt 1-year follow-up, there were no questions of false-positives, no HBV DNA detections, SCVs, or further incidents.ConclusionWe used both DNA and HBSAg for monitoring the exposed, because using only DNA would have risked missing an inter-dialysis SCV due to its 4-day turnaround time. Although HBSAg can be falsely positive from vaccination, results were available in ≤ 24 hours. As there are no specific recommendations for optimum SCV monitoring and mitigating this type of event, others may find our approach useful.Disclosures All authors: No reported disclosures.

Falsely positive anti-glomerular basement membrane antibodies in a patient with hantavirus induced acute kidney injury - a case report

BackgroundHantavirus infection is an uncommon cause of acute renal failure with massive proteinuria. Serology tests to support a presumptive diagnosis usually take a few days. During the initial work-up, autoimmune causes including anti-glomerular basement membrane (GBM) glomerulonephritis need to be excluded, because these require urgent therapy. In this case the delay in serological testing caused a dilemma in treatment initiation.Case presentationAn 18-year-old patient was admitted to the hospital with acute renal failure, erythrocyturia and massive proteinuria. Routine blood analysis showed leucocytosis (40,5 × 109/l) and a serum creatinine of 233 μmol/l. Infectious causes, e.g. leptospirosis or hantavirus infection, or an autoimmune disease, e.g., AAV or anti-GBM glomerulonephritis was the most feasible underlying diagnosis.Before hantavirus serology results were known, anti-GBM antibodies were positive. Treatment for anti-GBM glomerulonephritis was withheld, because of the absence of other signs and symptoms of the disease and slight improvement of renal function.The diagnosis of acute hantavirus infection was later on confirmed, by seroconversion of a follow-up serum sample. Without further intervention renal function recovered and anti-GBM antibodies disappeared.ConclusionHantavirus infection may induce anti-GBM antibodies, falsely suggestive of anti-GBM glomerulonephritis.Anti-GBM antibodies are supposed to be 100% specific. No earlier reports of false positive anti-GBM titers were reported. Nevertheless, the anti-GBM antibodies in this case were seen as an innocent bystander effect.Considering the need of urgent initiation of plasmapheresis and administration of immunosuppressants it may lead to diagnostic dilemmas with crucial therapeutic consequences. Knowledge of this anomaly when diagnosing acute renal failure, is very important.

Identifying Hesitation and Discomfort with Diagnosing Sepsis: Survey of a Pediatric Tertiary Care Center.

Pediatric sepsis remains a significant cause of morbidity and mortality despite the development of strategies proven to improve diagnosis and treatment. Specifically, early recognition and urgent therapy initiation are consistently associated with improved outcomes. However, providers bring these principles inconsistently to the bedside. The objective of this study was to describe practitioner knowledge of, and attitudes toward, sepsis as a means of identifying potentially modifiable factors delaying life-saving treatment. We hypothesized there would be difficulties with sepsis recognition and self-reported discomfort with making the diagnosis among all provider groups in a pediatric tertiary care center. Emergency department and inpatient pediatric physicians, nurses, and respiratory therapists in a single, freestanding children's hospital received an electronic survey. Likert scales permitted anonymous self-reporting of comfort and diagnostic delays. Seven clinical vignettes assessed diagnostic knowledge. Independent sample t tests and Chi-square compared responses. Three hundred two staff participated (73% response rate), 41% of whom had at least 10 years of clinical experience. One in 5 was uncomfortable alerting coworkers to a patient with suspected sepsis or septic shock, and almost half were uncomfortable doing so in cases of compensated shock. Every role self-reported diagnostic delays, including faculty physicians. On average, physicians answered a greater percentage of vignette questions correctly (66%), compared with nurses (58%; P = 0.013) and respiratory therapists (52%; P = 0.005). Sepsis knowledge deficits, provider discomfort, and diagnostic delays are prevalent within a tertiary care children's hospital. Their presence and scale suggest areas for future research and targeted intervention.