Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America

Microorganism colonization of peripheral venous catheters in a small animal clinical setting

OBJECTIVE

To compare the incidence of microorganism colonization of peripheral venous catheters (PVCs) placed in the Emergency Department (ED) to those placed in a routine preoperative setting. The relationship between catheter tip colonization and patient urgency (as assessed by triage priority) was also evaluated.

DESIGN

Prospective, observational study from January 2021 to October 2021.

SETTING

Emergency room and clinical areas of a large, urban, tertiary referral center.

ANIMALS

Three hundred dogs and 94 cats with a PVC in place for a minimum of 24 hours were enrolled in the study.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Two hundred and eighty-eight PVCs were placed in the ED and 106 were placed preoperatively. The overall colonization rate was 10.4% (41/394). Sixteen bacterial and 1 fungal genera were cultured. Eight of these bacterial genera (25/51 [49%] bacterial isolates) were resistant to at least 1 antimicrobial class. Twenty-nine of 288 (10.1%) catheters positive for colonization were placed in the ED, whereas 12 of 106 (11.3%) were placed preoperatively. There was no association between microorganism growth on catheters and clinical area of catheter placement. There was also no association between ED patient urgency and positive catheter tip culture. No significant risk factors were identified predisposing to colonization of PVCs.

CONCLUSIONS

The overall incidence of microorganism colonization of PVCs in this study population was equivalent to, or lower than, previously reported in veterinary literature. There was no statistical difference between the catheters placed in the ED and those placed for routine surgical procedures. Patient urgency did not affect the incidence of positivity of peripheral catheter tip cultures.

Etiology and Factors Affecting Severe Complications and Mortality of Febrile Neutropenia in Children with Acute Leukemia

Objective

Febrile neutropenia (FN) is an important complication that causes high rates of morbidity and mortality in patients with malignancies. We aimed to investigate the etiology, epidemiological distribution and its change over the years, clinical courses, and outcomes of FN in children with acute leukemia.

Materials and Methods

We retrospectively analyzed the demographic data, clinical characteristics, laboratory results, severe complications, and mortality rates of pediatric patients with FN between January 2010 and December 2020.

Results

In 153 patients, a total of 450 FN episodes (FNEs) occurred. Eighty-four (54.9%) of these patients were male, the median age of the patients was 6.5 (range: 3-12.2) years, and 127 patients (83%) were diagnosed with acute lymphoblastic leukemia. Fever with a focus was found in approximately half of the patients, and an etiology was identified for 38.7% of the patients. The most common fever focus was bloodstream infection (n=74, 16.5%). Etiologically, a bacterial infection was identified in 22.7% (n=102), a viral infection in 13.3% (n=60), and a fungal infection in 5.8% (n=26) of the episodes. Twenty-six (23.2%) of a total of 112 bacteria were multidrug resistant (MDR) The rate of severe complications was 7.8% (n=35) and the mortality rate was 2% (n=9). In logistic regression analysis, refractory/relapsed malignancies and high C-reactive protein (CRP) at first admission were found to be the most important independent risk factors for mortality. Prolonged neutropenia after chemotherapy, diagnosis of acute myeloid leukemia, identification of fever focus or etiological agents, invasive fungal infections, polymicrobial infections, and need for intravenous immunoglobulin treatment increased the frequency of severe complications.

Conclusion

We found that there was no significant change in the epidemiological distribution or frequency of resistant bacteria in our center in the last 10 years compared to previous years. Prolonged duration of fever, relapsed/refractory malignancies, presence of fever focus, and high CRP level were significant risk factors for poor clinical course and outcome.

Predictive performance of automated surveillance algorithms for intravascular catheter bloodstream infections: a systematic review and meta-analysis

BACKGROUND

Intravascular catheter infections are associated with adverse clinical outcomes. However, a significant proportion of these infections are preventable. Evaluations of the performance of automated surveillance systems for adequate monitoring of central-line associated bloodstream infection (CLABSI) or catheter-related bloodstream infection (CRBSI) are limited.

OBJECTIVES

We evaluated the predictive performance of automated algorithms for CLABSI/CRBSI detection, and investigated which parameters included in automated algorithms provide the greatest accuracy for CLABSI/CRBSI detection.

METHODS

We performed a meta-analysis based on a systematic search of published studies in PubMed and EMBASE from 1 January 2000 to 31 December 2021. We included studies that evaluated predictive performance of automated surveillance algorithms for CLABSI/CRBSI detection and used manually collected surveillance data as reference. We estimated the pooled sensitivity and specificity of algorithms for accuracy and performed a univariable meta-regression of the different parameters used across algorithms.

RESULTS

The search identified five full text studies and 32 different algorithms or study populations were included in the meta-analysis. All studies analysed central venous catheters and identified CLABSI or CRBSI as an outcome. Pooled sensitivity and specificity of automated surveillance algorithm were 0.88 [95%CI 0.84-0.91] and 0.86 [95%CI 0.79-0.92] with significant heterogeneity (I2 = 91.9, p < 0.001 and I2 = 99.2, p < 0.001, respectively). In meta-regression, algorithms that include results of microbiological cultures from specific specimens (respiratory, urine and wound) to exclude non-CRBSI had higher specificity estimates (0.92, 95%CI 0.88-0.96) than algorithms that include results of microbiological cultures from any other body sites (0.88, 95% CI 0.81-0.95). The addition of clinical signs as a predictor did not improve performance of these algorithms with similar specificity estimates (0.92, 95%CI 0.88-0.96).

CONCLUSIONS

Performance of automated algorithms for detection of intravascular catheter infections in comparison to manual surveillance seems encouraging. The development of automated algorithms should consider the inclusion of results of microbiological cultures from specific specimens to exclude non-CRBSI, while the inclusion of clinical data may not have an added-value. Trail Registration Prospectively registered with International prospective register of systematic reviews (PROSPERO ID CRD42022299641; January 21, 2022). https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022299641.

Utility of Differential Time to Positivity in Diagnosing Central Line-Associated Bloodstream Infections: A Systematic Review and Meta-Analysis

BACKGROUND

Differential time to positivity (DTP), defined as pathogen growth at least 2 hours earlier from catheter versus paired peripheral blood cultures, is sometimes used to diagnose central line-associated bloodstream infections (CLABSIs). Previous studies assessing DTP, however, have been small, provided conflicting results, and did not assess heterogeneity across important subgroups.

METHODS

We systematically reviewed the diagnostic characteristics of DTP for CLABSI using MEDLINE, Embase, WoS, CINAHL, LILACS, AMED, and the Cochrane database. Studies were included if they reported sensitivities, specificities, predictive values, likelihood ratios, or 2 × 2 tables of DTP for diagnosing CLABSI. Extracted data were analyzed by using forest plots, bivariate model meta-analysis, and QUADAS-2 quality assessment.

RESULTS

We identified 274 records, of which 23 met the criteria for meta-analysis. Among 2526 suspected CLABSIs, DTP demonstrated a summary sensitivity of 81.3% (95% confidence interval [CI]: 72.8%-87.7%), specificity of 91.8% (95% CI: 84.5%-95.8%), positive likelihood ratio of 9.89 (95% CI: 5.14-19.00), and negative likelihood ratio of 0.20 (95% CI: .14-.30). Covariate analysis based on catheter duration, study design, and patient immune status demonstrated no significant differences. However, DTP performed worse for Staphylococcus aureus (low sensitivity but high specificity) and Candida (high sensitivity but low specificity) compared to other organisms.

CONCLUSIONS

DTP performs well in ruling CLABSIs in or out. Obtaining paired catheter and peripheral blood cultures for DTP when the infectious source is unclear may prevent unnecessary line removal and diagnostic tests. However, this must be balanced against higher contamination rates from catheter cultures.

Predictive factors of infection in patients with chronic kidney disease using hemodialysis catheters

Background

Infection is the most frequent complication of central venous catheters used for hemodialysis.

Objectives

The purpose of this study was to the determine the central venous catheter-related infection rate at a dialysis center in the Brazilian state of Amazonas and to identify risk factors and the microbiological profile of the infections.

Methods

This was an observational study with prospective data collection over a 12-month period by chart analysis and face-to-face interviews with patients undergoing hemodialysis using central venous catheters at a dialysis center.

Results

96 central venous catheters were analyzed in 48 patients. 78 of these were non-tunneled central venous catheters (81.3%) and 18 were tunneled central venous catheters (18.7%), 53.1% of the catheters were exchanged because of infection and blood cultures were obtained from 35.2% of the patients who had catheter-related infections. Gram-negative bacteria were isolated from five of the nine blood cultures in which there was bacterial growth and Gram-positive bacteria were isolated from the other four. The most commonly isolated bacteria was Staphylococcus hominis, found in 22.2% of positive blood cultures.

Conclusion

The overall hemodialysis venous catheter infection rate was 10.1 episodes/1000 catheter days, 15.1 episodes/1000 catheters days in non-tunneled catheters and 3.3 episodes/1000 catheters days in tunneled catheters. The infection predisposing factors identified were use of non-tunneled catheters and having 2 hemodialysis sessions per week. Regarding the microbiological profile, over half of the bacteria isolated were Gram-negative.

Clinical characteristics of bloodstream infections in adult patients with solid tumours and a nomogram for mortality prediction: a 5-year case-controlled retrospective study in a tertiary-level hospital

Background

Bloodstream infections (BSIs) are one of the leading causes of death in cancer patients. Nevertheless, the risk factors of BSIs in solid tumors have rarely been ascertained adequately.

Methods

We conducted a single-center case-controlled retrospective study from 2017 to 2021 among adults with solid tumors in a tertiary-level hospital. The BSIs and control group were matched by the propensity score matching method. We found independent risk factors of occurrence and death of BSIs using univariate and multivariate regression analysis. Additionally, a nomogram was constructed to predict the risk of mortality in BSIs.

Results

Of 602 patients with solid tumors in the study period, 186 had BSIs and 416 had non-BSIs. The incidence of BSIs was 2.0/1,000 admissions (206/102,704), and the 30-day mortality rate was 18.8% (35/186). Compared to the control group, the BSIs had longer hospital stays (24.5 days vs. 20.0 days), and higher frequency complicating with organ failure (10.5% vs. 2.4%), nephropathy (19.6% vs. 3.8%), comorbidities≥3 (35.5% vs. 20.0%), and liver-biliary-pancreatic infections (15.6% vs. 5.3%) (all P<0.001). Among the 186 patients with BSIs, 35 died within 30 days after BSIs. Gram-negative bacteria were the most frequent microorganisms (124/192, 64.6%). Liver cancer, organ failure, a high level of lactate dehydrogenase and septic shock were the independent hazardous factors for death of BSIs. What's more, a nomogram was constructed to predict the 30-day survival rate of BSIs, which was proved to have good accuracy (AUC: 0.854; 95% confidence interval: 0.785~0923) and consistency.

Conclusion

Being aware of the risk factors of BSIs redounds to take preventive measures to reduce the incidence and death of BSIs.

Comparison of Clinical Performance Between Two Types of Symmetric-Tip Hemodialysis Catheters: A Single-Centre, Randomized Trial

PURPOSE

To compare the clinical performance of a newly designed, symmetric-tip Arrow-Clark™ VectorFlow® tunnelled haemodialysis catheter, with a Glidepath™, symmetric-tip tunnelled haemodialysis catheter.

MATERIAL AND METHODS

From November 2018 to October 2020, patients with End-Stage Renal Disease requiring a de novo tunnelled catheter for hemodialysis, were randomized to Vectorflow® (n = 50) or to Glidepath™ catheter (n = 48). The primary outcome was catheter patency at one year following catheter insertion. Catheter failure was defined as the removal of the catheter due to infectious complications, or low blood flow rate by intraluminal thrombosis or fibrin sheath occlusion. Secondary outcomes were blood flow rate, fractional urea clearance and urea reduction ratio during dialysis.

RESULTS

Demographic characteristics were not different between the two groups. At three months and on the one-year endpoint the patency rates with the Vectorflow® catheter were 95.83% and 83.33% respectively, compared to 93.02% at both endpoints with the Glidepath™ catheter (P = 0.27). Catheter failure to infectious complications or low blood flow rate was similar in both groups. Catheter blood flow rate reached the threshold of 300 ml/min at all time points for both catheters. All patients had a high mean fractional urea clearance (1.6-1.7).

CONCLUSIONS

The catheter patency rate was not significantly different in patients with a VectorFlow® or a Glidepath™ catheter. Both catheters presented satisfactory dialysis adequacy over one year.

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

BACKGROUND & AIMS

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.

METHOD

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.

RESULTS

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.

CONCLUSION

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.

CLINICAL TRIAL REGISTRATION

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 ».

The potential role of through the needle PIVC insertion in reducing early catheter contamination

HIGHLIGHTS

Over-the-needle (OTN) PIVC devices are at inherent risk of insertion related skin contamination. Through-the-needle (TTN) catheter deployment resulted in no measurable contamination in this study. OTN catheters were 1.67 times more likely to be contaminated than TTN in this study.

AIM

To compare a traditional over-the-needle peripheral intravenous catheter device to a through-the-needle (TTN) peripheral intravenous catheter device for early bacterial contamination during insertion.

METHODS

Five TTN test devices (OspreyIV 20 g SkyDance Vascular, Inc) and 5 OTN comparative devices (Insyte Autoguard 20 g Becton Dickinson) were aseptically inserted through targeted zones inoculated with 1 mL aliquot suspension of approximately 1 × 10 CFU of Staphylococcus aureus among 3 healthy sheep. Immediately after insertion, each study catheter was surgically removed from the surrounding tissue and cultured for the presence of Staphylococcus aureus inoculum that may have been transferred to the catheter during insertion.

RESULTS

Final culture results of the 5 test articles found no bacterial colonies. Final culture results of the 5 comparative articles revealed 2 of 5 were contaminated with bacterial colonies. The absolute risk reduction is 40%, or a 40% rate of contamination drops to a 0% rate of contamination when the TTN catheter deployment was used. The risk ratio achieved was 1.67, indicating catheters placed using the OTN deployment were 1.67 times more like to be contaminated than the TTN deployed catheters.

CONCLUSION

In this present ovine study, the data revealed that use of a novel TTN approach resulted in less contamination than the more traditional OTN approach. Traditional OTN devices, developed over 70 years ago, are at inherent risk of insertion-related contact contamination. The results of this research, as well as previously published studies, point toward considering physical catheter protection strategies such as TTN devices as a potential alternative to OTN devices.

Multidrug-Resistant Pathogens in Burn Wound, Prevention, Diagnosis, and Therapeutic Approaches (Conventional Antimicrobials and Nanoparticles)

Multidrug-resistant pathogens are one of the common causes of death in burn patients and have a high risk of nosocomial infections, especially pneumonia, urinary tract infections, and cellulitis. The role of prolonged hospitalization and empirical antibiotics administration in developing multidrug-resistant pathogens is undeniable. In the early days of admitting burn patients, Gram-positive bacteria were the dominant isolates with a more sensitive antibiotic pattern. However, the emergence of Gram-negative bacteria that are more resistant later occurs. Trustworthy guideline administration in burn wards is one of the strategies to prevent multidrug-resistant pathogens. Also, a multidisciplinary therapeutic approach is an effective way to avoid antibiotic resistance that involves infectious disease specialists, pharmacists, and burn surgeons. However, the emerging resistance to conventional antimicrobial approaches (such as systemic antibiotic exposure, traditional wound dressing, and topical antibiotic ointments) among burn patients has challenged the treatment of multidrug-resistant infections, and using nanoparticles is a suitable alternative. In this review article, we will discuss different aspects of multidrug-resistant pathogens in burn wounds, emphasizing the full role of these pathogens in burn wounds and discussing the application of nanotechnology in dealing with them. Also, some advances in various types of nanomaterials, including metallic nanoparticles, liposomes, hydrogels, carbon quantum dots, and solid lipid nanoparticles in burn wound healing, will be explained.

Clinical and Microbiological Outcomes and Follow-Up of Secondary Bacterial and Fungal Infections among Critically Ill COVID-19 Adult Patients Treated with and without Immunomodulation: A Prospective Cohort Study

BACKGROUND

Nearly 10% of COVID-19 cases will require admission to the intensive care unit (ICU). Our aim was to assess the clinical and microbiological outcomes of secondary infections among critically ill COVID-19 adult patients treated with/without immunomodulation.

METHODS

A prospective observational cohort study was performed between 2020 and 2022 at a single ICU. The diagnosis and severity classification were established by the ECDC and WHO criteria, respectively. Eligible patients were included consecutively at admission, and followed for +30 days post-inclusion. Bloodstream-infections (BSIs), ventilator-associated bacterial pneumonia (VAP), and COVID-19-associated invasive pulmonary aspergillosis (CAPA) were defined according to international guidelines. Patient stratification was performed by immunomodulatory therapy administration (dexamethasone, tocilizumab, baricitinib/ruxolitinib). The primary outcome was any microbiologically confirmed major infectious complication, secondary outcomes were invasive mechanical ventilation (IMV) requirement and all-cause mortality.

RESULTS

Altogether, 379 adults were included. At baseline, 249/379 (65.7%) required IMV and 196/379 (51.7%) had a cytokine storm. At +30 days post-inclusion, the rate of any microbiologically confirmed major infectious complication was 151/379 (39.8%), IMV requirement and all-cause mortality were 303/379 (79.9%) and 203/379 (53.6%), respectively. There were no statistically significant outcome differences after stratification. BSI, VAP, and CAPA episodes were mostly caused by Enterococcus faecalis (27/124, 22.1%), Pseudomonas aeruginosa (26/91, 28.6%), and Aspergillus fumigatus (20/20, 100%), respectively. Concerning the primary outcome, Kaplan-Meier analysis showed similar probability distributions between the treatment subgroups (118/299, 39.5% vs. 33/80, 41.3%, log-rank p = 0.22), and immunomodulation was not retained as its independent predictor in multivariate logistic regression.

CONCLUSIONS

Secondary infections among critically ill COVID-19 adult patients represent a relevant burden, probably irrespective of immunomodulatory treatment.

Treatment and outcome of gram-positive bacteremia in patients receiving extracorporeal membrane oxygenation

BACKGROUND

While guidance exists for management of blood stream infections with various invasive devices, there are currently limited data to guide antibiotic selection and duration for bacteremia in patients receiving extracorporeal membrane oxygenation (ECMO).

OBJECTIVE

To evaluate the treatment and outcomes of thirty-six patients with Staphylococcus aureus and Enterococcus bacteremia on ECMO support.

METHODS

Blood culture data was retrospectively analyzed from patients with Staphylococcus aureus bacteremia (SAB) or Enterococcus bacteremia who underwent ECMO support between March 2012 and September 2021 at Brooke Army Medical Center.

RESULTS

Of the 282 patients who received ECMO during this study period, there 25 (9%) patients developed Enterococcus bacteremia and 16 (6%) developed SAB. SAB occurred earlier in ECMO as compared to Enterococcus (median day 2 IQR (1-5) vs. 22 (12-51), p = 0.01). The most common duration of antibiotics was 28 days after clearance for SAB and 14 days after clearance for Enterococcus. 2 (5%) patients underwent cannula exchange with primary bacteremia, and 7 (17%) underwent circuit exchange. 1/3 (33%) patients with SAB and 3/10 (30%) patients with Enterococcus bacteremia who remained cannulated after completion of antibiotics had a second episode of SAB or Enterococcus bacteremia.

CONCLUSION

This single center case series is the first to describe the specific treatment and outcomes of patients receiving ECMO complicated by SAB and Enterococcus bacteremia. For patients who remain on ECMO after completion of antibiotics, there is a risk of a second episode of Enterococcus bacteremia or SAB.

Unraveling the Mystery of Fever Source: The Vital Role of Physical Examination in Hospitalized Patients With Emphasis on Peripheral Line-Associated Bloodstream Infections

Fever in hospitalized patients requires timely identification of the underlying cause for appropriate treatment. While laboratory tests and imaging studies are valuable, the significance of physical examination should not be overlooked. We present a case of peripheral line-associated bloodstream infection that was readily diagnosed through physical examination during an infectious disease consultation for fever of unknown origin. It is important for busy physicians to prioritize physical examinations to prevent diagnostic errors. Prompt and focused physical examinations contribute to improved patient outcomes and the prevention of healthcare-associated infections.

Tunneled femoral dialysis catheter: Practical pointers

One of the most challenging aspects of providing end-stage kidney disease care is to achieve adequate long-term access to the bloodstream to support hemodialysis (HD) therapy. Although upper extremity arteriovenous fistula remains the vascular access of choice for patients on HD, complications such as central venous stenosis, access thrombosis, or exhaustion of suitable access sites in the upper extremity, ultimately result in pursuing vascular access creation in the lower extremity. The current review focuses on the indications, contraindications, and clinically relevant practical procedural tips to successfully place a tunneled femoral dialysis catheter. The review highlights some of the prevailing misconceptions regarding femoral catheter placement practices.

Guidelines for Central Venous Port Placement and Management (Abridged Translation of the Japanese Version)

The central venous port has been widely used for patients who require long-term intravenous treatments, and the number of palcement has been increasing. The Japanese Society of Interventional Radiology developed a guideline for central venous port placement and management to provide evidence-based recommendations to support healthcare providers in the decision-making process regarding the central venous port. The guideline consisted of two parts: (i) a comprehensive review of topics including preoperative preparation, techniques for placement or removal, complications, and maintenance methods and (ii) recommendations for the six clinical questions regarding blood vessels for central venous port placement, port implantation site, prophylactic antibiotic therapy, imaging guidance for puncture, disinfectant prior to accessing the central venous port, and the optimal procedure at the end of drug administration via the central venous port, generated on the basis of the rating quality of evidence by systematic review.

Practices, Knowledge, and Attitudes of Nephrologists Towards Prescribing and Monitoring Vancomycin at Dialysis Centers

BACKGROUND

Vancomycin dosing protocols are varied in the literature for hemodialysis patients. This study sought to determine nephrologists' practices, knowledge, attitudes, and barriers toward prescribing and monitoring vancomycin at dialysis centers.

METHODS

A cross-sectional and multi-center study was conducted in Kuwait using a validated self-administered questionnaire among 168 nephrologists. Descriptive and comparative analyses were performed using SPSS (version 28).

RESULTS

The response rate was 75% (n = 126). Over half of nephrologists frequently prescribed a vancomycin loading dose of 1000 mg (53.2%) and a maintenance dose of 500 mg (51.6%) to all patients. Their overall median (IQR) percentage knowledge about the therapeutic monitoring of vancomycin was 66.7% (33.3) and was found to be higher in nephrologists aged ≤ 40 years and in registrars/senior registrars (p < 0.05). Their overall median (IQR) attitude score was 4.0 (1.0) [positive attitude]. Nephrologists with > 15 years of practice experience expressed higher attitudes (p < 0.05). The top two perceived barriers were a lack of clear local hospital/national guidelines (60.3%) for vancomycin dosing in dialysis and inconsistencies among different dosing references and guidelines (51.6%).

CONCLUSION

Findings showed that nephrologists have varying practices, moderate knowledge, and positive attitudes toward prescribing and monitoring vancomycin and highlight the need for interventions to overcome the perceived barriers.

Ultrasound-guided, long-axis, in-plane, infraclavicular axillary vein cannulation: A 6-year experience

BACKGROUND

Despite its potential advantages, ultrasound-guided cannulation of the axillary vein in the infraclavicular area is still rarely used as an alternative to other techniques. There are few large series demonstrating the safety and feasibility of this approach.

METHODS

Retrospective analysis of data on patients undergoing ultrasound-guided, long-axis, in-plane infraclavicular axillary vein cannulation for the incidence of complications and the failure rate from two secondary-care hospitals.

RESULTS

The analysis included 710 successful attempts of axillary vein long-axis, in-plane, US-guided cannulation, and 24 (3.3%) failed attempts. We recorded a 96.7% success rate with an overall incidence of complications of 13%, mainly malposition (8.1%). There was one case of pneumothorax (0.14%), five cases of arterial puncture (0.7%), and two cases of brachial plexus injury.

CONCLUSIONS

The US-guided axillary central venous cannulation (CVC) access technique can be undertaken successfully in patients, even in challenging circumstances. Taken together with existing work on the utility and safety of this technique, we suggest that it should be adopted more widely in clinical practice.

Relationship between COVID-19 and ICU-acquired colonization and infection related to multidrug-resistant bacteria: a prospective multicenter before-after study

PURPOSE

Patients presenting the most severe form of coronavirus disease 2019 (COVID-19) pneumonia, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have a prolonged intensive care unit (ICU) stay and are exposed to broad-spectrum antibiotics, but the impact of COVID-19 on antimicrobial resistance is unknown.

METHODS

Observational prospective before-after study in 7 ICUs in France. All consecutive patients with an ICU stay > 48 h and a confirmed SARS-CoV-2 infection were included prospectively and followed for 28 days. Patients underwent systematic screening for colonization with multidrug-resistant (MDR) bacteria upon admission and every week subsequently. COVID-19 patients were compared to a recent prospective cohort of control patients from the same ICUs. The primary objective was to investigate the association of COVID-19 with the cumulative incidence of a composite outcome including ICU-acquired colonization and/or infection related to MDR bacteria (ICU-MDR-col and ICU-MDR-inf, respectively).

RESULTS

From February 27th, 2020 to June 2nd, 2021, 367 COVID-19 patients were included, and compared to 680 controls. After adjustment for prespecified baseline confounders, the cumulative incidence of ICU-MDR-col and/or ICU-MDR-inf was not significantly different between groups (adjusted sub-hazard ratio [sHR] 1.39, 95% confidence interval [CI] 0.91-2.09). When considering both outcomes separately, COVID-19 patients had a higher incidence of ICU-MDR-inf than controls (adjusted sHR 2.50, 95% CI 1.90-3.28), but the incidence of ICU-MDR-col was not significantly different between groups (adjusted sHR 1.27, 95% CI 0.85-1.88).

CONCLUSION

COVID-19 patients had an increased incidence of ICU-MDR-inf compared to controls, but the difference was not significant when considering a composite outcome including ICU-MDR-col and/or ICU-MDR-inf.

Management of Complex Infections in Hemophagocytic Lymphohistiocytosis in Adults

Hemophagocytic lymphohistiocytosis (HLH) is a syndrome of excessive immune system activation and inflammatory response due to a variety of primary and secondary factors that can cause a range of clinical symptoms and, in severe cases, life-threatening conditions. Patients with HLH are at increased risk of infection due to their abnormal immune function as well as chemotherapy and immunosuppressive therapy at the time of treatment. At the same time, the lack of specific clinical features makes complex infections in HLH challenging to diagnose and treat. The management of complex infections in HLH requires a multidisciplinary and integrated approach including the early identification of pathogens, the development of anti-infection protocols and regimens, and the elimination of potential infection factors. Especially in HLH patients with septic shock, empirical combination therapy against the most likely pathogens should be initiated, and appropriate anti-infective regimens should be determined based on immune status, site of infection, pathogens, and their drug resistance, with timely antibiotic adjustment by monitoring procalcitonin. In addition, anti-infection prophylaxis for HLH patients is needed to reduce the risk of infection such as prophylactic antibiotics and vaccinations. In conclusion, complex infection in HLH is a serious and challenging disease that requires vigilance, early identification, and timely anti-infective therapy.

Risk Factors Associated with the Development of Hospital-Acquired Infections in Hospitalized Patients with Severe COVID-19

Recognition of risk factors for hospital-acquired infections (HAI) in patients with COVID-19 is warranted. We aimed to describe factors associated with the development of HAI in patients with severe COVID-19. We conducted a retrospective cohort study including all adult patients admitted with severe COVID-19 between March 2020 and November 2020. The primary outcome was HAI development. Bivariate and multiple logistic regression models were constructed. Among 1540 patients, HAI occurred in 221 (14%). A total of 299 episodes of HAI were registered. The most common HAI were hospital-acquired/ventilation-associated pneumonia (173 episodes) and primary bloodstream infection (66 episodes). Death occurred in 387 (35%) patients and was more frequent in patients with HAI (38% vs. 23%, p < 0.01). Early mechanical ventilation (aOR 18.78, 95% CI 12.56-28.07), chronic kidney disease (aOR 3.41, 95% CI 1.4-8.27), use of corticosteroids (aOR 2.95, 95% CI 1.92-4.53) and tocilizumab (aOR 2.68, 95% CI 1.38-5.22), age ≥ 60 years (aOR 1.91, 95% CI 1.27-2.88), male sex (aOR 1.52, 95% CI 1.03-2.24), and obesity (aOR 1.49, 95% CI 1.03-2.15) were associated with HAI. In patients with severe COVID-19, mechanical ventilation within the first 24 h upon admission, chronic kidney disease, use of corticosteroids, use of tocilizumab, age ≥ 60 years, male sex, and obesity were associated with a higher risk of HAI.

Usefulness of daptomycin lock therapy in children with catheter-related bacteremia after failed vancomycin lock therapy

PURPOSE

Catheter-related bacteremia (CRB) is a significant cause of morbidity, resource expenditure and prolonged hospital stays in patients with long-term catheters, whose numbers have increased considerably in recent years. Antibiotic lock therapy reaches high concentrations in the catheter, allowing good penetration into the biofilm, being vancomycin the most commonly used one in gram-positive infections. Several authors have recently reported the superior in vitro efficacy of daptomycin compared with vancomycin, especially for eradicating biofilms. Although there is some data on the use of daptomycin for antibiotic lock in animal models and adults, there are no data on its use in children.

METHODS

A descriptive study was conducted in a tertiary hospital, including patients younger than 16 years in whom daptomycin lock therapy was employed between 2018 and 2022.

RESULTS

We report three pediatric patients in whom CRB was confirmed on admission by paired blood cultures positive for CoNS sensitive to vancomycin, daptomycin and linezolid. All patients started vancomycin lock therapy and systemic antibiotic therapy with proven sensitivity for the isolated bacteria, without achieving negative blood cultures. Due to the persistence of positive cultures, vancomycin lock therapy was replaced by daptomycin, and blood cultures turned negative, with no relapses or need for catheter removal.

CONCLUSION

The use of daptomycin lock therapy could be considered in children with CoNS catheter infection, especially when other antibiotic lock therapy had failed.

Mussel-inspired proteins functionalize catheter with antifouling and antibacterial properties

Bacterial adhesion and subsequent biofilm formation on catheter can cause inevitably infection. The development of multifunctional antibacterial coating is a promising strategy to resist the bacteria adhesion and biofilm formation. Herein, a mussel-inspired chimeric protein MZAgP is prepared and employed to modify a variety of polymeric catheters. The MZAgP is composed of mussel-adhesive peptide, zwitterionic peptide, and silver-binding peptide, which can endow catheters with antifouling, bactericidal and biocompatibility performances. Expectedly, negligible biofilm is observed on the MZAgP coated catheters after incubating with bacteria for 120 h. And ignorable hemolysis and cytotoxicity are obtained on coated catheters. In addition, the modified catheters also display persistent antifouling and bacteriostatic properties throughout 168 h under hydrodynamic conditions. Moreover, the coated catheters still remain excellent antifouling and antibacterial properties even after 2 months of storage. This multifunctional coating may be promising as antibacterial and antibiofilm material, and the coated catheters are potential in clinical application.

Eradication of Staphylococcus epidermidis within Biofilms: Comparison of Systemic versus Supratherapeutic Concentrations of Antibiotics

Biofilm-forming bacterial infections result in clinical failure, recurring infections, and high health care costs. The antibiotic concentrations needed to eradicate biofilm require further research. We aimed to model an in vitro prosthetic joint infection (PJI) to elucidate the activity of traditional systemic concentrations versus supratherapeutic concentrations to eradicate a Staphylococcus epidermidis biofilm PJI. We evaluated S. epidermidis high-biofilm-forming (ATCC 35984) and low-biofilm-forming (ATCC 12228) isolates in an in vitro pharmacodynamic biofilm reactor model with chromium cobalt coupons to simulate prosthetic joint infection. Vancomycin, daptomycin, levofloxacin, and minocycline were used alone and combined with rifampin to evaluate the effect of biofilm eradication. We simulated three exposures: (i) humanized systemic dosing alone, (ii) supratherapeutic doses (1,000× MIC), and (iii) and dosing in combination with rifampin. Resistance development was monitored throughout the study. Simulated humanized systemic doses of a lipoglycopeptide (daptomycin), a fluoroquinolone (levofloxacin), a tetracycline (minocycline), and a glycopeptide (vancomycin) alone failed to eradicate a formed S. epidermidis biofilm. Supratherapeutic doses of vancomycin (2,000 μg/mL) and minocycline (15 μg/mL) with or without rifampin (15 μg/mL) failed to eradicate biofilms. However, a levofloxacin supratherapeutic dose (125 μg/mL) with rifampin eradicated the high-biofilm-producing isolate by 48 h. Interestingly, supratherapeutic-dose exposures of daptomycin (500 μg/mL) alone eradicated high- and low-biofilm-forming isolates in established biofilms. The concentrations needed to eradicate biofilms on foreign materials are not obtained with systemic dosing regimens. The failure of systemic dosing regimens to eradicate biofilms validates clinical findings with recurring infections. The addition of rifampin to supratherapeutic dosing regimens does not result in synergy. Supratherapeutic daptomycin dosing may be effective at the site of action to eradicate biofilms. Further studies are needed.

Impact of Infection Patterns on the Outcomes of Patients with Hematological Malignancies in Southwest China: A 10-Year Retrospective Case-Control Study

Background

This study aimed to assess the effect of infection patterns on the outcomes of patients with hematological malignancies (HM) and to identify the determinants of in-hospital mortality.

Methods

A case-control study was retrospectively conducted in a tertiary teaching hospital in Chongqing, Southwest China from 2011 to 2020. Clinical characteristics, microbial findings, and outcomes of HM patients with infections were retrieved from the hospital information system. Chi-square or Fisher's exact test was adopted to test the significance of mortality rate. Kaplan-Meier survival analysis and Log rank test were applied to evaluate and compare the 30-day survival rates of those groups. Binary logistic regression, Cox proportional hazards regression, and receiver operating characteristic curves were used to investigate the determinants of in-hospital mortality.

Results

Of 1,570 enrolled participants, 43.63% suffered from acute myeloid leukemia, 69.62% received chemotherapy, and 25.73% had hematopoietic stem cell transplantation (HSCT). Microbial infection was documented in 83.38% of participants. Co-infection and septic shock were reported in 32.87% and 5.67% of participants, respectively. Patients with septic shock suffered a significantly lower 30-day survival rate, while those with distinct types of pathogens or co-infections had a comparable 30-day survival rate. The all-cause in-hospital mortality was 7.01% and higher mortality rate was observed in patients with allo-HSCT (7.20%), co-infection (9.88%), and septic shock (33.71%). Cox proportional hazards regression illustrated that elderly age, septic shock, and elevated procalcitonin (PCT) were independent predictors of in-hospital mortality. A PCT cut-off value of 0.24 ng/mL predicted in-hospital mortality with a sensitivity of 77.45% and a specificity of 59.80% (95% CI = 0.684-0.779, P<0.0001).

Conclusion

Distinct infectious patterns of HM inpatients were previously unreported in Southwest China. It was the severity of infection, not co-infection, source of infection, or type of causative pathogen that positively related to poor outcome. PCT guided early recognition and treatment of septic shock were advocated.

Evaluation of antibiotic appropriateness at an outpatient oncology centre

Current evidence supporting antimicrobial stewardship programs focused largely in inpatient setting. With the shift in cancer management from inpatient to ambulatory setting, it is crucial to examine the prevalence and predictors of inappropriate antibiotics prescribing. This is a retrospective cross-sectional study conducted at the National Cancer Centre Singapore (NCCS). Patients at least 21 years, with an active or past cancer diagnosis and prescribed with at least one oral antibiotic by a NCCS physician from 1st July to 30th September 2019 were included. Antibiotic appropriateness was assessed using institutional antibiotic guidelines or published clinical practice guidelines. For cases where antibiotics appropriateness cannot be ascertained using these guidelines, an independent three-member expert panel was consulted. A total of 815 patients were screened; 411 (59.4% females) were included with mean age of 62.4 years. The top three cancer diagnoses were breast (26.5%), lung (15.6%) and head and neck (13.6%). More than half (58.6%) received appropriate antibiotic choice. Of which, 235 (97.5%), 238 (98.8%) and 194 (80.5%) received appropriate dose, frequency and duration respectively. The presence of non-oncologic immunosuppressive comorbidities (OR 4.890, 95% CI 1.556-15.369, p-value = 0.007), antibiotic allergy (OR 2.352, 95% CI 1.178-4.698, p-value = 0.015) and skin and soft tissue infections (OR 2.004, 95% CI 1.276-3.146, p-value = 0.003) were associated with a higher incidence of inappropriate antibiotic choice. This study highlighted that inappropriate antibiotic prescribing is prevalent in the ambulatory oncology setting. Predicators identified can aid in the design of targeted strategies to optimise antibiotic use in ambulatory oncology patients.

Breakage and Disappearance of a Part of the Midline Catheter Tip During Insertion

Midline catheters have been proposed as alternatives to central venous catheters and peripherally inserted central catheters. Midline catheters reduce the incidence of overall needle stick injuries during hospitalization, have lower complication rates than central venous catheters or peripherally inserted central catheters, and provide potential cost benefits for hospitals. Complications with midline catheters are similar to those of other intravenous catheters, and intravenous catheter breakage is very rare and invasive. We report a case wherein a midline catheter tip was broken during insertion and removed by open surgery. For the safe use of midline catheters, accurate and delicate insertion techniques should be practiced. More case studies are warranted to verify the usefulness and convenience of various types of midline catheters for their universal use.

Blood Culture Result Profile in Patients With Central Line-Associated Bloodstream Infection (CLABSI): A Single-Center Experience

Background Central line-associated bloodstream infection (CLABSI) is among the most common bloodstream infections in the university hospital and intensive care unit settings. This study evaluated the routine blood test findings and microbe profiles of bloodstream infection (BSI) by the presence and types of central vein (CV) access devices (CVADs). Methods A total of 878 inpatients at a university hospital who were clinically suspected for BSI and underwent blood culture (BC) testing between April 2020 and September 2020 were enrolled. Data regarding age at BC testing, sex, WBC count, serum C-reactive protein (CRP) level, BC test results, yielded microbes, and usage and types of CVADs were evaluated. Results The BC yields were detected in 173 patients (20%), suspected contaminating pathogens in 57 (6.5%), and 648 (74%) with a negative yield. The WBC count (p=0.0882) and CRP level (p=0.2753) did not significantly differ between the 173 patients with BSI and the 648 patients with negative BC yields. Among the 173 patients with BSI, 74 used CVADs and met the diagnosis of CLABSI; 48 had a CV catheter, 16 had CV access ports, and 10 had a peripherally inserted central catheter (PICC). Patients with CLABSI showed lower WBC counts (p=0.0082) and serum CRP levels (p=0.0024) compared to those with BSI who did not use CVADs. The most commonly yielded microbes in those with CV catheters, CV-ports, and PICC were Staphylococcus epidermidis (n=9; 19%), Staphylococcus aureus (n=6; 38%), and S. epidermidis (n=8; 80%), respectively. Among those with BSI who did not use CVADs, Escherichia coli (n=31; 31%) was the most common pathogen, followed by S. aureus (n=13; 13%). Conclusion Patients with CLABSI showed lower WBC counts and CRP levels than those with BSI who did not use CVADs. Staphylococcus epidermidis was among the most common microbes in CLABSI and accounted for the majority of yielded microbes in patients who used PICC.

Treatment decisions in VRE bacteraemia: a survey of infectious diseases pharmacists

Background

VRE infections increased in 2020. High-dose daptomycin (≥10 mg/kg) has shown mortality benefit over other regimens, though daptomycin resistance is increasing. Limited data exist on the practice patterns of ID pharmacists for VRE bloodstream infections (VRE BSIs).

Objectives

To describe practice patterns for VRE BSI in ID pharmacists.

Methods

A 22-question REDCap survey was distributed to ID pharmacist members of the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (ID PRN) via e-mail listserv. The survey was distributed on 7 April 2022 and remained open for 4 weeks.

Results

Sixty-eight pharmacists responded. All pharmacists completed additional training or certification in infectious diseases past their PharmD, and most (70.5%) had been practising for 10 years or less. Pharmacists at academic medical centres (80.0%) were more likely (P = 0.001) to have implemented the updated CLSI breakpoints than pharmacists at other types of institutions (55.2%). Daptomycin was the preferred drug for VRE BSI (92.6%), with 10 mg/kg (72.1%) being the preferred dose. Adjusted body weight was the most common weight (61.2%) used for obese patients. Fourteen days (76.1%) was the most common treatment duration for VRE BSI. Pharmacists defined persistent VRE BSI as 5 days (68.7%) after first blood culture.

Conclusions

ID pharmacists overwhelmingly selected high-dose daptomycin for VRE BSI. There were variations in practice and response rate when selecting combination therapy, managing persistent bacteraemia, and treating patients with high daptomycin MICs or previous exposure to daptomycin.

Sustained low catheter related infection (CRI) incidence in an observational follow-up study of 9924 catheters using automated data scripts as quality assurance for central venous catheter (CVC) management

Background

To maintain a low incidence of Catheter Related Infections (CRI) and Catheter Related Bloodstream Infections (CRBSI), continuous follow-up studies on catheter management are necessary. The aims of the present study were to investigate the incidence of catheter tip colonisation, CRI and CRBSI in the Region, to further explore the feasibility of automatic data collection and to investigate associations between independent variables and CRI.

Methods

Data from electronic patient charts on all documented central venous catheter (CVC) insertions from multiple hospitals in southern Sweden, between March 2019 and August 2020, were automatically extracted. Multivariable regression analyses were used to identify associated risk factors.

Results

In total, 9924 CVC insertions were included. The prevalence of CRI and CRBSI were 0.7% (n = 74) and 0.02% (n = 20) with incidences of 1.2/1000 catheter days and 0.3/1000 catheter days, respectively.

Conclusions

We found a sustained low incidence of CRI and CRBSI in the Region. Catheter tips were less likely to be colonised when the subclavian route was used compared to the internal jugular route and male sex as well as increased number of catheter lumens were associated with both catheter tip colonisation and CRI. By using automated scripts, data extraction was efficient and feasible but also demonstrated that real-time quality assurance should be recommended, since this is superior to current standard.

Determinants of morbidity and mortality related to health care-associated primary bloodstream infections in neonatal intensive care units: a prospective cohort study from the SEPREVEN trial

Background

Health care-associated primary bloodstream infections (BSIs), defined as not secondary to an infection at another body site, including central line-associated BSI, are a leading cause of morbidity and mortality in patients in neonatal intensive care units (NICUs). Our objective was to identify factors associated with severe morbidity and mortality after these infections in neonates in NICUs.

Methods

This ancillary study of the SEPREVEN trial included neonates hospitalized ≥2 days in one of 12 French NICUs and with ≥ 1 BSI during the 20-month study period. BSIs (all primary and health care-associated) were diagnosed in infants with symptoms suggestive of infection and classified prospectively as possible (one coagulase-negative staphylococci (CoNS)-growing blood culture) or proven (two same CoNS, or ≥1 recognized pathogen-growing blood culture). BSI consequences were collected prospectively as moderate morbidity (antibiotic treatment alone) or severe morbidity/mortality (life-saving procedure, permanent damage, prolonged hospitalization, and/or death).

Results

Of 557 BSIs identified in 494 patients, CoNS accounted for 378/557 (67.8%) and recognized bacterial or fungal pathogens for 179/557 (32.1%). Severe morbidity/mortality was reported in 148/557 (26.6%) BSIs. Independent factors associated with severe morbidity/mortality were corrected gestational age <28 weeks (CGA) at infection (P < .01), fetal growth restriction (FGR) (P = .04), and proven pathogen-related BSI vs. CoNS-related BSI (P < .01). There were no differences in severe morbidity and mortality between proven and possible CoNS BSIs. In possible BSI, S. epidermidis was associated with a lower risk of severe morbidity than other CoNS (P < .01), notably S. capitis and S. haemolyticus.

Conclusions

In BSIs in the NICU, severe morbidity/mortality was associated with low CGA at infection, FGR, and proven pathogen-related BSIs. When only one blood culture was positive, severe morbidity/mortality were less frequent if it grew with S. epidermidis compared to other CoNS. Further studies to help distinguish real CoNS BSIs from contaminations are needed.

Study registration

ClinicalTrials.gov (NCT02598609).

Analysis of cumulative antibiogram reports in intensive care units at an Egyptian University Hospital

BACKGROUND

Institutions must have access to antibiograms to monitor changes in antimicrobial resistance and direct empirical antibiotic therapy. The first facility-specific cumulative antibiogram was launched in the ICU in 2019. Consequently, many antibiogram-operation-related actions have been adopted in the institution based on reported data. This study aimed to analyze the cumulative antibiogram reports for multiple intensive care units (ICUs) for 2020, and compare the antimicrobial susceptibility testing (AST) patterns between the 2019 and 2020 years in an academic medical center.

METHODS

This cross-sectional study was performed of routine bacterial culture and AST data extracted from a laboratory information system in a 2252-bed capacity hospital. Only the first diagnostic isolate of a given species per patient per year was included in the study. Interpretation and reporting were done in accordance with the applicable Clinical and Laboratory Standards Institute and European Committee on Antimicrobial Susceptibility Testing guidelines.

RESULTS

Of the 46,791 clinical isolates, the Gram-negative bacilli isolation rate witnessed a significant increase: 35,670 isolates in 2020 versus. 33,652 isolates in 2019. Klebsiella pneumoniae showed a statistically significant increase, mainly in pediatric, emergency, and cardiothoracic ICUs (p < 0.001). Neonatal and pediatric ICUs showed statistically significant increases in Pseudomonas aeruginosa and Proteus mirabilis isolates (p < 0.001). A statistically significant decrease was noted in the prevalence of Acinetobacter, Escherichia coli, Burkholderia cepacia, and Enterobacter cloacae. The sensitivities of K. pneumoniae and E. coli to imipenem and tigecycline significantly improved (p < 0.001). The sensitivity to colistin was significantly decreased (p < 0.001). The sensitivity of P. aeruginosa isolates to colistin and carbapenems was improved (p < 0.001). We reported a statistically significant decrease in all Gram-positive cocci (11,121 in 2020 versus. 11,528 in 2019). Staphylococcus aureus showed a statistically significant increase (p < 0.001), particularly in the medical ICU.

CONCLUSION

The high susceptibility rates of Enterobacteriaceae toward colistin and tigecycline, should be cautiously considered in empiric therapy while looking for alternatives. The majority of isolates of Gram-positive cocci were coagulase negative staphylococci (CONS), we still need to confirm whether they are true pathogens or commensals before considering anti-staphylococcal agents in the empirical therapy. We underscored some corrective actions that might have improved the susceptibility rates, such as antibiotic cycling.

A novel incision technique of a totally implanted venous access port in the upper arm for patients with breast cancer

BACKGROUND

A totally implanted venous access port (TIVAP) in the upper arm is a safe and cost-effective vascular access device and is widely used in breast cancer patients. Traditional tunnelling technique increases the operation time and has an unsatisfied cosmetic effect, so we explored the feasibility, cosmetic effect and complications of an upper arm port with a novel incision in this retrospective study.

METHODS

We reviewed 489 cases of totally implantable venous access port implantation in the upper arm with two types of incisions in our centre from 1 January 2018 to 30 January 2022. The patients were divided into two different incision groups including the puncture site incision group (n = 282) and the conventional tunnelling group (n = 207). The comparison of the results was collected between the two groups, and contributing factors were analyzed for major complications.

RESULTS

A total of 489 patients were successfully implanted with arm ports using the puncture site incision technique (n = 282, 57.7%) and conventional tunnelling technique (n = 207, 42.3%). The average operation time of the two types of incisions was 36.5 ± 15 min in the puncture site incision group and 55 ± 18.1 min in the tunnel needle group (P < 0.05). In terms of complications, 33 catheter-related complications occurred (6.4%), including 9 cases of infection, 15 cases of catheter-related thrombosis and 7 cases of skin exposure. Fourteen patients in the puncture site incision group developed complications compared with 17 in the traditional incision group. There were no significant differences between the two groups in terms of overall complication events (5.0% and 8.2%, P = 0.145) while the same result was found in each complication event. Weight, total cholesterol and diabetes were found to be associated with device-related infections in the univariate Cox proportional hazard regression models. Diabetes was found to be associated with device-related infections in multivariate analysis while hypertension was associated with thrombosis.

CONCLUSIONS

The puncture site incision method is a novel technique with a better cosmetic appearance and less operation time than the traditional tunnelling technique, providing a comparable overall rate of complications. It offers a preferable choice for clinicians when dealing with different situations of patients. It is worthy of being used and promoted for patients requiring the totally implanted venous access port in the upper arm.

Application of epicutaneo-cava catheters with 24G indwelling needles in very low birth weight infants: a safe and simple innovative technique

Background

Epicutaneo-cava catheter (ECC) is an ideal venous access for very low birth weight (VLBW) infants. However, because veins of VLBW infants are thin, ECC catheter is difficult to insert, and the success rate of puncture is low. This study aimed to use ECC with 24G indwelling needles to improve the outcomes of VLBW infants.

Methods

This retrospective study enrolled 121 VLBW infants (birthweight <1,500 g) who required ECC catheterization and were admitted to the Neonatal Intensive Care Unit of the Children's Hospital of Zhejiang University School of Medicine between January 2021 and December 2021. The patients were divided into the indwelling needle group and the conventional technique group according to the technique of ECC. The demographic and treatment data of the two groups were collected, and the success rate of first attempt cannulation of ECC and catheter-related complications of the two groups were analyzed and compared.

Results

There were no significant differences in gender, age, and body weight between the two groups on the day of ECC insertion and venipuncture site. It can be seen through model analysis that the success rate of first-attempt cannulation of ECC in the indwelling needle group was significantly higher than in the conventional technique group. In contrast, average catheterization time and catheterization-related bleeding risk in the indwelling needle group were significantly lower than in the conventional technique group (p = 0.00,and 0.00, respectively). Infection during catheter placement, indwelling catheter duration and catheter-related infection between the two groups (p > 0.05).

Conclusion

Application of ECC with 24G indwelling needles in VLBW infants can improve the success rate of first attempt cannulation of ECC, reduce the time of catheterization and the risk of bleeding, which may be popularized for widespread application.

Novel Keto-Alkyl-Pyridinium Antifungal Molecules Active in Models of In Vivo Candida albicans Vascular Catheter Infection and Ex Vivo Candida auris Skin Colonization

New antifungal therapies are needed for both systemic, invasive infections in addition to superficial infections of mucosal and skin surfaces as well as biofilms associated with medical devices. The resistance of biofilm and biofilm-like growth phases of fungi contributes to the poor efficacy of systemic therapies to nonsystemic infections. Here, we describe the identification and characterization of a novel keto-alkyl-pyridinium scaffold with broad spectrum activity (2 to 16 μg/mL) against medically important yeasts and molds, including clinical isolates resistant to azoles and/or echinocandins. Furthermore, these keto-alkyl-pyridinium agents retain substantial activity against biofilm phase yeast and have direct activity against hyphal A. fumigatus. Although their toxicity precludes use in systemic infections, we found that the keto-alkyl-pyridinium molecules reduce Candida albicans fungal burden in a rat model of vascular catheter infection and reduce Candida auris colonization in a porcine ex vivo model. These initial preclinical data suggest that molecules of this class may warrant further study and development for nonsystemic applications.

Burkholderia cepacia infection in children without cystic fibrosis: a clinical analysis of 50 cases

Background

Burkholderia cepacia (B. cepacia) is an emerging pathogen of nosocomial infection in pediatric patient carrying cystic fibrosis. The clinical diagnosis and treatment of B. cepacia infection remains poorly studied. This study outlined the risk factors, antimicrobial susceptibility, and clinical characteristics aiming to improve the treatment of B. cepacia infection.

Methods

A retrospective study was conducted based on the 50 cases infection caused by B. cepacia in children without cystic fibrosis, which were diagnosed in the First Affiliated Hospital of Xiamen University, from January 1st, 2011 to December 31st, 2021.

Results

A total of 50 children were infected with B. cepacia, of whom 68% had an underlying health condition, such as cardiovascular disease (23.5%), respiratory disease (17.6%), nervous system disease (14.7%), and neoplastic disease (14.7%). At the onset of B. cepacia infection, 42 (84%) pediatric patients were in an intensive care unit (ICU), 33 (66%) underwent endotracheal intubation, and 32 (64%) had a central venous catheter (CVC). In addition, hospital-acquired cases were 46 (92%), and healthcare-acquired cases were 4 (12%). The most common infectious sites of B. cepacia were the respiratory tract (68%), followed by the blood (20%), and the urinary tract (12%). It indicated that B. cepacia was the most sensitive to ceftazidime (95.65%), followed by trimethoprim-sulfamethoxazole (88.68%), meropenem (82.98%), cefepime (77.78%), and levofloxacin (55.85%). The drug resistance rate of piperacillin-tazobactam, minocycline, aztreonam, cefoperazone-sulbactam and ceftriaxone was higher than 55%. 38 cases were cured or improved, eight had treatment terminated, and four died.

Conclusion

B. cepacia is an opportunistic pathogen normally found in immunocompromised pediatric patients and highly likely to lead to drug resistance. Nosocomial B. cepacia infections occurred mostly in patients in the ICU based on our observations. The surveillance of B. cepacia infections including changing epidemiology and increasing resistance of the microorganism is still very important. Treatment with effective antibiotics such as ceftazidime, meropenem, trimethoprim-sulfamethoxazole is associated with a favorable prognosis.

Randomized Clinical Trial of the Need for Antibiotic Treatment for Low-Risk Catheter-Related Bloodstream Infection Caused by Coagulase-Negative Staphylococci

According to clinical guidelines, the management of catheter-related bloodstream infections (CRBSI) due to coagulase-negative staphylococci (CoNS) includes catheter removal and antibiotic treatment for 5 to 7 days. However, in low-risk episodes, it remains uncertain whether antibiotic therapy is necessary. This randomized clinical trial aims to determine whether the non-administration of antibiotic therapy is as safe and effective as the recommended strategy in low-risk episodes of CRBSI caused by CoNS. With this purpose, a randomized, open-label, multicenter, non-inferiority clinical trial was conducted in 14 Spanish hospitals from 1 July 2019 to 31 January 2022. Patients with low-risk CRBSI caused by CoNS were randomized 1:1 after catheter withdrawal to receive/not receive parenteral antibiotics with activity against the isolated strain. The primary endpoint was the presence of any complication related to bacteremia or to antibiotic therapy within 90 days of follow-up. The secondary endpoints were persistent bacteremia, septic embolism, time until microbiological cure, and time until the disappearance of a fever. EudraCT: 2017-003612-39 INF-BACT-2017. A total of 741 patients were assessed for eligibility. Of these, 27 were included in the study; 15 (55.6%) were randomized to the intervention arm (non-antibiotic administration) and 12 (44.4%) to the control arm (antibiotic therapy as per standard practice). The primary endpoint occurred in one of the 15 patients in the intervention group (septic thrombophlebitis) and in no patients in the control group. The median time until microbiological cure was 3 days (IQR 1-3) in the intervention arm and 1.25 days (IQR 0.5-2.62) in the control arm, while the median time until fever resolution was zero days in both arms. The study was stopped due to the insufficient number of recruited patients. These results seem to indicate that low-risk CRBSI caused by CoNS can be managed without antibiotic therapy after catheter removal; efficacy and safety are not affected.

Short bowel syndrome: Complications and management

Short bowel syndrome (SBS) occurs when a patient loses bowel length or function significantly enough to cause malabsorption, oftentimes requiring lifelong parenteral support. In adults, this occurs most commonly in the setting of massive intestinal resection, whereas congenital anomalies and necrotizing enterocolitis predominate in children. Many patients with SBS develop long-term clinical complications over time related to their altered intestinal anatomy and physiology or to various treatment interventions such as parenteral nutrition and the central venous catheter through which it is administered. Identifying, preventing, and treating these complications can be challenging. This review will focus on the diagnosis, treatment, and prevention of several complications that can occur in this patient population, including diarrhea, fluid and electrolyte imbalance, vitamin and trace element derangements, metabolic bone disease, biliary disorders, small intestinal bacterial overgrowth, d-lactic acidosis, and complications of central venous catheters.

Risk Factors and Characteristics of Candidemia After Cardiac Surgery in Pediatric Patients in Central Israel

BACKGROUND

Candidemia is a serious complication in pediatric patients with congenital heart defects (CHD) after cardiac surgery. Information about the epidemiology, clinical characteristics and risk factors for candidemia in this vulnerable population remains limited.

METHODS

This retrospective case-control study was conducted in 2 pediatric intensive care units between 2004 and 2019. All patients <18 years old who developed candidemia following cardiac surgery were included. Each case was matched with 2 control patients based on age and date of surgery. Multivariable logistic regression analysis was conducted to determine the risk factors for postoperative candidemia.

RESULTS

Thirty-five candidemia cases were identified and matched to 70 control cases. The incidence of candidemia was 6.3 episodes per 1000 admissions. The median age for candidemia cases was 4 months. The attributable mortality was 28.5%. The predominant (54%) pathogens isolated were non- albicans Candida species, of which C. parapsilosis isolates demonstrated high resistance to fluconazole (70%). Independent risk factors associated with candidemia included cumulative antibiotic exposure for ≥4 days [OR: -4.3; 95% confidence interval (CI): 1.3-14.6; P = 0.02], the need for total parenteral nutrition or peritoneal dialysis (OR: -6.1; 95% CI: 2-18.8; P = 0.001), male sex (OR: 6.2; 95% CI: 1.9-20.3; P = 0.002) and delayed sternal closure≥2 days (OR: -3.2; 95% CI: 1-11.2; P = 0.05).

CONCLUSIONS

Postoperative candidemia in children with CHD is an uncommon but severe complication. Our study revealed an unexpectedly high frequency of fluconazole-resistant C. parapsilosis as the main cause of non- albicans candidemia. In addition to confirming previously recognized risk factors, our results reveal new potential risk factors such as delayed sternal closure and male sex.

Early identification of local infections in central venous catheters for hemodialysis: A systematic review

BACKGROUND

The use of central venous catheters (CVC) is associated with higher morbidity and mortality, related to infectious complications, contributing to poorer clinical outcomes and increased healthcare costs. According to the literature, the incidence of local infections related to CVC for hemodialysis is highly variable. This variability is related to differences in definitions of catheter-related infections.

OBJECTIVE

To identify signs and symptoms for determining local infections (exit site and tunnel tract infections) used in the literature in tunnelled and nontunnelled CVC for hemodialysis.

DESIGN

Systematic review METHODS: Structured electronic searches were conducted in five electronic databases, from 1 January 2000-31 August 2022, using key words and specific vocabulary, as well as manual searches in several journals. Additionally, vascular access clinical guidelines and infection control clinical guidelines were reviewed.

RESULTS

After validity analysis, we selected 40 studies and seven clinical guidelines. The definitions of exit site infection and tunnel infection used in the different studies were heterogeneous. Among the studies, seven (17,5 %) used the definitions of exit site and tunnel infection based on a clinical practice guideline. Three of the studies (7.5 %) used the Twardowski scale definition of exit site infection or a modification. The remaining 30 studies (75 %) used different combinations of signs and symptoms.

CONCLUSIONS

Definitions of local CVC infections are highly heterogeneous in the revised literature. It is necessary to establish a consensus regarding the definitions of hemodialysis CVC exit site and tunnel infections.

REGISTRATION

PROSPERO (CRD42022351097).

Effectiveness of Antimicrobial Lock Therapy for the Treatment of Catheter-Related and Central-Line-Associated Bloodstream Infections in Children: A Single Center Retrospective Study

Antimicrobial lock solutions (ALT) in combination with systemic antibiotics can represent a valid option to attempt central venous catheter (CVC) salvage in the case of catheter-related and central-line-associated bloodstream infections (CRBSI and CLABSI). However, data concerning the effectiveness and safety of ALT in children are limited. We aimed to share our center's experience in order to contribute to investigations into the causes of ALT failure in the pediatric population. All children consecutively admitted to Meyer Children's Hospital, University of Florence, Italy, from 1 April 2016 to 30 April 2022, who received salvage ALT to treat an episode of CRBSI/CLABSI, were reviewed. According to ALT failure or success, children were compared with the aim of identifying the risk factors for unsuccessful ALT outcome. Data from 28 children, 37 CLABSI/CRBSI episodes, were included. ALT was associated with clinical and microbiologic success in 67.6% (25/37) of children. No statistically significant differences were observed between the two groups, successes and failures, considering age, gender, reason for use, duration, insertion, type and presence of insertion site infection of the CVC, laboratory data and number of CRBSI episodes. Nevertheless, a trend towards a higher success rate was observed for a dwell time of 24 h for the entire duration of ALT (88%; 22/25 vs. 66.7%; 8/12; p = 0.1827), while the use of taurolidine and the infections sustained by MDR bacteria were associated with a tendency toward greater failure (25%; 3/12 vs. 4%; 1/25; p = 0.1394; 60%; 6/10 vs. 33.3%; 8/24; p = 0.2522). No adverse events, except one CVC occlusion, were observed. ALT combined with systemic antibiotics appears to be an effective and safe strategy for treating children with CLABSI/CRBSI episodes.

Use of the Dialkylcarbamoylchloride Dressing in the Care of Central Venous Access Exit Site in a Pediatric and Neonatal Population

Dialkylcarbamoylchloride dressing is a fatty acid derivative that has been shown in vitro to bind a number of pathogenic microorganisms. The purpose of this prospective study was to evaluate the safety and the efficacy of this technology in the care of the exit site of central venous catheter in a paediatric and neonatal population.

METHODS

The study was conducted from September 2020 to December 2022 at the Infermi Hospital in Rimini. Central venous catheters were placed using the SIC bundle for insertion. Dialkylcarbamoylchloride dressing was placed below the subcutaneous anchoring at the time of CVC placement and at each dressing change. Data about the catheters and the exit site were recorded and then compared with an historical cohort.

RESULTS

118 catheters were placed during the studied period. The dialkylcarbamoylchloride dressing was well-tolerated. No case of systemic or local infection was recorded. The comparison with the historical cohort showed a reduction in the rate of exit site infection (p value 0.03).

CONCLUSION

Dialkylcarbamoylchloride dressing is well-tolerated in paediatric and neonatal population. It represents a promising tool as a strategy for infection prevention.

Provision of Microbiology, Infection Services and Antimicrobial Stewardship in Intensive Care: A Survey across the Critical Care Networks in England and Wales

Infection rounds in Intensive Care Units (ICU) can impact antimicrobial stewardship (AMS). The aim of this survey was to assess the availability of microbiology, infection, AMS services, and antimicrobial prescribing practices in the UK ICUs. An online questionnaire was sent to clinical leads for ICUs in each region listed in the Critical Care Network for the UK. Out of 217 ICUs, 87 deduplicated responses from England and Wales were analyzed. Three-quarters of those who responded had a dedicated microbiologist, and 50% had a dedicated infection control prevention nurse. Infection rounds varied in their frequency, with 10% providing phone advice only. Antibiotic guidance was available in 99% of the units; only 8% of those were ICU-specific. There were variations in the availability of biomarkers & the duration of antibiotics prescribed for pneumonia (community, hospital, or ventilator), urinary, intra-abdominal, and line infections/sepsis. Antibiotic consumption data were not routinely discussed in a multi-disciplinary meeting. The electronic prescription was available in ~60% and local antibiotic surveillance data in only 47% of ICUs. The survey highlights variations in practice and AMS services and may offer the opportunity to further collaborations and share learnings to support the safe use of antimicrobials in the ICU.

Impact of antimicrobial stewardship with the Xpert MRSA/SA BC assay at a tertiary hospital in Japan

INTRODUCTION

Genetic testing is gaining increasing importance as a part of antimicrobial stewardship (AS). Rapid identification and determination of methicillin susceptibility using the Xpert MRSA/SA BC assay can improve the management of Staphylococcus aureus bacteremia (SAB) and reduce inappropriate antibiotic use. However, few reports have described the effectiveness of this approach.

METHODS

The present study aimed to assess the influence of AS using the Xpert MRSA/SA BC assay. Cases were classified into the pre-intervention group (n = 98 patients), in which SAB was identified by traditional culture (November 2017 to November 2019), and the post-intervention group (n = 97 patients), in which the Xpert MRSA/SA BC assay was performed when necessary (December 2019 to December 2021).

RESULTS

Patient characteristics, prognosis, duration of antimicrobial use, and length of hospital stay were compared between the groups. The Xpert assay was performed in 66 patients in the post-intervention group (68.0%). The two groups showed no significant differences in severity and mortality. The rate of cases treated with anti-MRSA agents reduced following the intervention (65.3% vs. 40.4%, p = 0.008). The number of cases involving definitive therapy within 24 h was higher in the post-intervention group (9.2% vs. 24.7%, p = 0.007). The hospitalization rate at >60 days was lower in Xpert implementation cases among MRSA bacteremia cases (28.6% vs. 0%, p = 0.01).

CONCLUSIONS

Thus, the Xpert MRSA/SA BC assay has potential as an AS tool, especially for early definitive treatment to SAB and reduction of long-term hospitalization in MRSA bacteremia cases.

Invasive Community-Acquired Methicillin-Resistant Staphylococcus aureus (MRSA) Infection in Children: A Report of Five Cases and Literature Review

Staphylococcus aureus developed resistance against most antibiotics; the most known resistant form is methicillin-resistant Staphylococcus aureus (MRSA), which can be acquired either from healthcare facilities or the community. The prevalence of hospital-acquired MRSA is higher than community-acquired MRSA (CA-MRSA). CA-MRSA has become an emerging infection and has been increasingly reported recently. Usually, CA-MRSA presents with skin and soft tissue infection but can cause severe invasive infection with significant morbidity. Invasive CA-MRSA needs rapid and aggressive treatment to prevent complications. For MRSA bacteremia that is persistent despite appropriate treatment, the possibility of metastatic invasive infection should be thought of. In this case series, we describe five pediatric cases of different age groups that had different presentations for invasive CA-MRSA infection. This report aims to highlight that physicians should be aware of the growing role of CA-MRSA in pediatrics; they should be meticulous in treating patients with CA-MRSA, and be aware of the complications of this disease and the appropriate empiric and target antibiotics regimen for such infections.

Impact of secondary sepsis on mortality in adult intensive care unit patients

RATIONALE

Septic patients admitted to the intensive care unit (ICU) suffer from immune dysregulation, potentially leading to a secondary sepsis episode. This study aims to (i) assess the secondary sepsis rate, (ii) compare the second with the first episodes in terms of demographics, clinical and laboratory characteristics, and outcomes, and iii) evaluate the outcome of secondary sepsis.

METHODS

A single-center, retrospective study (2014-2017) was conducted in a Greek ICU, including consecutive cases of adult patients admitted to the ICU for at least 48 h with a principal admission diagnosis of sepsis and stayed for at least 48 h. We searched for a secondary episode of sepsis following the primary-one. We performed survival analyses with Cox proportional hazard, Fine-Gray, and multistate models.

RESULTS

In this study, 121 patients that fulfilled the eligibility criteria were included. The secondary sepsis group included 28 (23.1 %) patients, with episode onset, median (interquartile range), 9.5 (7.7-16.2) days after ICU admission, who had less frequently had a medical admission diagnosis, a microbiologically confirmed first episode, and the C-reactive protein was lower. The overall ICU mortality of the cohort was 44.6 %. The group that developed secondary sepsis had higher mortality, but significance was lost in Cox regression [Hazard ratio (95 % CI) 0.59(0.31-1.16)]. However, after multistate modeling adjustment, the attributable mortality was estimated at 43.9 % (95 %CI ± 14.8 %).

CONCLUSION

Secondary sepsis was evident in a quarter of the study participants and may be associated with an increased risk of death.

Evaluation of a closed loop-blood sampling system in intensive care: A pilot randomised controlled trial. The ENCLOSE trial

OBJECTIVE

To test the feasibility of conducting a randomised controlled trial to evaluate the impact of a closed-loop blood sampling system and blood conservation bundle.

METHODS

Single site, parallel group, pilot randomised control trial comparing open system sampling to closed system sampling and conservation bundle aligned with national guidelines. Randomisation sequence was generated by an independent statistician and allocation concealment maintained via sealed opaque envelopes. The study setting was the general intensive care unit of a major metropolitan public hospital in Queensland, Australia. Participants were ≥ 18 years who had an arterial catheter inserted in intensive care. Main outcome measures included trial feasibility, blood sample loss, haematocrit (HCT) change, and packed red blood cell transfusion use.

RESULTS

Eighty patients were randomised (n = 39 open group, n = 41 closed group). Characteristics in each group were equal at baseline with overall median age 60 years (IQR 48.6-70.4), 58 % male, and median APACHE II score 16 (IQR 11-22). The proportion of patients eligible was 29 % and missed eligible was 65 %. Otherwise, feasibility criteria were met with proportion of eligible patients agreeing to enrolment 99 %, 100 % of patients receiving allocated treatment; only 1 % of data missing. Analysis demonstrated a significant reduction in mean daily blood sample losses (open 32.7 (SD 1.58) mL vs closed 15.5 (SD 5.79) mL, t = -8.454, df = 78, p < 0.001).

CONCLUSIONS

A large, multi-site trial is feasible with enhanced eligibility criteria, increased recruitment support. The intervention reduced daily blood sample volumes and transfusion use. Further trials are required to provide both effectiveness and implementation outcomes.

Variation Among Infectious Diseases Pharmacists for the Treatment of Staphylococcus aureus Bacteremia

Introduction: Staphylococcus aureus bacteremia (SAB) remains complex, in that optimal treatment for patients, including complicated or persistent infection, remains unclear. Two recent surveys have demonstrated practice variations in SAB among infectious diseases (ID) physicians. Objectives: The purpose of this survey was to examine practice variations in SAB among ID pharmacists. Methods: A thirty-five-question survey was electronically distributed to the American College of Clinical Pharmacy (ACCP) Infectious Diseases Practice and Research Network (IDPRN) in Fall 2019 to determine differences in SAB management. Data were analyzed utilizing Pearson's Chi-Square or Fisher's Exact Test. Results: A total of 106 ID pharmacists responded. Only 28% of pharmacists practiced at hospitals with mandatory ID consultation for SAB. A majority (75%) had rapid diagnostic technology (RDT) for identifying SABSI, but 32% of those facilities with RDT did not notify pharmacy with results. Anti-staphylococcal penicillins were preferred for MSSA blood stream infections (BSI) in patients with central nervous system infection and endocarditis, whereas cefazolin was favored for other MSSA BSI. For persistent MRSA BSI, 34% selected daptomycin alone while 38% elected to combine daptomycin and ceftaroline. Pharmacists at hospitals less than 500 beds were more likely to use daptomycin, while those at larger hospitals were more likely to use daptomycin and ceftaroline for persistent MRSA BSI (P < .05). Conclusions: A survey of ID pharmacists showed variation in the management of SABs, as well as the definition and treatment of persistent SAB. Mandatory ID consultation and RDT use to improve SAB management have not been optimized.

The effect of duration of antimicrobial treatment for bacteremia in critically ill patients on in-hospital mortality - Retrospective double center analysis

PURPOSE

Excessive duration of antibiotic treatment is a major factor for inappropriate antibiotic consumption. Although in some instances shorter antibiotic courses are as efficient as longer ones, no specific recommendations as to the duration of antimicrobial treatment for bloodstream infections currently exist. In the present study, we investigated the effect of antibiotic treatment duration on in-hospital mortality using retrospective data from two cohorts that included patients with bacteremia at two Swiss tertiary Intensive Care Units (ICUs).

MATERIALS AND METHODS

Overall 8227 consecutive patients requiring ICU admission were screened for bacteremia between 01/2012-12/2013 in Lausanne and between 07/2016-05/2017 in Bern. Patients with an infection known to require prolonged treatment or having single positive blood culture with common contaminant pathogens were excluded. The primary outcome of interest was the time from start of antimicrobial treatment to in-hospital death or hospital discharge, whichever comes first. The predictor of interest was adequate antimicrobial treatment duration, further divided into shorter (≤10 days) and longer (>10 days) durations. A time-dependent Cox model and a cloning approach were used to address immortality bias. The secondary outcomes were the median duration of antimicrobial treatment for patients with bacteremia overall and stratified by underlying infectious syndrome and pathogens in the case of secondary bacteremia.

RESULTS

Out of the 707 patients with positive blood cultures, 382 were included into the primary analysis. Median duration of antibiotic therapy was 14 days (IQR, 7-20). Most bacteremia (84%) were monomicrobial; 18% of all episodes were primary bacteremia. Respiratory (28%), intra-abdominal (23%) and catheter infections (17%) were the most common sources of secondary bacteremia. Using methods to mitigate the risk of confounding associated with antibiotic treatment durations, shorter versus longer treatment groups showed no differences in in-hospital survival (time-dependent Cox-model: HR 1.5, 95% CI (0.8, 2.7), p = 0.20; Cloning approach: HR 1.0, 95% CI (0.7,1.5) p = 0.83). Sensitivity analyses showed that the interpretation did not change when using a 7 days cut-off.

CONCLUSIONS

In this restrospective study, we found no evidence for a survival benefit of longer (>10 days) versus shorter treatment course in ICU patients with bacteremia.

TRIAL REGISTRATION

The study was retrospectively registered on clinicatrials.gov (NCT05236283), 11 February 2022. The respective cantonal ethics commission (KEK Bern # 2021-02302) has approved the study.

Lemierre’s Syndrome: A Cloaked Dagger

Lemierre's syndrome is a condition characterized by septicemia, with bacteremia, thrombophlebitis of the internal jugular vein (IJV), and septic embolization to distant organs following a recent upper respiratory infection (URI). Fusobacterium necrophorum, an anaerobic Gram-negative rod, has been mostly implicated as the causative organism of this condition that tends to affect healthy teenagers and young adults. While once regarded as a disease of old, it has seen a resurgence in recent times, possibly due to antibiotic stewardship and current trends of reduced antibiotic use for URIs. It is important that the modern physician has a high index of suspicion, as well as the characteristic presentation of this potentially fatal illness. Current treatment guidelines are centered on the use of appropriate antibiotics, drainage of purulent collections when possible, and, in some situations, anticoagulants have been utilized. This study describes a case of a young lady who presented with symptoms of chest pain and deteriorating oxygen saturations following recent treatment for acute tonsillitis.

Central venous catheter contamination rate in suspected sepsis patients - an observational clinical study

BACKGROUND

More than 160,000 central-line-associated bloodstream infections (CLABSIs) are estimated for Europe each year leading to about 25,000 deaths. We aimed at characterising the contamination of administration sets in suspected CLABSI cases in the intensive care unit (ICU).

METHODS

In ICU patients (period 02/2017-02/2018) with suspected CLABSI, all sampled central venous catheters (CVCs) were examined in 4 segments (from CVC tip to connected tubing systems) for contamination. A risk factor analysis using binary logistic regression was performed.

RESULTS

52 consecutively sampled CVCs with 1,004 elements were analysed with 45 elements being positive for at least one microorganism (4.48%). There was a significant association with the duration of catheterisation (p=0.038, n=50) with a daily increase of contamination risk by 11.5% (OR 1.115). The mean number of CVC manipulations was 40 within 72 hours (SD: 20.5), with no association with contamination risk (p=0.381). The contamination risk of the CVC segments decreased from proximal to distal. Non-replaceable components of the CVC had a high risk (14 times higher; p=0.01). A significant positive correlation was detected between positive tip cultures and microbial growth in the administration set (r(49)=0.437, p=0.001).

CONCLUSION

Although only a minority of CLABSI-suspect patients had positive blood cultures, the contamination rate of central venous catheters and administration set was high, possibly indicating a relevant under-reporting. The finding of identical species in adjacent segments underlines the role of upward or downward spread of microorganisms within the tubes, therefore aseptic tasks should be emphasized.