Central Line Associated Blood Stream Infections in Pediatric Hematology/Oncology Patients With Different Types of Central Lines

Reducing ambulatory central line-associated bloodstream infections: A family-centered approach

BACKGROUND

Ambulatory central line-associated bloodstream infections (CLABSIs) cause significant morbidity and mortality, especially in pediatric oncology. Few studies have had interventions directed toward caregivers managing central lines (CL) at home to reduce ambulatory CLABSI rates. We aimed to reduce and sustain our ambulatory CLABSI rate by 25% within 3 years of the start of a quality improvement intervention.

PROCEDURE

Plan-do-study-act cycles were implemented beginning April 2016. The main intervention was a family-centered CL care skill development curriculum for external CLs. Training began upon hospital CL insertion, followed by an ambulatory teach-back program to achieve home caregiver CL care independence. Other changes included: standardizing ambulatory nurse CL care practice (audits, a train the nurse trainer process, and workshops for independent home care agencies); developing aids for trainers and caregivers; providing supplies for clean surfaces; wide dissemination of the program; and minimizing opportunities of CLABSI (e.g., standardizing timing of CL removal). The outcome measure was the ambulatory CLABSI rate (excluding mucosal barrier injury laboratory-confirmed bloodstream infection), compared pre intervention (January 2015 to March 2016) to post intervention, including 2 years of sustainability (April 2016 to June 2023), using statistical process control charts. We estimated the total number of CLABSI and associated healthcare charges prevented.

RESULTS

The ambulatory CLABSI rate decreased by 52% from 0.25 to 0.12 per 1000 CL days post intervention, achieved within 27 months; 117 CLABSI were prevented, with $4.2 million hospital charges and 702 hospital days avoided.

CONCLUSIONS

Focusing efforts on home caregivers CL care may lead to reduction in pediatric oncology ambulatory CLABSI rates.

Catheter-related complications in onco-hematologic children: A retrospective clinical study on 227 central venous access devices

BACKGROUND

The use of central venous access devices (CVADs) is of paramount importance to safely deliver antiblastic and support therapies in children with cancer. Though, in pediatric patients, as much as in adults, CVADs are potentially associated with severe complications which may result in unscheduled interruption of therapy, hospitalization, increased morbidity/mortality, and increased cost of care.

METHODS

We have reviewed retrospectively our experience with CVADs in children with solid tumors and hematologic diseases, with the purpose of verifying if the adoption of well-defined insertion and maintenance bundles might be effective in reducing catheter-related complications, and in particular catheter-related thrombosis.

RESULTS

A total of 227 CVADs were analyzed: 175 peripherally inserted central catheters (PICCs), 50 centrally inserted central catheters (CICCs), and 2 femorally inserted central catheters. All CVADs were non-valved, non-cuffed power injectable polyurethane catheters; 81% were tunneled. Median dwelling time of CVADs was 172 days, for a total number of 39,044 catheter days. A very low incidence of both symptomatic catheter-related thrombosis (0.9%) and catheter-related blood stream infection (0.56 episodes per 1000 catheter days) was found. Unscheduled removal or guidewire replacement because of mechanic complications occurred in 15.7% of CVADs. There was no difference in terms of complications between PICCs and CICCs or between tunneled and non-tunneled catheters.

CONCLUSIONS

Our experience with CVADs in oncologic and hematologic children suggests that catheter-related complications may be minimized by the adoption of appropriate insertion and maintenance bundles.

Central Line-Associated Bloodstream Infection Risk Factors in a Pediatric Population

BACKGROUND

Central venous line (CVL) placement in children is often necessary for treatment and may be complicated by central line-associated bloodstream infection (CLABSI). We hypothesize that line type and clinical and demographic factors at line placement impact CLABSI rates.

METHODS

This is a single-institution case-control study of pediatric patients (≤18 years old) admitted between January 1, 2015, and December 31, 2019. Case patients had a documented CLABSI. Control patients had a CVL placed during the study period and were matched by sex and age in a 2:1 ratio. Bivariate and multivariate logistic regression analysis was performed.

RESULTS

We identified 78 patients with a CLABSI and 140 patients without a CLABSI. After controlling for pertinent covariates, patients undergoing tunneled or non-tunneled CVL had higher odds of CLABSI than those undergoing PICC (OR 2.51, CI 1.12-5.64 and OR 3.88, CI 1.06-14.20 respectively), and patients undergoing port placement had decreased odds of CLABSI compared to PICC (OR .05, CI 0.01-.51). There were lower odds of CLABSI when lines were placed for intravenous medications compared to those placed for solid tumor malignancy (OR .15, CI .03-.79). Race and age were not statistically significant risk factors.

DISCUSSION

Central lines placed for medication administration compared to solid tumors, PICC compared to tunneled and non-tunneled central lines, and ports compared to PICC were associated with lower odds of CLABSI. Future improvement efforts should focus on PICC and port placement in appropriate patients to decrease CLABSI rates.

Tunnelled external versus implanted port central venous catheters in paediatric oncology: a systematic review and meta-analysis

OBJECTIVE

To evaluate and compare the complications associated with tunnelled external and implanted port (PORT) central venous catheters (CVCs) in children with cancer.

DESIGN

A systematic review in accordance with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines was performed (pre-registered on PROSPERO: CRD42022300869). MEDLINE, Web of Science and the Cochrane Library databases were searched.

PATIENTS

Patients ≤18 years of age with haematological or solid malignancies.

INTERVENTIONS

Studies comparing tunnelled external and PORT CVCs.

MAIN OUTCOMES MEASURES

Infection, mechanical failure, thrombosis, bleeding, acceptability, quality of life (QoL), cost, premature removal, and days from insertion to removal for any reason.

RESULTS

Twenty-three observational studies met the inclusion criteria, representing 6644 devices and 6032 patients. Tunnelled external CVCs were associated with an increased risk for systemic infection (OR 2.10, 95% CI 1.59 to 2.77, p<0.001, 16 studies, 3425 devices). There was no significant difference in the risk of localised infection (OR 1.15, 95% CI 0.66 to 2.01, p=0.62, 5 studies, 979 devices). Tunnelled external CVCs were also associated with a significantly increased risk of mechanical complications (OR 2.47, 95% CI 1.21 to 5.05, p=0.01, 11 studies, 2187 devices) and premature device removal (OR 3.24, 95% CI 1.28 to 8.22, p=0.01, 6 studies, 1514 devices).

CONCLUSION

This study shows that PORTs associate with a reduced risk of infectious and mechanical complications, and a lower overall risk of removal, compared with tunnelled external CVCs in children with cancer. Further work is required to confirm these findings in a prospective randomised trial and to compare cost implications and acceptability to patients and caregivers.

Prolong the flushing and locking interval of TIVAD is feasible in COVID-19: An overview of systematic reviews

The aim of the overview was to synthesize existing systematic reviews (SRs) of flushing interval for patients who inserted totally implanted venous catheter devices (TIVAD). Regular flushing is indispensable for catheter patency, the recommended flushing interval of TIVAD is 4 weeks, however, there is an argument for prolonging the maintenance interval, which has been proved by many SRs. However, the flushing interval range from 4-week to 3-month. The discrepancy in maintenance period could puzzle health professionals and hinder best practice into the clinic. So, we performed the overview by following the PRISMA statement. The PubMed, Ovid, Wan Fang database, Web of Science, CINAHL, CNKI, EMBASE, Cochrane Library were searched from inception to November 2021. The AMSTAR-2, the PRISMA statement, and ROBIS tool were used to assess SRs' method, report quality, and risk of bias, respectively. Then all results were synthesized, the quality of SRs' results was evaluated with GRADE. Finally, five SRs were included. However, non-randomized and small sample size of original studies result in the limitation of SRs. The evidence grade of conclusions is low, bias of mixed factors in included studies, further large sample sizes, RCTs need to be conducted in the future. Prolonged flushing interval was feasible based on the recent evidence, especially during the COVID-19 pandemic because the overwhelming healthcare system and inconvenience of transportation made maintenance not as easy as it used to be. There is no difference of complication between prolonged flushing interval (⩾4-week) and 4-week period, and it can also reduce healthcare cost with no harm to patients.

Central-line-associated bloodstream infections and central-line-associated non-CLABSI complications among pediatric oncology patients

OBJECTIVE

To assess central venous catheter (CVC) harm in pediatric oncology patients, we explored risks for central-line-associated bloodstream infections (CLABSIs) and central-line-associated non-CLABSI complications (CLANCs).

DESIGN

Retrospective cohort study.

SETTING

Midwestern US pediatric oncology program.

PATIENTS

The study cohort comprised 592 pediatric oncology patients seen between 2006 and 2016.

METHODS

CLABSIs were defined according to Centers for Disease Control and Prevention (CDC)/National Health Safety Network (NHSN) definitions. CLANCs were classified using a novel definition requiring CVC removal. Patient-level and central-line-level risks were calculated using a negative binomial model to adjust for correlations between total events and line numbers.

RESULTS

CVCs were inserted in 62% of patients, with 175,937 total catheter days. The inpatient CLABSI and CLANC rates were 5.8 and 8.5 times higher than outpatient rates. At the patient level, shared risks included acute myeloid leukemia (AML) and age <1 year at diagnosis. At the line level, shared risks included age <1 year at diagnosis, non-mediports, and >1 lumen. AML was a CLABSI-specific risk. CLANC-specific risks included non-brain-tumor diagnosis, younger age at diagnosis or central-line placement, and age <1 year at diagnosis or line placement. Multivariable risks were for CLABSI >1 lumen and for CLANC age <1 year at placement.

CONCLUSIONS

Among patients with CVCs, CLABSI and CLANC rates were similar, higher among inpatients than outpatients. For both CLABSIs and CLANCs, infants and patients with AML were at higher risk. In both univariate and multivariate models, lines with >1 lumen were associated with CLABSIs and placement during infancy with CLANCs.

Developing the Key Driver Diagram by Analyzing Home Central Line Caregiver Proficiency Factors

Caregivers of pediatric oncology and stem cell transplant patients often care for central lines (CLs) at home. Methods to achieve caregiver CL care proficiency, and interventions designed with caregiver input are lacking.

Methods

Caregivers of pediatric oncology and stem cell transplant patients patients with an external CL or removed within 2 weeks were eligible for a survey assessing knowledge, the value of training strategies, and comfort. We mapped responses (n = 79) and acceptability/challenges of introducing a pilot caregiver CL teach-back clinic program onto the capability, opportunity, motivation behavioral (COM-B) model of change to identify drivers of caregiver CL care proficiency. A working group, including caregivers, refined and approved a final driver diagram.

Results

Survey: Ninety-four percent of caregivers answered knowledge questions correctly (capability); 95% considered hands-on training helpful (opportunity); 53% were not very comfortable with CL care (motivation). Teach-back: Seventy-nine percent of caregivers were interested in a teach-back as additional training; 38% participated (opportunity); 20% refused participation due to being overwhelmed/not having time (motivation). Thirty-three percent of participants had a CL proficiency assessment (capability). Drivers of home caregiver CL care proficiency included: support for the caregiver's physical capability to perform CL care; enabling the CL care nurse trainer role; facilitating and increasing training opportunities, and engaging caregivers early and continuously to motivate proficiency development appropriately.

Conclusions

An approach centered on caregivers as main stakeholders can identify drivers to co-design an intervention for improved home CL care delivery. A standardized process to train and evaluate caregivers with multiple hands-on opportunities might be beneficial.

Risk of bacterial bloodstream infection does not vary by central-line type during neutropenic periods in pediatric acute myeloid leukemia

BACKGROUND

Bloodstream infections (BSIs) are a frequent cause of morbidity in patients with acute myeloid leukemia (AML), due in part to the presence of central venous access devices (CVADs) required to deliver therapy.

OBJECTIVE

To determine the differential risk of bacterial BSI during neutropenia by CVAD type in pediatric patients with AML.

METHODS

We performed a secondary analysis in a cohort of 560 pediatric patients (1,828 chemotherapy courses) receiving frontline AML chemotherapy at 17 US centers. The exposure was CVAD type at course start: tunneled externalized catheter (TEC), peripherally inserted central catheter (PICC), or totally implanted catheter (TIC). The primary outcome was course-specific incident bacterial BSI; secondary outcomes included mucosal barrier injury (MBI)-BSI and non-MBI BSI. Poisson regression was used to compute adjusted rate ratios comparing BSI occurrence during neutropenia by line type, controlling for demographic, clinical, and hospital-level characteristics.

RESULTS

The rate of BSI did not differ by CVAD type: 11 BSIs per 1,000 neutropenic days for TECs, 13.7 for PICCs, and 10.7 for TICs. After adjustment, there was no statistically significant association between CVAD type and BSI: PICC incident rate ratio [IRR] = 1.00 (95% confidence interval [CI], 0.75-1.32) and TIC IRR = 0.83 (95% CI, 0.49-1.41) compared to TEC. When MBI and non-MBI were examined separately, results were similar.

CONCLUSIONS

In this large, multicenter cohort of pediatric AML patients, we found no difference in the rate of BSI during neutropenia by CVAD type. This may be due to a risk-profile for BSI that is unique to AML patients.

Early removal of a permanent catheter during the acute management of the unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection: a multi-disciplinary survey and review of the literature

There are no guidelines for the optimal manner and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infections (CRBSI). Our goals were to examine current practices of permanent central catheter management and choice of removal in the hemodynamically unstable pediatric patient with suspected CRBSI among practitioners in diverse subspecialties. We performed a literature review on the subject, and conducted a multi-disciplinary survey included pediatric oncologists, pediatric emergency medicine physicians, and pediatric intensive care physicians whom we queried about their choice of permanent central catheter management and removal while treating the hemodynamically unstable pediatric patient with suspected CRBSI. Most of the 78 responders (n = 47, 59%) preferred to utilize the existing permanent central catheter for initial intravenous access rather than an alternative access. There were no significant differences between physician subspecialties (p = 0.29) or training levels (p = 0.14). Significantly more pediatric emergency medicine physicians preferred not to remove the permanent central catheter at any time point compared to the pediatric hemato-oncologists, who preferred to remove it at some point during the acute presentation (44.4% vs. 9.4%, respectively, p = 0.02).

CONCLUSION

Our study findings reflect the need for uniform guidelines on permanent central catheter use and indications for its removal in the hemodynamically unstable pediatric patient. We suggest that permanent central catheter removal should be urgently considered in a deteriorating patient who failed to be stabilized with medical treatment.

WHAT IS KNOWN

• There are no guidelines for the optimal choice and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection (CRBSI).

WHAT IS NEW

• We found variations in practices among pediatricians from diverse subspecialties and conflicting data in the literature. • There is a need for prospective studies to provide uniform guidelines for optimal management of suspected CRBSI in the hemodynamically unstable pediatric patient.

Risk factors for catheter-related infection in children with cancer: A systematic review and meta-analysis

RATIONALE

To understand the risk factors for catheter-related infection during treatment of pediatric cancer is essential to implement measures to prevent its occurrence.

BACKGROUND

We performed a comprehensive systematic review of the literature with meta-analysis to identify and synthesize the main risk factors for catheter-related infection in children undergoing oncological treatment.

METHODS

Systematic searches were conducted in Medline, Embase, Lilacs, and BVS (Biblioteca Virtual em Saúde) until January 2022, following PRISMA guidelines. The search was not limited to language or dates. Risk factors were divided into host-related, assistance-related, and catheter types. We also describe the most common pathogens.

RESULTS

Thirteen studies were included in the review. Diagnosis of hematological neoplasm, the intensity of treatment, blood transfusion in the 4-7 days before the infection, type of long-term catheters (tunneled externalized catheters, double lumen, greater diameter), inpatient treatment, and a longer period of hospitalization were the most consistent risk factors. Metanalysis showed that neutropenia at the moment of catheter placement is not a risk factor for central-line-associated bloodstream infections, however, there is high heterogeneity between studies. Staphylococcus epidermidis was the most common pathogen reported.

CONCLUSIONS

Understanding risk factors is an essential step to reduce morbidity and mortality of catheter-related infection. Education for preventive measures, reduction of hospitalization, wisely choosing the most adequate type of catheter, and the best moment for catheter insertion may reduce the occurrence of catheter-related infection.

Trends of Racial/Ethnic Disparities in Pediatric Central Line-Associated Bloodstream Infections

BACKGROUND AND OBJECTIVES

Central line-associated bloodstream infections (CLABSIs), eminently preventable nosocomial infections, are a substantial source of morbidity, mortality, and increased resource utilization in pediatric care. Racial or ethnic disparities in health outcomes have been demonstrated across an array of medical specialties and practices in pediatric patients. However, it is unknown whether disparities exist in the rate of CLABSIs. Our objective was to evaluate the trends in racial and ethnic disparities of CLABSIs over the past 5 years.

METHODS

This is a retrospective cohort study using data from Pediatric Health Information System database collected from tertiary children's hospitals in the United States. Participants included 226 802 children (<18 years) admitted to the emergency department or inpatient ward between 2016 and 2021 who required central venous catheter placement. The primary outcome was risk-adjusted rate of CLABSI, occurring during the same admission, across race and ethnicity.

RESULTS

Of the 226 802 children, 121 156 (53.4%) were White, 40 589 (17.9%) were Black, and 43 374 (19.1%) were Hispanic. CLABSI rate decreased in all racial/ethnic groups over the study period, with the rates being consistently higher in Black (relative risk [RR], 1.27; 95% confidence interval [CI], 1.17-1.37; P < .01) and Hispanic children (RR, 1.16; 95% CI, 1.08-1.26; P < .01) than in White children. There was no statistically significant evidence that gaps in CLABSI rate between racial/ethnic groups narrowed over time.

CONCLUSIONS

CLABSI rate was persistently higher among Black and Hispanic children than their White peers. These findings emphasize the need for future exploration of the causes of persistent racial and ethnic disparities in pediatric patients.

Central-line–associated bloodstream infections in a pediatric oncology and hematology hospital at home program

Objective:

Central-line–associated bloodstream infections (CLABSIs) are associated with significant morbidity among pediatric oncology-hematology patients, and risk factors remain largely unknown in the setting of hospital at home (HAH). Children in HAH receive intensive treatment (eg, chemotherapy and parenteral nutrition), with frequent central-line handling; thus, they may be at higher risk for CLABSI.

Methods:

We conducted a monocentric retrospective study of patients with a central line included in our HAH program from January 1 to December 31, 2016. HAH patient characteristics for children developing CLABSIs were compared to those who did not, based on blood cultures positive for infection and clinical data of all patients included.

Results:

Overall, 492 HAH stays were analyzed, with 144 patients. The overall CLABSI rate in these patients was 2.6 per 1,000 central-line days. Children who developed CLABSIs were younger (median age, 2.5 vs 8.8 years; P < .001), suffered more from hematological pathologies (malignant or nonmalignant, 75% vs 52%; P = .02), and had more frequently undergone hematopoietic stem-cell transplantation (30.8% vs 6.5%; P = .01). In addition, these patients often had a tunneled externalized catheter as the central line and were more frequently given parenteral nutrition at home (46% vs 8%; P < .001).

Conclusions:

CLABSI rates for children in HAH were more similar to those of inpatients than to rates previously reported for ambulatory patients. The factors associated with infection identified herein should be further validated in multicentric studies and considered to improve HAH practices, parallel to prevention measures used in the inpatient setting.

Quality improvement knowledge in pediatric hematology/oncology physicians: A need for improved education

Pediatric hematology/oncology fellows face unique quality improvement challenges given the danger of chemotherapy and caring for immunocompromised patients. Curricula to teach pediatric hematology/oncology fellows about quality improvement are lacking. We conducted a needs assessment of pediatric hematology/oncology physicians as a first step for creating a quality improvement curriculum for pediatric hematology/oncology fellows. Curricular topics were identified: root cause analysis, run charts, process mapping, chemotherapy/medication safety, implementation/adherence to guidelines. Identified barriers to curriculum implementation included a possible lack of quality improvement expertise, lack of awareness of quality improvement resources, and limited time.

Families' experiences of central-line infection in children: a qualitative study

OBJECTIVE

Central venous access devices (CVADs), often known as central lines, are important for delivering medically complex care in children, and are increasingly used for children living at home. Central line-associated bloodstream infection (CLABSI) is a serious, life-threatening complication. Although the physical consequences of CLABSIs are well documented, families' views and experiences of CLABSI are poorly understood.

DESIGN

Qualitative study using semistructured interviews with participants from 11 families of a child living at home with a CVAD.

PARTICIPANTS

Parents of children aged 4-12 years living at home with a CVAD. Four fathers and nine mothers participated in interviews.

RESULTS

The risk of CLABSI is a constant fear for families of a child with a CVAD. Though avoiding infection is a key priority for families, it is not the only one: maintaining a sense of 'normal life' is another goal. Infection prevention and control require much work and expertise on the part of families, contributing significantly to families' physical and emotional workload.

CONCLUSIONS

Living with the risk of CLABSI poses additional burdens that impact on the physical and emotional well-being of families. Services to better support families to manage these burdens are needed.

Peripherally inserted central catheters have a protective role and the effect of fluctuation curve feature in the risk of bloodstream infection compared with central venous catheters: a propensity-adjusted analysis

Background

The prevention of peripherally inserted central catheters (PICC)-associated BSI and central venous catheters (CVC)-associated BSI have been a topic of national importance in China. Therefore, we aimed to explore the epidemiological characteristics of central line-associated bloodstream infection (CLABSI), and to evaluate whether PICCs were associated with a protective effect for CLABSI.

Methods

A retrospective cohort study was conducted in teaching hospital in Western China. All adult patients received a CVC or PICC during their hospital stay were included from January 2017 to December 2020. Primary endpoint was CLABSI up to 30 days after CVC or PICC placement. Propensity scores with a 2:1 match was used to account for potential confounders, and restricted cubic spline was used to visualize the risk of CLABSI at different time points during the catheterization.

Results

A total of 224687 devices (180522 PICCs and 45965 CVCs) in 24879 patients were included. The overall incidence was 1.8 CLABSIs per 1000 catheter-days. The odds ratio (OR) value increased day by day after PICC insertion, reached a relatively high point on the 4th day, and decreased from days 5 through 8. From the 9th day of intubation the OR value began to gradually increase day by day again. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR = 3.27, 95% CI 2.38–4.49) compared with PICCs.

Conclusions

PICCs have a protective role and the effect of fluctuation curve feature in CLABSI when compared to CVCs, and the first 8 calendar days after CVC insertion are the acute stage of CVC-associated BSI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07265-x.

Postoperative Rather Than Preoperative Neutropenia Is Associated With Early Catheter-related Bloodstream Infections in Newly Diagnosed Pediatric Cancer Patients

BACKGROUND

The relationship of early catheter-related bloodstream infections (CRBSIs) with perioperative neutropenia and antibiotic prophylaxis is not well established. We sought to evaluate perioperative factors associated with early CRBSIs in newly diagnosed pediatric cancer patients, particularly hematologic indices and antibiotic use.

METHODS

We retrospectively reviewed national registry records of newly diagnosed pediatric cancer patients with port-a-caths inserted using standardized perioperative protocols where only antibiotic use was not regulated. Thirty-day postoperative CRBSI incidence was correlated with preoperative factors using logistic regression and with postoperative blood counts using linear trend analysis.

RESULTS

Among 243 patients, 17 CRBSIs (7.0%) occurred at median 14 (range, 8-28) postoperative days. Early CRBSIs were significantly associated with cancer type [acute myeloid leukemia and other leukemias (AML/OLs) vs. solid tumors and lymphomas (STLs): odds ratio (OR), 5.09; P = 0.0036; acute lymphoblastic leukemia vs. STL: OR 0.83; P = 0.0446] but not preoperative antibiotics, absolute neutrophil counts and white blood cell counts. Thirty-day postoperative absolute neutrophil counts and white blood cell trends differed significantly between patients with acute lymphoblastic leukemia and STLs (OR 0.83, P < 0.05) and between AML/OLs and STLs (OR 5.09, P < 0.005), with AML/OL patients having the most protracted neutropenia during this period.

CONCLUSIONS

Contrary to common belief, low preoperative absolute neutrophil counts and lack of preoperative antibiotics were not associated with higher early CRBSI rates. Instead, AML/OL patients, particularly those with prolonged neutropenia during the first 30 postoperative days, were at increased risk. Our findings do not support the use of empirical preoperative antibiotics and instead identify prolonged postoperative neutropenia as a major contributing factor for early CRBSI.

Vascular Access in Pediatric Oncology and Hematology: State of the Art

Management and successful use of vascular access are critical issues in pediatric patients affected by malignancies. Prolonged course of disease, complex and various treatment protocols require long-lasting vascular access providing adequate tools to administrate those therapies and to collect routine blood sampling without painful and repeated venipuncture. For these reasons, central venous catheters are currently an important component in pediatric onco-hematological care, with a direct influence on outcome. Indeed, there are peculiar issues (techniques of insertion, management, complications etc.) which must be well-known in order to improve the outcome and the quality of life of children with cancer.

Mechanical complications of central venous catheters in children: A cohort study

BACKGROUND

Despite the numerous advantages of central venous catheters (CVCs), they have been associated with a variety of complications. Surveillance for mechanical complications of CVCs is not routine, so the true incidence and impact of this adverse patient outcome remains unclear.

SETTING AND METHODS

Prospectively collected CVC data on mechanical complications were reviewed from a centralized database for all in-hospital patient days at our tertiary-care hospital from January 2001 to June 2016 in patients aged <19 years. Patient demographics, CVC characteristics, and rates of mechanical complications per 1,000 days of catheter use were described.

RESULTS

In total, 8,747 CVCs were placed in 5,743 patients during the study period, which captured 780,448 catheter days. The overall mechanical complication rate was 6.1 per 1,000 catheter days (95% confidence interval [CI], 5.9-6.3). The highest complication rates were in nontunneled lines; this was consistent throughout the 15-year study period. Also, 521 CVCs (∼6%) were removed due to mechanical complications before therapy termination. Catheters with tip location in the superior vena cava or right atrium had the fewest complications.

CONCLUSIONS

Mechanical complications of CVCs are a common and significant event in the pediatric population. We propose that CVC-associated mechanical complications become a routinely reported patient safety outcome.

Oral Antibiotic Management of Acute Osteomyelitis of the Hand: Outcomes and Cost Comparison to Standard Intravenous Regimen

Background: Acute, direct inoculation osteomyelitis of the hand has traditionally been managed by intravenous antibiotics. With proven high levels of bone and joint penetration, specific oral antimicrobials may deliver clinical efficacy but at substantially lower cost. Methods: Sixty-nine adult patients with surgically proven acute, direct inoculation osteomyelitis of the hand were evaluated for clinical response on a 6-week postdebridement regimen of susceptibility-matched oral antibiotics. Inclusion required gross purulence and bone loss demonstrated at the initial debridement and radiographic evidence of bone loss. Excluded were 2 patients with extreme medical comorbidities. There were 53 men and 16 women with a mean age of 46 years. Mean follow-up was 16 weeks (±10). The cost model for the outpatient oral antibiotic treatment was intentionally maximized using Walgreen's undiscounted cash price. The cost model for the traditional intravenous treatment regimen was intentionally minimized using the fully discounted Medicare fee schedule. Results: All patients achieved resolution of osteomyelitis by clinical and radiographic criteria. In addition, 7 patients underwent successful subsequent osteosynthesis procedures at the previously affected site without reactivation. The mean postdebridement direct cost of care per patient in the study cohort was $482.85, the cost of the antibiotic alone. The postdebridement direct cost of care per patient on a regimen of vancomycin 1.5 g every 12 hours via peripherally inserted central catheter line was $21 646.90. Conclusions: Acute, direct inoculation osteomyelitis of the hand can be successfully managed on oral antibiotic agents with substantial direct and indirect cost savings.

A comparative two-cohort study of pediatric patients with long term stay in ICUs

During the last decades, the number of patients with long stay admissions (LSA) in PICU has increased. The purpose of this study was to identify factors associated with PICU LSA, assessing healthcare resources use and changes in the profile of these patients. A retrospective, observational, single-center study was carried out. Characteristics of LSA were compared between two periods (2006–2010 and 2011–2015). During the earlier period there were 2,118 admissions (3.9% of them LSA), whereas during the second period, there were 1,763 (5.4% of them LSA) (p = 0.025). LSA accounted for 33.7% PICU stay days during the first period and 46.7% during the second (p < 0.001). Higher use of non-invasive ventilation (80.2% vs. 37.8%, p = 0.001) and high-flow oxygen therapy (68.8% vs. 37.8%, p = 0.005) was observed in the 2011–2015 cohort, whereas the use of arterial catheter (77.1% vs. 92.6%, p = 0.005), continuous infusion of adrenaline (55.2% vs. 75.9%, p = 0.004), and hemoderivative transfusion (74% vs. 89.2%, p = 0.010) was less frequent. In the 2006–2010 cohort, hospital-acquired infections were more common (95.2% vs. 68.8%, p < 0.001) and mortality was higher (26.8% vs. 13.8%, p = 0.026). The number of long-stay PICU admissions have increased entailing an intensive use of healthcare resources. These patients have a high risk for complications and mortality.

Pediatric Ambulatory Central Line-Associated Bloodstream Infections

BACKGROUND

Inpatient pediatric central line-associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes.

METHODS

Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors.

RESULTS

Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4-5.5) and low albumin (OR 2.3; 95% CI: 1.2-4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12-0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16-0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5-13).

CONCLUSIONS

Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.

Impact of a Best Practice Prevention Bundle on Central Line-associated Bloodstream Infection (CLABSI) Rates and Outcomes in Pediatric Hematology, Oncology, and Hematopoietic Cell Transplantation Patients in Inpatient and Ambulatory Settings

BACKGROUND

Pediatric hematology, oncology, and hematopoietic cell transplantation (HCT) patients are at increased risk for bloodstream infections. The authors sought to evaluate the influence of a standardized best practice central venous catheter (CVC) maintenance bundle on the burden of and risk factors for mucosal barrier injury (MBI) and non-MBI central line-associated bloodstream infections (CLABSIs) across a common inpatient and ambulatory continuum in this high-risk population.

METHODS

A retrospective cohort study of patients with underlying malignancy, hematologic disorders, and HCT recipients with a CVC in place at the time of CLABSI diagnosis in both inpatient and ambulatory settings from January 1, 2012 to December 31, 2016. Descriptive, nonparametric statistics were used to describe patient characteristics and outcomes. Logistic regression analyses were applied to identify potential risk factors for inpatient versus ambulatory and MBI versus non-MBI CLABSI.

RESULTS

During the 5-year period, 118 of 808 (14.6%) patients had 159 laboratory-confirmed CLABSIs for ambulatory and inpatient CLABSI rates of 0.27 CLABSI/1000 and 2.2 CLABSI/1000 CVC days, respectively. CLABSI occurred more frequently in hospitalized patients after HCT and with underlying leukemia, most frequently caused by Gram-negative bacteria. MBI CLABSI accounted for 42% of all CLABSI with a 3-fold higher risk in hospitalized patients. Having multiple CVC or a CVC that was not a port independently associated with higher CLABSI risk.

CONCLUSIONS

In our cohort, non-MBI CLABSI continued to account for the majority of CLABSI. CVC type is independently associated with higher overall CLABSI risk. Further studies are needed to reliably define additional prevention strategies when CLABSI maintenance bundles elements are optimized in this high-risk population.

Alcohol-impregnated caps and ambulatory central-line-associated bloodstream infections (CLABSIs): A randomized clinical trial

OBJECTIVE

To evaluate the effect of 70% isopropyl alcohol-impregnated central venous catheter caps on ambulatory central-line-associated bloodstream infections (CLABSIs) in pediatric hematology-oncology patients.

DESIGN

This study was a 24-month, cluster-randomized, 2 period, crossover clinical trial.

SETTING

The study was conducted in 15 pediatric healthcare institutions, including 16 pediatric hematology-oncology clinics.

PARTICIPANTS

All patients with an external central line followed at 1 of the 16 hematology-oncology clinics.

INTERVENTION

Usual ambulatory central-line care per each institution using 70% isopropyl alcohol-impregnated caps at home compared to usual ambulatory central-line care in each institution without using 70% isopropyl alcohol-impregnated caps.

RESULTS

Of the 16 participating clinics, 15 clinics completed both assignment periods. As assigned, there was no reduction in CLABSI incidence in clinics using 70% isopropyl alcohol-impregnated caps (1.23 per 1,000 days) compared with standard practices (1.38 per 1,000 days; adjusted incidence rate ratio [aIRR], 0.83; 95% CI, 0.63-1.11). In the per-protocol population, there was a reduction in positive blood culture incidence in clinics using 70% isopropyl alcohol-impregnated caps (1.51 per 1,000 days) compared with standard practices (1.88 per 1,000 days; aIRR, 0.72; 95% CI, 0.52-0.99). No adverse events were reported.

CONCLUSIONS

Isopropyl alcohol-impregnated central-line caps did not lead to a statistically significant reduction in CLABSI rates in ambulatory hematology-oncology patients. In the per-protocol analysis, there was a statistically significant decrease in positive blood cultures. Larger trials are needed to elucidate the impact of 70% isopropyl alcohol-impregnated caps in the ambulatory setting.

REGISTRATION

ClinicalTrials.gov; NCT02351258.

Instituting a New Central Line Policy to Decrease Central Line-associated Blood Stream Infection Rates During Induction Therapy in Pediatric Acute Lymphoblastic Leukemia Patients

BACKGROUND

Children with acute lymphoblastic leukemia (ALL) require central lines to facilitate their care. Peripherally inserted central catheters (PICCs) may have lower rates of central line-associated bloodstream infections (CLABSIs) versus other central lines.

OBJECTIVES

The objective of this study was to compare the CLABSI rate in the first month of therapy after initiating a policy to place PICCs in new patients with severe neutropenia (SN) and Mediports in those with moderate-to-no neutropenia. We also examined thrombosis rates.

DESIGN/METHOD

We prospectively gathered data on new patients for 2.5 years following the policy change and retrospectively for the 2 years prior and compared rates of CLABSIs and thrombosis.

RESULTS

CLABSIs decreased in SN patients from 7.52/1000 to 3.11/1000 line days (P=0.33). The CLABSI rate for all patients with SN who had a Mediport was 13.39/1000 versus 4.08/1000 line days for those that received PICCs (P=0.15). The thrombosis rate for Mediport patients was 3.13 clots/1000 versus 7.65/1000 line days for PICC patients, but the difference was not significant (P= 0.11).

CONCLUSION

The differences observed suggest that placing PICCs versus Mediports in new ALL patients with SN may result in a lower incidence of CLABSIs in the first month of therapy without a significant increase in thrombosis.

Costs of ambulatory pediatric healthcare-associated infections: Central-line–associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs)

Objective:

Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery.

Design:

Retrospective case-control study.

Setting:

Four academic medical centers.

Patients:

Children aged 0–22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries.

Methods:

Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0.

Results:

Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005–$10,362) and $6,502 (95% CI, $2,261–$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, −$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022–$8,719).

Conclusions:

Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.

Occurrence and Risk Factors for Unplanned Catheter Removal in a PICU: Central Venous Catheters Versus Peripherally Inserted Central Venous Catheters

OBJECTIVES

We aimed to identify the occurrence and risk factors for unplanned catheter removal due to catheter-associated complications and the effects on catheter survival probability in a PICU.

DESIGN

Retrospective, single-center, observational study of cases involving conventional central venous catheters or peripherally inserted central venous catheters.

SETTING

The PICU of a tertiary children's hospital.

PATIENTS

Consecutive PICU patients with central venous catheters between April 2016 and February 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified unplanned catheter removals that were related to central line-associated bloodstream infection, thrombosis, and mechanical complications. During the study period, 582 central venous catheters and 474 peripherally inserted central venous catheters were identified. The median durations of catheter placement were 4.0 days for central venous catheters and 13.0 days for peripherally inserted central venous catheters (p < 0.001), and unplanned catheter removals due to catheter-associated complications were in 52 (8.9%) central venous catheter cases and 132 (27.8%) peripherally inserted central venous catheter cases (p < 0.001) (15.0 and 16.0 per 1,000 catheter-days, respectively [p = 0.75]). Unplanned catheter removal was associated with a peripheral catheter tip position among both central venous catheters and peripherally inserted central venous catheters (p < 0.001 and p = 0.001), and it was associated with surgical patient status among peripherally inserted central venous catheters (p = 0.009). In contrast, the use of ultrasound-guided insertion was associated with a lower occurrence of unplanned catheter removal among peripherally inserted central venous catheters (p = 0.01). With regard to catheter survival probability, there was no significant difference between central venous catheters and peripherally inserted central venous catheters (p = 0.23). However, peripherally inserted central venous catheters had a lower occurrence of central line-associated bloodstream infection than central venous catheters (p = 0.03), whereas there was no significant difference in the rates of thrombosis (p = 0.29) and mechanical complications (p = 0.84) between central venous catheters and peripherally inserted central venous catheters.

CONCLUSIONS

In a PICU, peripherally inserted central venous catheters had lower occurrence of central line-associated bloodstream infection than central venous catheters; however, similar catheter survival probabilities were observed between both catheters. A central catheter tip position for both catheters and ultrasound-guided insertion for peripherally inserted central venous catheters may help limit unplanned catheter removal due to catheter-associated complications.

Extracorporeal Membrane Oxygenation as a Bridge to Chimeric Antigen Receptor T-cell Therapy for Severe Refractory Sepsis in the Setting of Relapsed Refractory Pediatric Acute Lymphoblastic Leukemia: A Case Report

Pediatric oncology patients with sepsis are at higher risk of morbidity and mortality compared with pediatric patients without malignancy. Historically, patients with relapsed and/or refractory disease were not considered candidates for aggressive life support strategies including extracorporeal membrane oxygenation support.

Central line bundle including split-septum device and single-use prefilled flushing syringes to prevent port-associated bloodstream infections: a cost and resource-utilization analysis

Background

Central line bundle programs were found to be effective in decreasing central line-associated bloodstream infection rates in pediatric cancer patients with ports. However, cost-effectiveness studies of central line bundle programs in pediatric cancer patients are limited, and most available data are from intensive care unit or adult studies.

Methods

In this cross-sectional study spanning 6 years, comprehensive assessment of total health care costs attributable to CLABSI’s associated with ports between two periods.

Results

This cross-sectional study was carried out in the pediatric hematology-oncology ward of Dr. Behçet Uz Children’s Hospital from 1 August November 2011 to 31 July 2017. The CLABSI rates decreased significantly from 8.31 CLABSIs to 3.04 per 1000 central line days (p < 0.001). In the pre-bundle period, total attributable costs spent for of patients with CLABSI were $130,661, and in the bundle period, total attributable costs spent for patients with CLABSI were $116,579. Within bundle implantation, 71 potential CLABSI were prevented, which saved an additional $208,977.

Conclusion

Our study shows that central line bundles decreases not only the CLABSI rate but also decreases attributable costs due to CLABSI. Expenses spent for bundle elements, were covered by savings by preventing CLABSI with higher costs.

Length of Stay Predicts Risk of Early Infection for Hospitalized Patients Undergoing Central Venous Port Placement

PURPOSE

To compare early totally implantable central venous port catheter-related infection rates after inpatient vs outpatient placement and to determine whether the risk associated with inpatient placement is influenced by length of hospital stay.

MATERIALS AND METHODS

In this single-institution retrospective study, 5,301 patients (3,618 women; mean age 57 y) underwent port placement by interventional radiologists between October 2004 and January 2018. The 30-day infection rate was compared between inpatients and outpatients using survival analysis. Among inpatients, the effect of time from admission to port placement and from placement to discharge was analyzed using a survival regression tree.

RESULTS

The 30-day infection rate was 3.6% (95% confidence interval [CI] = 1.9%-6.1%) among 386 inpatients and 1.0% (95% CI = 0.7%-1.3%) among 4,915 outpatients (hazard ratio [HR] = 3.6, 95% CI = 2.0-6.6, P < .001). Inpatient placement was a significant risk factor after accounting for covariates in multivariate analysis (HR = 2.2, 95% CI = 1.0-4.7, P = .05) and controlling for demographic differences by propensity score matching (HR = 2.8, 95% CI = 1.0-7.8, P = .04). Infection rate was 11% (95% CI = 4.7%-22%) among 65 inpatients in whom time from admission to placement was ≥ 7 days, 5.1% (95% CI = 1.9%-11%) among 129 inpatients in whom admission to placement was < 7 days and time to discharge was > 3 days, and 0% (95% CI = 0%-2.1%) among 192 inpatients in whom admission to placement was < 7 days and time to discharge was ≤ 3 days (P < .001).

CONCLUSIONS

Inpatient port placement was associated with a higher risk of early infection. However, a clinical decision tree based on shorter length of stay before and after placement may identify a subset of hospitalized patients not at increased risk for infection.

Risk factors for central line-associated bloodstream infections in children with tunneled central venous catheters

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are among the most common complications of central venous catheters (CVCs). The aim of this study was to examine the epidemiology of CLABSIs in tunneled CVCs and analyze their risk factors in a general pediatric population.

METHODS

Children with a tunneled CVC inserted at the University Children's Hospital Zürich between January 2009 and December 2015 were eligible for the study. The influence of CVC dwell time on the risk of CLABSI was examined using life tables. Hazard ratios (HRs) for CLABSIs were analyzed using Cox regression for age and diagnosis with cluster robust standard errors.

RESULTS

Fifty-five CLABSIs were observed in 193 patients with 284 tunneled CVCs. Overall, CVCs in children with gastrointestinal disorders and in children 2 to 5 years of age showed the highest incidence rates of 6.06 and 5.85 CLABSIs per 1,000 catheter days, respectively, during the first 90 days after placement. Gastrointestinal disease (HR, 3.89; 95% CI, 2.19-6.90; P < .001) and age 2 to 5 years (HR, 2.48; 95% CI, 1.45-4.22; P = .001) were identified as independent risk factors for CLABSI. In children without gastrointestinal disease, tunneled CVCs showed an increasing risk of CLABSI after a dwell time of 90 days.

CONCLUSIONS

The need for tunneled CVCs requires the evaluation of targeted CLABSI prevention measures, especially in young children with underlying gastrointestinal disease.

Surveillance of home health central venous catheter care outcomes: Challenges and future directions

BACKGROUND

Limited data are available regarding central venous catheter (CVC)-related complications that occur in home care. A practical out-of-hospital surveillance mechanism is needed.

METHODS

Home health/infusion agencies in 4 states submitted monthly data from January 2011 through March 2015. Data were collected by patient age and included number of patients on service with a CVC, device days, central line-associated bloodstream infection (CLABSI), CVC-occlusions, doses of fibrinolytics administered, and number of patients receiving fibrinolytics.

RESULTS

Ten agencies from 4 states contributed data across the study period. A total of 913 occlusions and 73 CLABSIs occurred during the 51-month surveillance period. The CLABSI rates per 1,000 device days per year across the study surveillance period ranged from 0-0.40 for pediatric and from 0-0.37 for adult patients, whereas occlusion rates per 1,000 device days ranged from 0.26-1.59 for pediatric and from 2.59-33.29 for adult patients. Doses of fibrinolytic agents administered per 1,000 device days ranged from 0.26-1.80 in pediatric and 3.53-33.85 in adult patients.

CONCLUSIONS

Opportunities exist to further expand efforts to quantify the presence of CVCs in home settings to enable improvements with measuring and tracking patient outcomes as they relate to CVC care. Exploration of continued sustainability of surveillance and data validation are warranted to optimize home health/infusion care practices and outcomes.

Incidence, severity and outcome of central line related complications in pediatric oncology patients; A single center study

BACKGROUND

Central venous access device (CVAD)-related complications are associated with high morbidity rates. This study was performed to underline the importance of CVAD-complication prevention and treatment.

METHODS

An audit of practice of CVAD-related complications in pediatric oncology patients receiving a CVAD between January 2015 and June 2017 was performed. CVADs included were totally implantable venous access ports (TIVAPs), Hickman-Broviac® (HB), nontunneled, and peripherally inserted CVADs.

RESULTS

A total of 201 children, with 307 CVADs, were analyzed. The incidence rates per 1000 CVAD-days for the most common complications were 1.66 for malfunctions, and 1.51 for central line-associated bloodstream infections (CLABSIs). Of all CVADs inserted, 37.1% were removed owing to complications, of which 45.6% were owing to CLABSIs. In 42% of the CLABSIs, the CLABSI could be successfully cured with systemic antibiotic treatment only. Of all included patients, 5.0% were admitted to the intensive care unit owing to CLABSI. The HB-CVAD compared to the TIVAP was a risk factor for CVAD-related complications, CLABSIs and dislocations in particular.

CONCLUSIONS

The incidence of CVAD-related complications is high. Research on the prevention and treatment of CVAD-related complications in pediatric oncology patients should be a high priority for all health care professionals.

TYPE OF STUDY

Prognosis study (retrospective).

LEVEL OF EVIDENCE

Level II.

Clinical profile and outcome of antibiotic lock therapy for bloodstream infections in pediatric hematology/oncology patients in a tertiary care hospital, Karachi, Pakistan

Background

Intravascular catheters are susceptible to infections, thus requiring catheter removal and leading to increased morbidity and costs. Antibiotic lock therapy (ALT) is a therapeutic technique that is used to salvage the catheter. The aim of this study was to evaluate the outcome of antibiotic lock therapy in bloodstream infections in pediatric hematology/oncology patients in a tertiary care hospital, Karachi.

Methods

A retrospective review was performed from January 2013 to December 2017 of pediatric hematology/oncology patients with bloodstream infections and who received ALT at Aga Khan University Hospital. All cases of polymicrobial infections, catheter removal, or malfunction before the completion of ALT were excluded. Descriptive analysis was carried out using SPSS version 20.

Results

A total of nine hematology/oncology patients were eligible. The catheter was salvaged in 7/9 (77.8%) children, and in 2/9 (22.2%) cases, catheter was removed because of persistent bacteremia. The most common organism isolated was Staphylococcus non-aureus species (33.3%). Relapse with a similar pathogen occurred in 2 (22.2%) patients and 2 (22.2%) of them developed an exit-site infection.

Conclusion

In our experience, in almost two thirds of the cases, the catheter was salvaged, but disappointingly, relapses were high when the infection was due to Staphylococcus spp. Although this is a small study, our results show that ALT can be a potential safe adjunctive strategy to treat catheter-related bloodstream infections (CRBSI). However, we need larger prospective studies to test the safety and efficacy of ALT to develop specific ALT recommendations and guidelines particularly in children.

Peripherally inserted central catheters are associated with lower risk of bloodstream infection compared with central venous catheters in paediatric intensive care patients: a propensity-adjusted analysis

PURPOSE

Central line-associated bloodstream infection (CLABSI) is an important cause of complications in paediatric intensive care units (PICUs). Peripherally inserted central catheters (PICCs) could be an alternative to central venous catheters (CVCs) and the effect of PICCs compared with CVCs on CLABSI prevention is unknown in PICUs. Therefore, we aimed to evaluate whether PICCs were associated with a protective effect for CLABSI when compared to CVCs in critically ill children.

METHODS

We have carried out a retrospective multicentre study in four PICUs in São Paulo, Brazil. We included patients aged 0-14 years, who needed a CVC or PICC during a PICU stay from January 2013 to December 2015. Our primary endpoint was CLABSI up to 30 days after catheter placement. We defined CLABSI based on the Center for Disease Control and Prevention's National Healthcare Safety Networks (NHSN) 2015 surveillance definitions. To account for potential confounders, we used propensity scores with inverse probability weighting.

RESULTS

A total of 1660 devices (922 PICCs and 738 CVCs) in 1255 children were included. The overall CLABSI incidence was 2.28 (95% CI 1.70-3.07)/1000 catheter-days. After covariate adjustment using propensity scores, CVCs were associated with higher risk of CLABSI (adjHR 2.20, 95% CI 1.05-4.61; p = 0.037) compared with PICCs. In a sensitivity analysis, CVCs remained associated with higher risk of CLABSI (adjHR 2.18, 95% CI 1.02-4.64; p = 0.044) after adding place of insertion and use of parenteral nutrition to the model as a time-dependent variable.

CONCLUSIONS

PICC should be an alternative to CVC in the paediatric intensive care setting for CLABSI prevention.

Risk for Health Care-Associated Bloodstream Infections in Pediatric Oncology Patients With Various Malignancies

This was a retrospective cohort study to identify the rates, predictors, and outcomes of health care-associated bloodstream infections (HA-BSI) among children with solid tumors, lymphoma, lymphoid leukemia, and myeloid leukemia. The study population included 4500 children ≤18 years old at a pediatric hospital in New York City from 2006 to 2014. A total of 147 HA-BSI cases were identified; using multivariable logistic regression modeling, children with a hematologic diagnosis (lymphoma, lymphoid leukemia, myeloid leukemia) were at greater risk for HA-BSI than those with a solid tumor diagnosis (all P values <.0001). The odds of mortality for patients with HA-BSI were 6.98 (95% confidence interval 3.02-16.10) times that of those without HA-BSI. Although malignancy type was identified as risk factor for HA-BSI, there was no significant difference in overall mortality from HA-BSI by tumor type ( P = .51).