Prediction of central venous catheter-related bloodstream infections (CRBSIs) in patients with haematologic malignancies using a modified Infection Probability Score (mIPS)

Systematic review finds risk of bias and applicability concerns for models predicting central line-associated bloodstream infection

OBJECTIVES

To systematically review the risk of bias and applicability of published prediction models for risk of central line-associated bloodstream infection (CLA-BSI) in hospitalized patients.

STUDY DESIGN AND SETTING

Systematic review of literature in PubMed, Embase, Web of Science Core Collection, and Scopus up to July 10, 2023. Two authors independently appraised risk models using CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies (CHARMS) and assessed their risk of bias and applicability using Prediction model Risk Of Bias ASsessment Tool (PROBAST).

RESULTS

Sixteen studies were included, describing 37 models. When studies presented multiple algorithms, we focused on the model that was selected as the best by the study authors. Eventually we appraised 19 models, among which 15 were regression models and four machine learning models. All models were at a high risk of bias, primarily due to inappropriate proxy outcomes, predictors that are unavailable at prediction time in clinical practice, inadequate sample size, negligence of missing data, lack of model validation, and absence of calibration assessment. 18 out of 19 models had a high concern for applicability, one model had unclear concern for applicability due to incomplete reporting.

CONCLUSION

We did not identify a prediction model of potential clinical use. There is a pressing need to develop an applicable model for CLA-BSI.

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.

Scheduled removal of central venous catheters (CVC) to prevent CVC-related bloodstream infections in patients with hematological disease or autologous stem cell transplantation: a registry-based randomized simulation-study

Although not generally recommended, scheduled central venous catheter (CVC) removal is sometimes carried out in order to reduce the CVC-related bloodstream infection (CRBSI) incidence. We conducted a simulation for scheduled CVC removal within the multicenter CRBSI registry (SECRECY). Non-tunneled jugular and subclavian CVC in patients with hematological disease or with germ cell tumors (including patients receiving autologous stem cell transplantation [SCT]) were included. Cases were randomized in a 1:1:1:1 ratio to either a simulated, scheduled CVC removal after 7, 14, and 21 days, or to non-simulated, unscheduled CVC removal (control group). The primary endpoint was definitive CRBSI incidence for a scheduled CVC removal after 14 days (dCRBSI-D14rmv). Among other, secondary endpoints were definite CRBSI incidence for a scheduled removal after 7 days (dCRBSI-D7rmv) and 21 days (dCRBSI-D21rmv). Data on 2984 CVC were included. Patients' median age was 59 (range 16-95) years, 58.8% being male. The vast majority (98.4%) were patients with hematological malignancies. Jugular veins were the main insertion site (93.2%). dCRBSI-D14rmv was 3.10/1000 CVC days as compared to 4.15/1000 CVC days in the control group (p = 0.23). There was a significant difference between dCRBSI-D7rmv (0.86/1000 CVC days) and controls (p < 0.001), but not between dCRBSI-D21rmv (4.10/1000 CVC days) and controls (p = 0.96). Our data suggest that in patients with hematological diseases or autologous SCT recipients scheduled CVC removal after 14 days does not result in a lower CRBSI incidence compared to unscheduled removal.Trial registration: DRKS00006551, 2014/09/29, retrospectively registered.

Peripherally inserted central catheter-related bloodstream infections in patients with hematological malignancies: A retrospective 7-years single-center study

OBJECTIVES

We sought to investigate the nature and incidence of bloodstream infection complications and to identify the risk factors of central catheter-related bloodstream infections (CRBSI).

METHODS

During the study period, 291 consecutive patients with hematological malignancies who underwent PICC placement were retrospectively enrolled. We analyzed the covariates that were specified a priori for their association with CRBSI through multivariate Cox proportional hazards regression models. The association between each predictor and the related outcome was expressed using hazard ratios (HRs) with corresponding 95% confidence intervals (CIs).

RESULTS

Of 391 peripherally inserted central catheter (PICCs) were inserted in 291 patients for a total of 63,714 catheter days during 7 years, with an infection rate of 0.71/1,000 catheter days. Among the patients with hematological malignancies, those with acute leukemia were prone to CRBSI. Having previous bloodstream infection (BSI) (HR 18.139; 95% CI, 8.19-40.174; P < .0001), the number of PICCs insertions (HR 4.695; 95% CI, 1.842-11.967; P = .001) (twice), (HR 6.794; 95% CI, 1.909-24.181; P = .003) (≥3 times) were significantly associated with CRBSI. Not accompanied by chronic comorbidities (HR 0.34; 95% CI, 0.131-0.887; P = .028) and longer duration of PICC use (days) (HR 0.997; 95% CI, 0.994-0.999; P = .008) might be protective factors preventing CRBSI.

CONCLUSIONS

Our finding suggests that previous BSI and a higher number of PICC insertions are associated with an increased risk of CRBSI. A lack of chronic comorbidities may help prevent CRBSI.

Pharmacogenetics-Based Preliminary Algorithm to Predict the Incidence of Infection in Patients Receiving Cytotoxic Chemotherapy for Hematological Malignancies: A Discovery Cohort

Introduction: Infections in hematological cancer patients are common and usually life-threatening; avoiding them could decrease morbidity, mortality, and cost. Genes associated with antineoplastics’ pharmacokinetics or with the immune/inflammatory response could explain variability in infection occurrence.

Objective: To build a pharmacogenetic-based algorithm to predict the incidence of infections in patients undergoing cytotoxic chemotherapy.

Methods: Prospective cohort study in adult patients receiving cytotoxic chemotherapy to treat leukemia, lymphoma, or myeloma in two hospitals in Santiago, Chile. We constructed the predictive model using logistic regression. We assessed thirteen genetic polymorphisms (including nine pharmacokinetic—related genes and four inflammatory response-related genes) and sociodemographic/clinical variables to be incorporated into the model. The model’s calibration and discrimination were used to compare models; they were assessed by the Hosmer-Lemeshow goodness-of-fit test and area under the ROC curve, respectively, in association with Pseudo-R².

Results: We analyzed 203 chemotherapy cycles in 50 patients (47.8 ± 16.1 years; 56% women), including 13 (26%) with acute lymphoblastic and 12 (24%) with myeloblastic leukemia.

Pharmacokinetics-related polymorphisms incorporated into the model were CYP3A4 rs2242480C>T and OAT4 rs11231809T>A. Immune/inflammatory response-related polymorphisms were TLR2 rs4696480T>A and IL-6 rs1800796C>G. Clinical/demographic variables incorporated into the model were chemotherapy type and cycle, diagnosis, days in neutropenia, age, and sex. The Pseudo-R² was 0.56, the p-value of the Hosmer-Lemeshow test was 0.98, showing good goodness-of-fit, and the area under the ROC curve was 0.93, showing good diagnostic accuracy.

Conclusions: Genetics can help to predict infections in patients undergoing chemotherapy. This algorithm should be validated and could be used to save lives, decrease economic costs, and optimize limited health resources.

Venue of catheter insertion does not significantly impact the event of central line-associated bloodstream infection in patients with haematological diseases

Background

Central line-associated bloodstream infection (CLABSI) is a serious complication of central venous catheter (CVC) placement in patients with haematological diseases associated with neutropenia and immunosuppression. However, whether the venues where CVC are inserted influence CLABSI development remains unclear.

Methods

We investigated whether CVC insertion at venues with different standards of cleanliness altered the occurrence of CLABSI. We evaluated data from 279 patients (545 CVC insertions) with haematological diseases including age, sex, underlying disease, reason for insertion, insertion site, number of lumens, venue, dates of insertion and removal, complete blood counts, percentage of neutrophils and serum albumin concentrations at the time of CVC insertion.

Findings

Overall, 55 CLABSI events occurred during a period of 23,434 catheter days (2.35 per 1,000 catheter days). In total, 153 and 190 patients underwent 226 and 305 CVC insertions, respectively in a ward and in an operating room, respectively. Univariate analysis identified the operating room (P = 0.017), allogeneic haematopoietic stem cell transplantation (P < 0.001), triple lumen catheter (P = 0.002), haemoglobin (P = 0.019), white blood cell count (P = 0.012) and percentage of neutrophils (P = 0.012) as significant factors for the development of CLABSI. However, multivariate analysis adjusted for age, reason for insertion, insertion site, number of lumens, haemoglobin, percentage of neutrophils and platelet counts found no significant differences between the venue where CVC were inserted and CLABSI development (P = 0.158).

Conclusion

The venue of CVC insertion is unlikely to influence CLABSI development in patients with haematological diseases.

Detection of central venous catheter-related bloodstream infections in haematooncological patients

BACKGROUND

Catheter-related bloodstream infections (CRBSIs) are currently detected in patients with clinically suspicion. The aim of our study was to evaluate whether CRBSIs could be anticipated and detected in a subclinical stage by peptide nucleic acid fluorescence in situ hybridization (PNA FISH) using universal hybridization probes or acridine orange leucocyte cytospin (AOLC) tests in haematooncological patients with central venous catheters (CVCs) in situ.

MATERIALS AND METHODS

Peptide nucleic acid fluorescence in situ hybridization and AOLC tests using blood samples from one CVC lumen/port chamber in haematooncological patients were continuously performed. These results were compared to those obtained from routinely performed CRBSI diagnostic tests.

RESULTS

One hundred and eighty-two patients with 342 catheter periods were investigated. Seventeen CRBSI cases were detected in 6466 CVC days by routine measures resulting in a CRBSI rate of 2.6/1000 catheter days. Two of 17 showed positive PNA FISH tests, and five positive AOLC test results before the diagnosis were established with routine measures. The screening revealed further seven patients with positive universal PNA FISH tests and 10 positive AOLC tests without symptoms indicative for infection and were therefore considered not to have CRBSI.

CONCLUSIONS

Sampling of only one CVC lumen/port chamber screening for CRBSI in haematooncological patients seems not to be a useful tool for anticipative diagnosis of CRBSI. Reasons for false-negative results might include origin of CRBSIs from the other CVC lumina not sampled for screening, and false-positive results might origin from catheter colonization without subsequent spread of micro-organisms into the peripheral bloodstream.