The Centers for Disease Control and Prevention definition of mucosal barrier injury-associated bloodstream infection improves accurate detection of preventable bacteremia rates at a pediatric cancer center in a low- to middle-income country

The Effect of Gastrointestinal Mucositis Care Training Given to Pediatric Leukemic Patients and Caregivers on Mucosal Barrier Injury

BACKGROUND

Management of chemotherapy-induced mucosal barrier damage and oral/anal mucositis in leukemia is challenging.

OBJECTIVE

The aim of this study was to investigate the effect of mucositis care training given to children receiving leukemia treatment and their caregivers on caregiver knowledge and skills, the development of gastrointestinal mucositis in children, the mean oral mucositis area in children, and the mucosal barrier injury laboratory-confirmed bloodstream infection in the clinic.

METHODS

A stepped-wedge, quasi-experimental, unpaired control group design was used. The participants in the control group were given routine training, and the intervention group members were given mucositis care training in accordance with the guideline recommendations.

RESULTS

No significant difference was found between groups in developing anal mucositis, but a significant difference in developing oral mucositis was documented, with the mean mucositis area of children being 8.36 ± 3.97 cm2 in the control group and 4.66 ± 2.90 cm2 in the intervention group. The mucosal barrier injury laboratory-confirmed bloodstream infection ratio was 4 per 1000 catheter days in the control group and 3 per 1000 catheter days in the intervention group.

CONCLUSION

Mucositis care training had a significant positive effect on caregivers' knowledge and skills, the development of oral mucositis, and the mean oral mucositis area in children. However, the training had no effect on the development of anal mucositis or the infection rate in the clinic.

IMPLICATIONS FOR PRACTICE

Nurses might increase the knowledge and skill levels of caregivers with training on mucositis care, prevent the development of mucositis, and reduce the mean mucositis area. Training might also contribute to the reduction in the infection rate of the clinic.

Hematopoietic stem-cell transplantation in a zoo of multidrug-resistant organisms: Data from a cancer center in eastern India

BACKGROUND

Infections by multidrug-resistant organisms (MDRO) are a major hurdle in hematopoietic stem-cell transplants (HSCTs). Conditioning regimens lead to mucosal barrier injury, which in-turn leads to transmigration of gut bacteria and sepsis. Pre-transplant stool and throat surveillance cultures can guide empirical antibiotic policy during the neutropenic period. In this paper, we document colonization with MDRO in pre-transplant surveillance cultures and the correlation with bloodstream infections in HSCT patients and analyze transplant outcomes with respect to these infections.

METHODS

A single-center, retrospective study on HSCT was performed between January 2021 and December 2021. The incidence of bacterial infections, percentage of MDROs, correlation with pre-transplant stool/throat surveillance cultures, and their impact on overall 100-day and post-100-day to 6-month post-transplant survival were analyzed.

RESULTS

Sixty-four patients were included in the study. Pre-transplant stool surveillance cultures were positive for MDRO in 85.9% of patients. Almost half (48.5%) of the isolates were positive for carbapenemase-producing genes (mainly New Delhi metallo-beta-lactamase-1 [NDM-1] and oxacillinase-48 [OXA-48]). Eighteen patients (18/64, 28%) had a positive blood culture for MDRO in the peri-engraftment neutropenic period. Correlation between surveillance and blood cultures was seen in 61% (11/18) of patients. All-cause mortality was 14.1% (9/64) and 25% (16/64) in patients at 100 days and 6 months post-HSCT, respectively. The 100-day and post-100-day all-cause mortality rates were higher in patients with Gram-negative MDRO bloodstream infections (p < .012 and <.008, respectively).

CONCLUSION

MDRO infections can adversely affect HSCT outcomes. Pre-transplant stool and throat surveillance cultures may guide empirical antibiotic policy and lead to favorable transplant outcomes.

Tracking gut microbiome and bloodstream infection in critically ill adults

BACKGROUND

The gut microbiome is believed to contribute to bloodstream infection (BSI) via translocation of dominant gut bacteria in vulnerable patient populations. However, conclusively linking gut and blood organisms requires stringent approaches to establish strain-level identity.

METHODS

We enrolled a convenience cohort of critically ill patients and investigated 86 bloodstream infection episodes that occurred in 57 patients. Shotgun metagenomic sequencing was used to define constituents of their gut microbiomes, and whole genome sequencing and assembly was done on 23 unique bloodstream isolates that were available from 21 patients. Whole genome sequences were downloaded from public databases and used to establish sequence-identity distribution and define thresholds for unrelated genomes of BSI species. Gut microbiome reads were then aligned to whole genome sequences of the cognate bloodstream isolate and unrelated database isolates to assess identity.

RESULTS

Gut microbiome constituents matching the bloodstream infection species were present in half of BSI episodes, and represented >30% relative abundance of gut sequences in 10% of episodes. Among the 23 unique bloodstream organisms that were available for whole genome sequencing, 14 were present in gut at the species level. Sequence alignment applying defined thresholds for identity revealed that 6 met criteria for identical strains in blood and gut, but 8 did not. Sequence identity between BSI isolates and gut microbiome reads was more likely when the species was present at higher relative abundance in gut.

CONCLUSION

In assessing potential gut source for BSI, stringent sequence-based approaches are essential to determine if organisms responsible for BSI are identical to those in gut: of 14 evaluable patients in which the same species was present in both sites, they were identical in 6/14, but were non-identical in 8/14 and thus inconsistent with gut source. This report demonstrates application of sequencing as a key tool to investigate infection tracking within patients.

A surveillance program for long-term central venous access-associated infections in outpatient chemotherapy services

OBJECTIVE

In this study, we described the first results of a surveillance system for infections associated with long-term central venous catheters (LT-CVC) in patients under outpatient chemotherapy.

DESIGN

This was a multicentric, prospective study.

SETTING

Outpatient chemotherapy services.

PARTICIPANTS

The study included 8 referral cancer centers in the State of São Paulo.

INTERVENTION

These services were invited to participate in a newly created surveillance program for patients under chemotherapy. Several meetings were convened to share previous experiences on LT-CVC infection surveillance and to define the surveillance method. Once the program was implemented, all bloodstream infection (LT-CVC BSIs), tunnel infection, and exit-site infections associated with LT-CVC were reported. Data from January to May 2021 were analyzed. The median monthly number of chemotherapy sessions per clinic was 925 (IQR, 270-5,855). We used Poisson regression to analyze the association of rates with the characteristics of the services.

RESULTS

In total, 107 LT-CVC infections were reported, of which 95% were BSIs, mostly associated with totally implantable devices (76%). Infections occurred a median of 4 days after the last catheter manipulation and 116 after the LT-CVC insertion. Also, 102 microorganisms were isolated from LT-CVC BSIs; the most common pathogen was Staphylococcus epidermidis, at 22%. Moreover, 44 infections (44%) fulfilled the criteria for CVC-related LT-CVC BSI and 27 infections (27%) met the criteria for mucosal barrier injury. The 1-year cumulative LT-CVC BSI rate was 1.94 per 1,000 CVC days of use. The rates were higher in public hospitals (IRR, 6.00; P < .001) and in hospitals that already had in place surveillance for LT-CVC infections (IRR, 2.01; P < .01).

CONCLUSION

Our study describes an applicable surveillance method for infections in cancer outpatients using LT-CVC.

Association between parenteral nutrition-containing intravenous lipid emulsion and bloodstream infections in patients with single-lumen central venous access: A secondary analysis of a randomized trial

BACKGROUND

Distinguishing primary bloodstream infections (BSIs) related to central venous access devices (CVADs) from those that occur through other mechanisms, such as a damaged mucosal barrier, is difficult.

METHODS

Secondary analysis was conducted on data from patients with CVADs that were collected for a large, randomized trial. Patients were divided into two groups: those who received parenteral nutrition (PN)-containing intravenous lipid emulsion (ILE) and those who did not have PN-containing ILE. This study investigated the influence of PN-containing ILE (ILE PN) on primary BSIs in patients with a CVAD.

RESULTS

Of the 807 patients, 180 (22%) received ILE PN. Most (627/807; 73%) were recruited from the hematology and hematopoietic stem cell transplant unit, followed by surgical (90/807; 11%), trauma and burns (61/807; 8%), medical (44/807; 5%), and oncology (23/807; 3%). When primary BSI was differentiated as a central line-associated BSI (CLABSI) or mucosal barrier injury laboratory-confirmed BSI (MBI-LCBI), the incidence of CLABSI was similar in the ILE PN and non-ILE PN groups (15/180 [8%] vs 57/627 [9%]; P = 0.88) and the incidence of MBI-LCBI was significantly different between groups (31/180 [17%] ILE PN vs 41/627 [7%] non-ILE PN; P < 0.01).

CONCLUSION

Our data indicate that twice as many primary BSIs in ILE PN patients are due to MBIs than CVADs. It is important to consider the MBI-LCBI classification, as some CLABSI prevention efforts aimed at CVADs for the ILE PN population may be better directed to gastrointestinal tract protection interventions.

Predictors of Central Vascular Access Device Bloodstream Infections in Patients With Acute Leukemia and Neutropenia: A Retrospective Case-Control Chart Review

Central vascular access devices (CVADs) are standard for the treatment of leukemia. The objectives of this study were to examine predictors for central line-associated bloodstream infection (CLABSI) and causative microorganisms. A retrospective case/control design was used to examine electronic health records (EHRs) of patients with acute leukemia, a CVAD, and neutropenia. Variables were examined for differences between those who developed bacteremia (cases: n = 10) and those who did not (controls: n = 13). Variables included conditions of health (eg, patient history, laboratory results at the time of nadir, nutritional intake during hospitalization, and CVAD care practices). Fisher exact and Mann-Whitney U tests were used for comparison. Nine organisms were identified, including viridans group streptococci (20%) and Escherichia coli (20%). No statistical differences in variables were found between groups. However, over 50% of the nutritional intake data was missing due to lack of documentation. These findings indicate that further study is needed to examine barriers for electronic documentation. The data collection site found opportunities to improve patient care that included education regarding the daily care of CVADs, collaboration with nutritional services to ensure accurate assessments, and coordination with clinical information systems to improve clinical documentation compliance.

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.

Outcomes for critical illness in children with cancer: Analysis of risk factors for adverse outcome and resource utilization from a specialized center in Mexico

Introduction

Children with cancer have a higher risk of adverse outcomes during critical illness than general pediatric populations. In Low- and middle-income countries, lack of resources can further negatively impact outcomes in critically ill children with cancer.

Methods

In this study, we describe the outcomes of a large cohort of children with cancer including mortality and resource utilization. We performed a retrospective review of all patients admitted to our PICU between December 12th, 2013 and December 31st, 2019. Outcomes were defined as recovery or death and resource utilization was described via use of critical care interventions, Length of stay as well as PICU- and Mechanical Ventilation- free days.

Results

Overall mortality was 6.9% while mortality in the unplanned admissions was 9.1%. This remained lower than expected mortality based on PIM2 scoring. Type of PICU admission, Neurological Deterioration as a cause of PICU admission, and PIM2 were significant as risk factors in univariate analysis, but only PIM2 remained significant in the multivariate analysis.

Discussion

Our Study shows that high survival rates are achievable for children with cancer with critical illness in resource-limited settings with provision of high-quality critical care. Organizational and clinical practice facilitating quality improvement and early identification and management of critical illness may attenuate the impact of known risk factors for mortality in this population.

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

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

The Golden Hour: Sustainability and Clinical Outcomes of Adequate Time to Antibiotic Administration in Children with Cancer and Febrile Neutropenia in Northwestern Mexico

PURPOSE

Time to antibiotic administration (TTA) is a commonly used standard of care in pediatric cancer settings in high-income countries. Effective interventions to improve outcomes in cancer patients with febrile neutropenia (FN) often address timely and appropriate antibiotic administration. We assessed the effectiveness of a locally adapted multimodal strategy in decreasing TTA in a resource-constrained pediatric cancer center in Mexico.

METHODS

We conducted a prospective observational study between January 2014 and April 2019. A three-phase (phase I: execution, phase II: consolidation, phase III: sustainability) multimodal improvement strategy that combined system change, FN guideline development, education, auditing and monitoring, mentoring, and dissemination was implemented to decrease TTA in inpatient and ambulatory areas. Sustainability factors were measured by using a validated tool during phases I and III.

RESULTS

Our population included 105 children with cancer with 204 FN events. The baseline assessment revealed that only 50% of patients received antibiotics within 60 minutes of prescription (median time: inpatient, 75 minutes; ambulatory, 65 minutes). After implementing our improvement strategy, the percentage of patients receiving antibiotics within 60 minutes of prescription increased to 88%. We significantly decreased median TTA in both clinical areas during the three phases of the study. In phase III (sustainability), the median TTA was 40 minutes (P = .023) in the inpatient area and 30 minutes (P = .012) in the ambulatory area. The proportion of patients with sepsis decreased from 30% (baseline) to 5% (phase III) (P = .001).

CONCLUSION

Our results demonstrate that locally adapted multimodal interventions can reduce TTA in resource-constrained settings. Mentoring and dissemination were novel components of the multimodal strategy to improve FN-associated clinical outcomes. Improving local infrastructure, ongoing monitoring systems, and leadership engagement have been key factors to achieving sustainability during the 5-year period.

Line days as a determinant of central line-associated bloodstream infections in pediatric patients with tunneled femoral peripherally inserted central catheters

BACKGROUND

Ultrasound (US)-guided tunneled femoral peripherally inserted central catheters (PICCs) are a safe central venous access option in infants and neonates. Studies have shown, however, that femoral central venous access has the potential for high central line-associated bloodstream infection (CLABSI) rates with a significant increase in risk around line day 30, though no studies have evaluated these risks exclusively for tunneled femoral PICCs.

OBJECTIVE

The primary purpose of this study was to evaluate the relationship between line duration and the risk of CLABSI in tunneled femoral PICCs in children.

MATERIALS AND METHODS

Four hundred forty-five patients (196 females, 249 males; median age: 49.4 days; median weight: 3.7 kg) who underwent 573 tunneled femoral PICC placements or exchanges from Jan. 1, 2017, to Jan. 31, 2020, were included in the study. All tunneled femoral PICCs were placed using US technique and catheter specifications, including catheter size (French) and length (cm), were retrieved from the electronic medical record. The location of the PICC placement, the number of lumens, the laterality of placement, and the patient's age and weight were also recorded. Only non-mucosal barrier injury CLABSIs, according to the Centers for Disease Control and Prevention (CDC) definitions, were counted as CLABSI for this study. The number of central line days until a CLABSI event was analyzed with an accelerated failure time model using the exponential, Weibull, and log-normal distributions to determine the probability of a CLABSI over time, taking into consideration the recorded covariates.

RESULTS

Tunneled femoral PICC placements accounted for 14,855 line days, during which 20 non-mucosal barrier injury CLABSIs (CLABSI rate of 1.35 per 1,000 line days) occurred during the study period. The highest CLABSI rate occurred in PICCs placed in the neonatal intensive care unit (NICU) at 2.01 per 1,000 line days and the lowest occurred in PICCs placed in interventional radiology at 0.26 per 1,000 line days. Overall, PICCs placed outside of interventional radiology had a CLABSI rate of 1.72 per 1,000 line days. The CLABSI rate during the first 30 days a line was in situ was lower than the rate after 30 days (0.51 per 1,000 line days vs. 3.06 per 1,000 line days, respectively). Statistical modeling and hazard estimation using the Akaike information criterion corrected for small sample size (AICc)-average of log-normal, Weibull and exponential distributions demonstrate the daily risk of CLABSI rapidly increases from day 1 to day 30, with the risk remaining high for the duration of line days.

CONCLUSION

While tunneled femoral PICCs are a relatively safe and effective central venous access alternative, the rate of CLABSI appears to rapidly increase with increasing line days until around day 30 and then remains high thereafter.

Mucosal barrier injury-associated bloodstream infections in pediatric oncology patients

BACKGROUND

Single-center reports of central line-associated bloodstream infection (CLABSI) and the subcategory of mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) in pediatric hematology oncology transplant (PHO) patients have focused on the inpatient setting. Characterization of MBI-LCBI across PHO centers and management settings (inpatient and ambulatory) is urgently needed to inform surveillance and prevention strategies.

METHODS

Prospectively collected data from August 1, 2013, to December 31, 2015, on CLABSI (including MBI-LCBI) from a US PHO multicenter quality improvement network database was analyzed. CDC National Healthcare Safety Network definitions were applied for inpatient events and adapted for ambulatory events.

RESULTS

Thirty-five PHO centers reported 401 ambulatory and 416 inpatient MBI-LCBI events. Ambulatory and inpatient MBI-LCBI rates were 0.085 and 1.01 per 1000 line days, respectively. Fifty-three percent of inpatient CLABSIs were MBI-LCBIs versus 32% in the ambulatory setting (P  <  0.01). Neutropenia was the most common criterion defining MBI-LCBI in both settings, being present in ≥90% of events. The most common organisms isolated in MBI-LCBI events were Escherichia coli (in 28% of events), Klebsiella spp. (23%), and viridans streptococci (12%) in the ambulatory setting and viridans streptococci (in 29% of events), E. coli (14%), and Klebsiella spp. (14%) in the inpatient setting.

CONCLUSION

In this largest study of PHO MBI-LCBI inpatient events and the first such study in the ambulatory setting, the burden of MBI-LCBI across the continuum of care of PHO patients was substantial. These data should raise awareness of MBI-LCBI among healthcare providers for PHO patients, help benchmarking across centers, and help inform prevention and treatment strategies.

Prospective Initiative to Reduce Mucosal Barrier Injuries and Bloodstream Infections in Patients With Hematologic Malignancy Receiving Inpatient Chemotherapy

PURPOSE:

Mucosal barrier injury (MBI) occurs during periods of prolonged neutropenia in patients receiving cytotoxic chemotherapy for hematologic malignancies. This can lead to laboratory-confirmed bloodstream infections (LCBIs) and subsequent complications, including sepsis, organ failure, and possible death. There are no published prevention strategies for MBI. The purpose of our proposal was to decrease our MBI-LCBI events per month by 25%.

METHODS:

A multidisciplinary team was assembled to achieve this proposal. Cause-and-effect diagrams in addition to Pareto charts were used to investigate potential interventions. Using Plan-Do-Study-Act (PDSA) cycles, multiple tests of change were designed over the course of 3 years.

RESULTS:

The number of baseline events per month for MBI-LCBIs was 1.1. With the completion of the first PDSA cycle, the MBI-LCBI events dropped to 1.0 event per month. A second PDSA cycle involving implementation of an oral care kit improved to 0.35 events per month. This unfortunately was not sustained, and a root cause analysis demonstrated that physician noncompliance with ordering the oral kit was the main reason. After the change of a physician-driven protocol to a nurse-driven protocol, the third PDSA cycle resulted in a decrease in MBI-LCBI events to 0.89 events per month.

CONCLUSION:

To our knowledge, this is the first published report of an intervention to prevent MBI-LCBI events. Through a multidisciplinary approach and with quality improvement tools, we were able to demonstrate a significant reduction in MBI-LCBI events.

Comparison of epidemiological, clinical and microbiological characteristics of bloodstream infection in children with solid tumours and haematological malignancies

Bloodstream infection (BSI) is a serious complication in immunocompromised hosts. This study compares epidemiological, clinical and microbiological characteristics of BSI among children with haematological malignancies (HM) and solid tumours (ST). The study was conducted from October 2012 through to November 2015 at a referral hospital for cancer care and included the first BSI episode detected in 210 patients aged 18 years or less. BSI cases were prospectively detected by daily laboratory-based surveillance. The Centers for Disease Control and Prevention definitions for primary or secondary BSI were used. A higher proportion of use of corticosteroids (P = 0.02), chemotherapy (P = 0.01) and antibiotics (P = 0.05) before the BSI diagnosis; as well as of neutropenia (P < 0.001) and mucositis (P < 0.001) at the time of BSI diagnosis was observed in patients with HM than with ST. Previous surgical procedures (P = 0.03), mechanical ventilation (P = 0.01) and bed confinement (P < 0.001) were more frequent among children with ST. The frequency of use of temporary (P = 0.01) and implanted vascular lines (P < 0.01) was significantly higher in children with ST than with HM while the tunnelled line (P = 0.01) use was more frequent in children with HM as compared to ST. Most (n = 181) BSI cases were primary BSI. BSI associated with a tunnelled catheter was more frequent in children with HM (P < 0.01), whereas BSI associated with an implanted (P < 0.01) or temporary central line (P < 0.02) was more common in patients with ST. BSI associated with mucosal barrier injury was more frequent (P = 0.01) in children with HM. Indication for intensive care was more frequent in children (P = 0.05) with ST. Mortality ratio was similar in children with ST and HM, and length of hospital stay after BSI was higher in patients with HM than with ST (median of 19 vs. 13 days; P = 0.02). Infection caused by Gram-negative bacteria (P = 0.04) and polymicrobial infections (P = 0.05) due to Gram-positive cocci plus fungus was more common in patients with HM. These findings suggest that the characteristics of BSI acquisition and mortality can be cancer-specific.

Comparison of complication rates and incidences associated with different peripherally inserted central catheters (PICC) in patients with hematological malignancies: a retrospective cohort study

Patients with hematological malignancies (HM) or undergoing hematopoietic cell transplantation (HCT) require reliable vascular access. Peripherally inserted central catheters (PICC) meet this need, however, studies suggest these patients have higher rates of PICC-associated complications. This retrospective cohort study evaluates the influence of PICC type on the rates and incidences of complications. Four hundred and eighty-five dual lumen PICCs were inserted into 469 complex patients with HM or undergoing HCT: 161 Groshong^®, 60 PowerPICC^® Solo, 165 BioFlo^®, and 99 Arrow^®. The rates and incidences of complications differed significantly across the PICC types. The overall rate of complication ranged from 7.40 to 26.4/1000 catheter days (CDs). The rate of deep vein thrombosis (0.31-1.48/1000 CDs) and occlusion differed across the PICC types, while the rate of central line-associated bloodstream infection (0.53-0.74/1000 CDs) did not. Following multivariate adjustment, PICC type was associated with complication rate. This highlights that PICC type should be considered in clinical decisions.

Infection Prevention in Pediatric Oncology and Hematopoietic Stem Cell Transplant Recipients

Pediatric patients with malignancies and transplant recipients are at high risk of infection-related morbidity and mortality. Children at the highest risk for infections are those with acute myeloid leukemia (AML), relapsed acute lymphoblastic leukemia (ALL), and hematopoietic stem cell transplant recipients (HSCT). These patients are at high risk for life-threatening bacterial, viral, and fungal infections which are associated with prolonged hospital stay, poor quality of life, and increased healthcare cost and death. Recognition of risk factors which predisposes them to infections, early identification of signs and symptoms of infections, prompt diagnosis, and empiric/definitive treatment are the mainstay in reducing infection-related morbidity and mortality. Infection control and prevention programs also play a crucial role in preventing hospital-acquired infections in these immunosuppressed hosts.

A Retrospective Analysis of Bloodstream Infections in Pediatric Allogeneic Stem Cell Transplant Recipients: The Role of Central Venous Catheters and Mucosal Barrier Injury

Background: Bloodstream infections (BSIs) are a leading cause of morbidity and mortality in children undergoing hematopoietic stem cell transplant (HSCT). Indwelling central venous catheters (CVCs) increase risk for BSIs, yet mucosal barrier injury–associated laboratory-confirmed bloodstream infection (MBI-LCBI) may also occur due to translocation of pathogenic organisms from the gastrointestinal tract into the bloodstream. The purpose of this study was to determine the association between stool organisms and BSIs in children with CVCs who underwent HSCT. Methods: We performed a retrospective analysis of 78 children who received allogeneic HSCT over 3 years (2012-2014). Surveillance stool cultures were analyzed pre- and post-HSCT to assess correlations between organisms isolated from stool and CVC cultures. Results: Twenty-four of 78 children experienced 31 BSIs. Fifteen (48%) of these isolates were identified in stool within 30 days of the positive blood culture, and 11 (36%) isolates met criteria for MBI-LCBI. Conclusions: Mucosal barrier injury leads to translocation of pathogenic organisms into the bloodstream and accounts for a significant number of BSIs in children undergoing HSCT. Nursing assessment of mucosal changes during HSCT and interventions to preserve intact mucosa are essential to prevent MBI-LCBI.

Addressing regional disparities in pediatric oncology: Results of a collaborative initiative across the Mexican-North American border

BACKGROUND

Cancer is emerging as a major cause of childhood mortality in low- and middle-income countries. In Mexico, cancer is the number one cause of death in children aged 5-14. Until recently, many children with cancer from Baja California, Mexico, went untreated. We reasoned that an initiative inspired by the St. Jude Children's Research Hospital (SJCRH) "twinning" model could successfully be applied to the San Diego-Tijuana border region. In 2008, a twinning project was initiated by Rady Children's Hospital, SJCRH, and the General Hospital Tijuana (GHT). Our aim was to establish a pediatric oncology unit in a culturally sensitive manner, adapted to the local healthcare system.

PROCEDURE

An initial assessment revealed that despite existence of basic hospital infrastructure at the GHT, the essential elements of a pediatric cancer unit were lacking, including dedicated space, trained staff, and uniform treatment. A 5-year action plan was designed to offer training, support the staff financially, and improve the infrastructure.

RESULTS

After 7 years, accomplishments include the opening of a new inpatient unit with updated technology, fully trained staff, and a dedicated, interdisciplinary team. Over 700 children have benefited from accurate diagnosis and treatment.

CONCLUSIONS

Initiatives that implement long-term partnerships between institutions along the Mexican-North American border can be highly effective in establishing successful pediatric cancer control programs. The geographic proximity facilitated accelerated training and close monitoring of project development. Similar initiatives across other disciplines may benefit additional patients and synergize with pediatric oncology programs to reduce health disparities in underserved areas.

Bacterial bloodstream infections in the allogeneic hematopoietic cell transplant patient: new considerations for a persistent nemesis

Bacterial bloodstream infections (BSI) cause significant transplant-related morbidity and mortality following allogeneic hematopoietic cell transplantation (allo-HCT). This manuscript reviews the risk factors for and the bacterial pathogens causing BSIs in allo-HCT recipients in the contemporary transplant period. In addition, it offers insight into emerging resistant pathogens and reviews clinical management considerations to treat and strategies to prevent BSIs in allo-HCT patients.