Catheter-related bloodstream infection in adult haematology patients: catheter removal practice and outcome

Oral minocycline as systemic therapy for uncomplicated venous access device-related bloodstream infection with coagulase-negative staphylococci after allogeneic hematopoietic cell transplantation

BACKGROUND

Venous access device-related bloodstream infection (VAD-BSI) with coagulase-negative staphylococci (CoNS) is a common complication after allogeneic hematopoietic cell transplantation (alloHCT). Standard systemic antimicrobial therapy for uncomplicated VAD-BSI with methicillin-resistant CoNS consists of intravenous (IV) vancomycin (vanco). This requires hospitalization, needs new competent venous access, exposes patients to potential toxicity (mainly renal) and increases the risk of commensal flora dysbiosis with selection of vanco-resistant enterococci. Combined with VAD management (removal or antibiotic locks), oral minocycline (mino) has been evaluated as an alternative systemic therapy for the treatment of uncomplicated VAD-BSIs with CoNS at our center, primarily when the reference treatment with IV vanco was not possible (renal failure or allergy) or when hospitalization was refused by patients. Here, we retrospectively report our single center experience with this mino-based approach.

PATIENTS AND METHODS

From January 2012 to December 2020, 24 uncomplicated VAD-BSIs with CoNS in 23 alloHCT patients were treated with oral mino as systemic antibiotic therapy in combination with VAD management. VAD were implantable ports (n = 17), tunneled catheter (n = 1) or PIC-lines (n = 6). Staphylococci were S. epidermidis (n = 21) or S. haemolyticus (n = 3). Mino was administered with a loading dose of 200 mg followed by 100 mg BID for 7-14 days. For 8 VAD-BSIs, patients were initially treated with IV vanco for the first 1-3 days followed by oral mino, while 16 VAD-BSIs were treated with oral mino as the sole antimicrobial agent for systemic therapy. VAD management consisted of catheter removal (for tunneled catheters and PIC-lines, n = 7) or antibiotic locks with vanco (n = 15) or gentamicin (n = 2) administered at least 3 times a week for 14 days (for ports).

RESULTS

Overall, clearance of bacteremia (as assessed by negativity for the same CoNS of surveillance peripheral blood cultures drawn between day+ 3 and +30 after initiation of systemic therapy) was achieved in all but 1 patient (with port) who had persistent bacteremia at day +9. No complication such as suppurative thrombophlebitis, endocarditis, distant foci of infection or BSI-related death was observed in any patient during the 3-month period after initiation of treatment. Regarding the 17 port-BSI cases for which VAD conservative strategy was attempted, failure of 3-month VAD preservation was documented in 7/17 cases and 3-month recurrence of VAD-BSI was observed in 3/17 cases (with 1 patient with cellulitis). Treatment with mino was well tolerated except for a mild skin rash in one patient.

CONCLUSION

Further prospective studies are needed to evaluate efficacy and safety of this approach.

Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO)

Cancer patients frequently require central venous catheters for therapy and parenteral nutrition and are at high risk of central venous catheter-related infections (CRIs). Moreover, CRIs prolong hospitalization, cause an excess in resource utilization and treatment cost, often delay anti-cancer treatment, and are associated with a significant increase in mortality in cancer patients. We therefore summoned a panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and updated our previous guideline on CRIs in cancer patients. After conducting systematic literature searches on PubMed, Medline, and Cochrane databases, video- and meeting-based consensus discussions were held. In the presented guideline, we summarize recommendations on definition, diagnosis, management, and prevention of CRIs in cancer patients including the grading of strength of recommendations and the respective levels of evidence. This guideline supports clinicians and researchers alike in the evidence-based decision-making in the management of CRIs in cancer patients.

Ethanol locks for the prevention of catheter-related infection in patients with central venous catheter: A systematic review and meta-analysis of randomized controlled trials

Background

The widespread use of central venous catheters (CVCs) has exposed patients to a high risk of catheter-related infection (CRI), which is linked to substantial morbidity and mortality. Several strategies for preventing CRI, including ethanol lock prophylaxis, have been explored. This study aimed to provide a comprehensive summary of randomized controlled trials (RCTs) assessing the efficacy and safety of ethanol locks for preventing CRI in patients with CVC.

Methods

We searched six electronic databases, earlier relevant meta-analyses and the reference lists of the included studies for RCTs that assessed the effects of ethanol locks on CRI in patients with CVC versus a control group. Two authors independently assessed the methodological quality of the included studies using the Cochrane Risk of Bias tool and extracted relevant information according to a predesigned extraction form. Data were analyzed using the Cochrane Collaboration’s RevMan 5.3.

Results

Nine studies involving 2451 patients were included. Although limited in power, the results of the meta-analysis indicated a positive effect of ethanol lock prophylaxis on reducing catheter-related bloodstream infection (CRBSI) compared to heparin alone [OR = 0.53, 95% CI 0.34, 0.82, P = 0.004]. The effects on other outcomes, such as exit site infection, catheter dysfunction, catheter removal, thrombosis and mortality, were not statistically significant (P > 0.05). Moreover, although the effect of ethanol on CRBSI was in the expected direction compared to 0.9% NaCl locks, this effect was not statistically significant (P > 0.05).

Conclusions

The present data indicate that ethanol lock prophylaxis is a potential candidate for the prevention of CRBSI in patients with CVC. However, more attention should be paid to the uniform ethanol lock procedure and toxic effects after long-term ethanol lock exposure.

Performance of differential time to positivity as a routine diagnostic test for catheter-related bloodstream infections: a single-centre experience

OBJECTIVE

To assess the performance of differential time to positivity (DTP) for the diagnosis of catheter-related bloodstream infections (CRBSI).

METHODS

From all episodes of bloodstream infections (BSI) diagnosed during a 15-year period (2003-17) those in which a paired set of blood cultures drawn from a catheter and a peripheral vein were positive for the same microorganism and had a clinically and/or microbiologically defined source were selected. To assess diagnostic discrimination ability and accuracy of DTP for CRBSI, area under the receiver operating characteristic curves (AUC) and performance characteristics of a DTP ≥2 h were computed.

RESULTS

A total of 512 BSI were included, of which 302 (59%) were CRBSI. Discrimination ability of DTP was low for Staphylococcus aureus (AUC 0.656 ± 0.06), coagulase-negative staphylococci (AUC 0.618 ± 0.081), enterococci (AUC 0.554 ± 0.117) and non-AmpC-producing Enterobacteriaceae (AUC 0.653 ± 0.053); moderate for Pseudomonas aeruginosa (AUC 0.841 ± 0.073), and high for AmpC-producing Enterobacteriaceae (AUC 0.944 ± 0.039). For the entire sample, DTP had a low-to-moderate discrimination ability (AUC 0.698 ± 0.024). A DTP ≥2 h has a low sensitivity for coagulase-negative staphylococci (60%) and very low for S. aureus (34%), enterococci (40%) and non-AmpC-producing Enterobacteriaceae (42%). A DTP cut-off of 1 h improved sensitivity (90%) for AmpC-producing Enterobacteriaceae.

CONCLUSIONS

Differential time to positivity performs well for diagnosing CRBSI only when AmpC-producing Enterobacteriaceae and P. aeruginosa are involved. Performance is low for common Gram-positive organisms and non-AmpC-producing enteric bacilli; a negative test should not be used to rule out CRBSI due to these microorganisms. A DTP ≥1 h may improve accuracy for AmpC-producing Enterobacteriaceae, particularly Enterobacter spp.

Catheter-related bloodstream infections in patients with intestinal failure receiving home parenteral support: risks related to a catheter-salvage strategy

Background

In intestinal failure (IF) patients receiving home parenteral support (HPS), catheter-related bloodstream infections (CRBSIs) frequently result in replacement of their tunneled central venous catheters (CVCs), which may lead to future loss of central venous access.

Objective

This observational study investigated the consequences of a catheter-salvage strategy related to CRBSIs.

Design

All CRBSIs from 2002 to 2016 in the Copenhagen IF and microbiological databases were retrospectively analyzed. Catheter salvage was defined by successful antimicrobial therapy with a retained CVC at discharge. Re-occurrences of CRBSIs with the same microbial species and identical antibiogram were defined as a relapse (<30 d) or as a recurrent (30-100 d) infection. Cox regression analyses incorporated a frailty factor to account for recurrent events and overrepresentation by some patients. Cumulative incidence curves are presented with a competing risk model.

Results

There were 2006 tunneled CVCs inserted in 715 adult HPS patients covering 2014.3 CVC years, with a CRBSI incidence rate of 1.83/1000 (n = 1350) and a mortality rate of 0.007/1000 CVC days (n = 5). The mean ± SD salvage rate was 55.3% ± 5.5%, varying according to infection type [monoinfections (62.9% ± 4.4%) and polyinfections (58.6% ± 17.3%)] and causative microorganism [coagulase-negative Staphylococci (CoNS) (68.1% ± 9.4%), Staphylococcus aureus (42.6% ± 17.5%), and Enterobacteriaceae (54.3% ± 16.7%)]. The overall risk of CRBSI relapse was 7.5%, and the risk of CRBSI recurrence was 7.3%. The HR for a subsequent CRBSI was 14% lower in a replaced than in a retained CVC (95% CI: 0.74, 0.99). The HR for a new CRBSI after catheter salvage was 36% higher after polyinfections than after monoinfections (95% CI: 1.03, 1.79). Enterobacteriaceae entailed an increased risk of CRBSI recurrence compared with CoNS (2.26; 95% CI; 1.08, 4.75) and S. aureus (4.45; 95% CI: 1.28, 15.5).

Conclusions

High catheter-salvage rates related to CRBSIs were achievable and safe in HPS patients within a broad range of microorganisms but contributed to an increased risk of CRBSI relapse or recurrence.

A Novel Catheter System for Totally Implantable Intravenous Drug Therapy: Assessment of Catheter Function and Patency with Trepostinil Therapy

Background

Catheter failure, either due to dislodgment, occlusion or infection is the leading complication of chronic intravenous drug therapy. Better drug delivery techniques are required to advance life saving therapies that require this delivery method. This study evaluated the chronic performance of a fully implantable drug delivery system that incorporates a novel intravenous catheter. The system was designed to reduce complications associated with intravascular drug delivery including catheter occlusion, breakage, migration, and infection.

Methods

Twelve canines were implanted with a novel central venous catheter (Model 10642; Medtronic, Minneapolis, MN) connected to a totally implanted programmable drug pump (Model 8637 SynchroMed II®, Medtronic). The drug delivery systems infused saline (n=6) or treprostinil (n=6) (Remodulin®; United Therapeutics, Research Triangle Park, NC) for either 12 or 26 weeks at a continuous flow rate of 540 μL/day. Catheter performance was assessed at 0 (implant), 2, 4, 8, 12, 16, 20, and 24 weeks by quantifying delivery pressure, delivery volume and steady state Treprostinil concentrations.

Results

All catheters remained patent and free of complications for the duration of the study. Analysis of pressure waveforms during bolus delivery showed low and unchanged catheter resistance throughout the study. Measurement of pump delivery volume accuracy showed that the delivered volume was statistically similar to the calculated delivery (product of flow rate and elapsed time). Measurement of plasma treprostinil levels showed stable concentrations over the study period. There were no catheter dislodgments or breakage. Pathology showed all catheters free from fibrosis and thrombus and minimal changes to the vascular endothelium.

Conclusions

The Model 10642 vascular catheter along with the SynchroMed II implantable drug delivery system showed promising performance in a chronic animal model.

Catheter-related infections in patients with haematological malignancies: novel preventive and therapeutic strategies

Central venous catheters are essential for the treatment of patients with haematological malignancies and the recipients of stem-cell transplant. This patient population is, however, at high risk for catheter-related bloodstream infections that can result in substantial morbidity, mortality, and health-care-associated costs. Efficient prevention, early diagnosis, and effective treatment are essential to providing the best care to these patients. Although confirming the catheter as a source of infection remains challenging, the Infectious Diseases Society of America definition of catheter-related bloodstream infection remains the most precise definition to use in these patients. Gram-positive bacteria, particularly coagulase-negative Staphylococcus spp, remain the leading cause of catheter-related bloodstream infection, although an increase in Gram-negative bacteria as the causative agent has been noted. Although removal of the line and appropriate intravenous antibiotics remain the mainstay of treatment in most cases, novel technologies, including exchange with antibiotic-coated catheters and treatment with lock solutions, are particularly relevant in this patient population. In this Review we present the types of central venous catheters used in this patient population and analyse the different definitions of catheter-related infections, with an overview of their prevention and management.

Prosthetic Device Infections

The immunocompromised host is a particularly vulnerable population in whom routine and unusual infections can easily and frequently occur. Prosthetic devices are commonly used in these patients and the infections associated with those devices present a number of challenges for both the microbiologist and the clinician. Biofilms play a major role in device-related infections, which may contribute to failed attempts to recover organisms from routine culture methods. Moreover, device-related microorganisms can be difficult to eradicate by antibiotic therapy alone. Changes in clinical practice and advances in laboratory diagnostics have provided significant improvements in the detection and accurate diagnosis of device-related infections. Disruption of the bacterial biofilm plays an essential role in recovering the causative agent in culture. Various culture and nucleic acid amplification techniques are more accurate to guide directed treatment regimens. This chapter reviews the performance characteristics of currently available diagnostic assays and summarizes published guidelines, where available, for addressing suspected infected prosthetic devices.

Surveillance for Catheter-Associated Bloodstream Infection in Hematology Units: Quantifying the Characteristics of a Practical Case Definition

We evaluated 66 patients in a hematology unit, who used a total of 106 central venous catheters (CVCs), to identify CVC-associated bloodstream infections using standard and modified surveillance case definitions. Compared with the National Nosocomial Infection Surveillance system criteria, a modified case definition used by treating physicians demonstrated 100.0% sensitivity and 94.3% specificity. This case definition provides a practical method for effectively excluding CVC-associated bloodstream infection.

Health care workers' knowledge and practices regarding the prevention of central venous catheter-related infection

BACKGROUND

Central venous catheter-related infection (CVC-RI) is considered a common cause of increased morbidity, mortality, and medical care costs in intensive care units (ICUs). The objective in this descriptive study was to assess the knowledge of health care workers in ICUs about guidelines for the prevention of CVC-RI and their adherence to these guidelines in practices.

METHODS

Health care workers were assessed for their actual practices during central venous catheter (CVC) insertion and care. Then a questionnaire was distributed to the health care workers to assess their knowledge regarding the prevention of CVC-RI.

RESULTS

All the health care workers (N = 100; 40 physicians, 60 nurses) in the ICUs (levels I and III and triage) of Alexandria Main University Hospital participated in the present study. The response rate was 100%. The total percentage of correct answers of the health care workers about the guidelines for the prevention of CVC-RI was low. There was no significant difference between physicians' and nurses' knowledge regarding the total score on the questionnaire (P = .134). However, physicians had a significantly higher knowledge about the pathophysiology of CVC-RI and skin antisepsis items than nurses. There were no significant differences between the knowledge of physicians and nurses in other items except for CVC care, where nurses showed significantly higher knowledge than physicians (P = .001).

CONCLUSION

The results of the present study revealed health care worker's low knowledge regarding the prevention of CVC-RI and low compliance with the standard guidelines of CVC care. Therefore, health care workers should be periodically evaluated for their knowledge and practices regarding guidelines for the prevention of CVC-RI.

Central venous catheter-related infections in hematology and oncology: 2012 updated guidelines on diagnosis, management and prevention by the Infectious Diseases Working Party of the German Society of Hematology and Medical Oncology

BACKGROUND

Cancer patients are at increased risk for central venous catheter-related infections (CRIs). Thus, a comprehensive, practical and evidence-based guideline on CRI in patients with malignancies is warranted.

PATIENTS AND METHODS

A panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) has developed a guideline on CRI in cancer patients. Literature searches of the PubMed, Medline and Cochrane databases were carried out and consensus discussions were held.

RESULTS

Recommendations on diagnosis, management and prevention of CRI in cancer patients are made, and the strength of the recommendation and the level of evidence are presented.

CONCLUSION

This guideline is an evidence-based approach to the diagnosis, management and prevention of CRI in cancer patients.

Vascular catheter-associated infections: a microbiological and therapeutic update

The increasing incidence of central venous catheter (CVC)-related infections can be ascribed to the wider indications to central venous catheterization, to the higher attention to this issue paid by clinicians and microbiologists, and to the patient population referred to hospitals, increasingly characterized by different degrees of immunosuppression and often in critical clinical conditions. This phenomenon implies a higher health care burden and higher related costs, as well as a significant attributable mortality, that varies however according to the pathogen involved. The microorganisms most frequently involved in CVC-related infections are coagulase-negative staphylococci, Staphylococcus aureus, aerobic Gram-negative bacilli, and Candida albicans. In the management of suspected or proven central venous catheter-related infections, several issues need to be addressed: the need to remove the device or the possibility of salvage, the immediate start of calculated antibiotic therapy or the possibility of waiting for results of microbiological diagnostics and proceeding to etiologically-guided therapy. The preferred conservative method is the "Antibiotic-Lock technique" (ALT), based on the endoluminal application of antibacterials at extremely high concentrations in situ for a period of time long enough to ensure bactericidal activity. On the other hand, immediate catheter removal and initiation of appropriate calculated therapy immediately after an adequate diagnostic work-up are strongly recommended in a clinical setting of severe sepsis or septic shock.

Gram-negative organisms predominate in Hickman line-related infections in non-neutropenic patients with hematological malignancies

BACKGROUND

Catheter-related blood stream infections (CRBSI) cause significant morbidity and mortality in patients with hematological malignancies. Previous studies have identified a predominance of gram-positive organisms causing CRBSI but they included both neutropenic and non-neutropenic patients with solid organ and hematological malignancies. The aim of our study was to evaluate the incidence and microbiological profile of CRBSIs in a specific cohort of patients with hematological malignancies in their non-neutropenic phase of illness.

METHODS

A detailed retrospective review was done from January 2003 to December 2005 on all patients with hematological malignancies who had double-lumen non-antibiotic impregnated tunneled CVCs (Hickman catheters) inserted in our hospital to identify those fulfilling our criteria for CRBSI episodes.

RESULTS

Amongst 273 evaluable patients, 61 developed CRBSI on 70 occasions. In contrast to previous studies, there was a predominance of gram-negative infections (68%). The majority (73%) of initial CRBSI episodes required catheter removal within 7 days of onset. Vancomycin and cefepime was the most common initial antibiotic regimen used.

CONCLUSIONS

This study highlights the predominance of gram-negative infections in our cohort of non-neutropenic patients with underlying hematological malignancies who had Hickman catheters whose lines were not salvageable in the majority of cases. Empiric monotherapy with an antimicrobial agent with broad spectrum gram-negative cover needs to be given upfront pending results of the nature and sensitivity of organisms identified.

Prevention of Coagulase-Negative Staphylococcal Central Venous Catheter–Related Infection Using Urokinase Rinses: A Randomized Double-Blind Controlled Trial in Patients With Hematologic Malignancies

Purpose

Fibrin deposition at the intraluminal surface of the indwelling part of the central venous catheter (CVC) surface increases the risk of CVC-related coagulase-negative staphylococci (CoNS) infection. Therefore, repetitive enzymatic dissolution of fibrin by urokinase might reduce the risk of CVC-related infection. We undertook this study to investigate whether three times weekly urokinase rinsing of CVC reduces the incidence or severity of CVC-related infections by CoNS in patients undergoing intensive cytotoxic treatment for hematologic malignancies.

Patients and Methods

In a double-blind setting, all consecutive patients with a CVC were randomly allocated to receive either urokinase rinses (5 mL of 5,000 U/mL) or placebo (saline), both three times weekly.

Results

The percentage of patients with at least one positive culture with CoNS was lower in patients receiving urokinase compared with patients receiving placebo (26% v 42%, respectively; relative risk [RR] = 0.61; 95% CI, 0.39 to 0.94). Major CVC-related CoNS infection occurred less frequently in patients receiving urokinase versus placebo (1.2% v 14.1%, respectively; RR = 0.09; 95% CI, 0.01 to 0.50). Secondary complications, including CVC-related thrombosis, were observed less frequently in the urokinase group compared with the placebo group (1.3% v 9.0%, respectively; RR = 0.14; 95% CI, 0.02 to 0.82). No severe bleeding complications attributable to urokinase were observed.

Conclusion

Three times weekly urokinase rinsing reduces the incidence of CVC-related CoNS infection in patients treated with intensive cytotoxic therapy for hematologic malignancies, with acceptable safety.

Central venous access device infections in children with hemophilia: a comparison of prophylaxis and episodic therapy

Prophylaxis was recommended as the optimal treatment regimen for severe hemophilia by several expert committees. This led to increased utilization of prophylaxis and, subsequently, central venous access devices (CVADs). Although prophylaxis is the preferred treatment, episodic therapy is used by many. CVADs are employed to facilitate administration of prophylactic and episodic infusions; however, there are no data on the risk of CVAD-related infections for prophylaxis compared with episodic therapy. Data from the Study for the Prevention of Joint Disease in Preschool Children with Severe Hemophilia, a randomized clinical trial of prophylaxis versus episodic therapy, were used to evaluate the association between CVAD-related infection and treatment. The crude and adjusted rate ratios for first CVAD-related infection per 1000 CVAD days associated with episodic therapy versus prophylaxis were 1.42 (95% confidence interval: 0.46-4.40) and 1.23 (95% confidence interval: 0.33-4.56), respectively. Although we cannot make a definitive statement about treatment and CVAD-related infection risk, this study suggests that prophylaxis likely does not put children at higher risk of CVAD-related infection than episodic therapy. Given the need for CVADs in some children and the benefits of prophylaxis, we conclude there is no reason to recommend against prophylaxis on the basis of existing knowledge of CVAD-related infection risk.