Central venous catheter infections in burn patients with scheduled catheter exchange and replacement

Central venous catheter tip colonization and associated bloodstream infection in patients with severe burns under routine catheter changing

BACKGROUND

Although routine changing of central venous catheters (CVCs) is commonly performed in patients with severe burns, information on pathogen colonization of the CVC tip and associated bloodstream infections (BSIs) is limited in those patients.

METHODS

The medical records of 214 patients with severe burns who underwent routine CVC changing at 7-day intervals and their results of 686 pairs of CVC tips and concurrent blood cultures were retrospectively reviewed to evaluate the CVC colonization rate and associated BSI pathogens.

RESULTS

Of the 686 CVCs, 137 (20.0%) were colonized by pathogens, and 81 (59.1%) of them had BSIs caused by the same pathogen. Nonflame burn (P = .002), total body surface area burn ≥30% (P = .004), femoral catheterization (P = .001), CVC changing during pre-existing BSI (P < .001), and renal replacement therapy (P = .017) were associated with catheter-related BSI in the multivariate analysis. Most BSIs were caused by Gram-negative bacteria (most commonly Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa).

CONCLUSIONS

The CVC colonization rate in patients with severe burns and routine CVC changing was not high. Lengthening the CVC duration might be attempted in patients at a lower risk of catheter-related BSI although further prospective studies are necessary.

Reducing umbilical catheter migration rates by using a novel securement device

OBJECTIVE

This study evaluates the effectiveness of a novel device, LifeBubble, in reducing umbilical cord catheter (UC) migration and associated complications in neonates.

STUDY DESIGN

A retrospective review was performed at Oregon Health & Science University's NICU (2019-2021) to compare standard adhesive securement with LifeBubble. The primary outcomes were UC migration, discontinuation due to malposition, and CLABSI incidence. Differences between groups were statistically analyzed and logistic regression used to adjust for potential confounders.

RESULTS

Among 118 neonates (57 LifeBubble, 61 adhesive), LifeBubble significantly reduced migration of any UC > 1 vertebral body (12.3% vs. 55.7%), including UVC migration (5.3% vs. 39.3%) and UAC migration (7.0% vs 23.0%), as well as UVC discontinuation due to malposition (5.6% vs 37.7%). The number needed to treat (NNT) to prevent one instance of UVC discontinuation is 4.

CONCLUSION

LifeBubble effectively reduces UC migration and premature discontinuation, indicating its potential to enhance neonatal care and safety.

Surviving Sepsis After Burn Campaign

INTRODUCTION

The Surviving Sepsis Campaign was developed to improve outcomes for all patients with sepsis. Despite sepsis being the primary cause of death after thermal injury, burns have always been excluded from the Surviving Sepsis efforts. To improve sepsis outcomes in burn patients, an international group of burn experts developed the Surviving Sepsis After Burn Campaign (SSABC) as a testable guideline to improve burn sepsis outcomes.

METHODS

The International Society for Burn Injuries (ISBI) reached out to regional or national burn organizations to recommend members to participate in the program. Two members of the ISBI developed specific "patient/population, intervention, comparison and outcome" (PICO) questions that paralleled the 2021 Surviving Sepsis Campaign [1]. SSABC participants were asked to search the current literature and rate its quality for each topic. At the Congress of the ISBI, in Guadalajara, Mexico, August 28, 2022, a majority of the participants met to create "statements" based on the literature. The "summary statements" were then sent to all members for comment with the hope of developing an 80% consensus. After four reviews, a consensus statement for each topic was created or "no consensus" was reported.

RESULTS

The committee developed sixty statements within fourteen topics that provide guidance for the early treatment of sepsis in burn patients. These statements should be used to improve the care of sepsis in burn patients. The statements should not be considered as "static" comments but should rather be used as guidelines for future testing of the best treatments for sepsis in burn patients. They should be updated on a regular basis.

CONCLUSION

Members of the burn community from the around the world have developed the Surviving Sepsis After Burn Campaign guidelines with the goal of improving the outcome of sepsis in burn patients.

Epidemiology and etiology of blood stream infections in a Belgian burn wound center

BACKGROUND

Infections are a major cause of morbidity in burn patients. We aimed to investigate the epidemiology and antibiotic susceptibility of blood stream infections in order to gain a better understanding of their role and burden in our Burn Wound Center.

METHODS

This retrospective epidemiological investigation analyzed data derived from medical files of patients admitted to our Burn Wound Center having had at least one positive blood culture between 1 January and 31 December 2018. We focused on the prevalence of causative agents in blood stream infections in function of the time after injury and on their drug sensitivity.

RESULTS

Among the 363 patients admitted to our Burn Wound Center during the study period, 29 had at least one episode of blood stream infection. Gram-negative organisms accounted for 56,36% of the pathogens in blood stream infections, Gram-positives for 38,17%, and yeasts for 5,45%. Pseudomonas aeruginosa was the most common bacterium (20%), followed by Staphylococcus epidermidis (16.36%), Escherichia coli and Klebsiella pneumoniae (9,09% each). A third of the Gram-negative isolates were multidrug resistant. Gram-positive cocci were isolated from blood cultures at a median of 9 days after the injury, earlier than Gram-negative rods (median 15 days). The main sources of blood stream infections were the burn wounds, followed by infected catheters.

CONCLUSIONS

Multidrug resistant bacteria must be considered when selecting empirical antibiotic therapy in septic burn patients. In our center, we need to update our antibiotic guidelines, to review the hospital infection control measures and to introduce routine typing technology.

Thrombosis and infections of peripherally inserted central catheters in burn patients: A 3-year retrospective study and a systematic review

AIMS

Peripherally inserted central catheters (PICCs) are becoming common and effective in acute and critical care settings recently. Burn patients need special considerations because of restricted insertion sites, burn wounds, hyper coagulation, high infection rates and others. However, the safety of PICCs in burn patients are not well elucidated and no related protocol has been formed. This study aims to investigate the thrombosis and infections of PICCs in burn patients.

METHODS

This was a single center retrospective study and a systematic review. All the burn patients with PICCs between January 1, 2018 and December 31, 2020 were included. A systematic search of Medline, PubMed, EMBASE and Web of Science was performed from inception to 4 June 2021 following PRISMA guidelines. Upper extremity vein thrombosis (UEVT) and central line-associated bloodstream infection (CLABSI) were the main outcome.

RESULTS

A total of 85 successful PICCs in 78 patients were included. Most patients were male (79.5%), adults(80.8%) and injured by flame(74.4%). The mean TBSA was 50.3% and 76.9% of patients had TBSA more than 30%. Most PICCs were punctured once (60.0%) and inserted less than 30 days after injury (80.0%) through basilar vein (70.6%). The overall line days were 2195 days and the mean line days was 25.8 ± 18.3 days. Six PICCs were complicated by UEVT (7.1%) in 21.2 ± 17.3 days after insertion. Patients with UEVT had significantly higher rate of bacteremia and later insertions than those without UEVT. One patient developed CLABSI and the CLABSI rate was 1.2% and 0.5 per 1000 line days. Six PICCs had catheter colonization. No significant risk factors were identified. Five articles involving 293 patients and 319 PICCs were ultimately evaluated in systematic review. The overall incidence of UEVT was 3.2% and CLABSI was 6.9% in burn populations.

CONCLUSION

PICCs in burn patients had acceptable incidence of UEVT and CLABSI with relative long line durations. A standardized PICC guideline for burn patients is required to further improve the feasibility and safety of PICCs.

Reduction of central-line-associated bloodstream infection (CLABSI) in resource limited, nonintensive care unit (ICU) settings

PURPOSE

There was limited study available on successful intervention for central-line-associated bloodstream infection (CLABSI) done at nonintensive care unit (ICU) and resources-limited setting. The objective of this study was to design, implement and evaluate a strategy to reduce CLABSI rate in non-ICU settings at general medical wards of Hospital Tuanku Ja'afar Seremban.

DESIGN/METHODOLOGY/APPROACH

Preinterventional study was conducted in one-month period of January 2019, followed by intervention period from February to March 2019. Postintervention study was conducted from April to July 2019. The CLABSI rates were compared between pre and postintervention periods. A multifaceted intervention bundle was implemented, which comprised (1) educational program for healthcare workers, (2) weekly audit and feedback and (3) implementation of central line bundle of care.

FINDINGS

There was a significant overall reduction of CLABSI rate between preintervention and postintervention period [incidence rate ratio (IRR) of 0.06 (95 percent CI, 0.01-0.33; P = 0.001)].

PRACTICAL IMPLICATIONS

CLABSI rates were reduced by a multifaceted intervention bundle, even in non-ICU and resource-limited setting. This includes a preinterventional study to identify the risk factors followed by a local adaption of the recommended care bundles. This study recommends resources-limited hospitals to design a strategy that is suitable for their own local setting to reduce CLABSI.

ORIGINALITY/VALUE

This study demonstrated the feasibility of a multifaceted intervention bundle that was locally adapted with an evidence-based approach to reduce CLABSI rate in non-ICU and resource-limited setting.

Candidemia in pediatric burn patients: Risk factors and outcomes in a retrospective cohort study

Background and Purpose :

Despite advances in burn care and management, infections are still a major contributor to morbidity and mortality rates in patients with burn injuries. Regarding this, the present study was conducted to investigate the prevalence and importance of candidemia in pediatric burn patients.

Materials and Methods:

Blood samples were collected from the patients and cultured in an automated blood culture system. Candida species were identified using specific culture media. The relationship between candidemia and possible risk factors was evaluated and compared to a control group.

Results:

A total of 71 patients with the mean age of 4.52±3.63 years were included in the study. Blood cultures showed candidemia in 19 (27%) patients. Based on the results, C. albicans was the most common fungus among patients with and without candidemia. The results of statistical analysis also showed that candidemia was significantly correlated with total body surface area (TBSA), mechanical ventilation, duration of total parenteral nutrition, length of intensive care unit (ICU) stay, presence of neutropenia, and R-Baux score (all P≤0.001). In this regard, TBSA, length of ICU stay, R-Baux score, and Candida score were identified as the determinant factors for mortality due to candidemia.

Conclusion:

Candidemia increases the mortality and morbidity rates associated with burn injuries. Prompt diagnostic and prevention measures can reduce the unfortunate outcomes via controlling the possible risk factors.

Innovations in Infection Prevention and Treatment

Background: Patients with large, acute burn injuries are a major challenge for clinicians. The loss of skin barrier protection against micro-organisms combined with the induced immunosuppression after burn injury makes this population especially vulnerable to infection. For burn-injured patients who survive immediate management considerations and burn resuscitation after acute injury, sepsis remains the primary cause of death. The purpose of this article is to describe current strategies and innovations in burn sepsis prevention and management. Methods: This work reviews the current understanding of the systemic inflammatory response to burn injury and burn sepsis as well as current strategies in insolation and infection prevention, newer burn unit design strategies in the context of infection prevention, and novel therapies being considered in topical antimicrobial wound care management. Results: A review of burn sepsis is key to understanding current paradigms and innovation in burn management and prevention. Key management principles begin from the time of injury and persist throughout the patient's hospital course. This includes use of personal protective equipment, burn unit design considerations, and knowledge of critical care principles such as central venous catheter management strategies. Innovations on wound dressing types, forms, and use have been key to better controlling burn wound sepsis and improving wound healing. Products incorporating nanotechnology, novel anions, oxygen, and even light have been key to introducing previously unconsidered methods to fight or prevent infection. Conclusion: Understanding the pathophysiology and source identification of sepsis from burn wounds has been a key contributor in developing innovative prevention and therapeutic strategies in burn management. The emergence of drug-resistant pathogens and the difficulty of systemic antibiotic agents to reach poorly vascularized wounds have further reinforced the need to anticipate management strategies moving forward. A proactive, multidisciplinary approach is necessary to minimize the morbidity and mortality associated with infection control.

Patient Safety in Burn Care: Application of Evidence-based Medicine to Improve Outcomes

This article reviews 5 areas in burn care that increasingly use evidence-based medicine to optimize quality and safety: resuscitation protocols, transfusion practices, vascular access, venous thromboembolic prophylaxis, and rational use of antibiotics.

Infection in burn patients in a referral center in Colombia

INTRODUCTION

Worldwide, burns are responsible for more than 300,000 deaths annually; infection is a major cause of morbidity and mortality in these patients. Early identification and treatment of infection improves outcome. Toward this end it's necessary to identify the institutions flora and organisms that most frequently produces infection.

OBJECTIVES

To characterize infections developed by burn patients hospitalized at the University Hospital of Santander (HUS).

METHODOLOGY

Burn patients hospitalized in the HUS from January 1 to December 2014 were followed. Medical information regarding infections, laboratory and pathology reports were obtained. Statistical analysis with measures of central tendency, proportions, global and specific incidence density plus overall and specific incidence was obtained. For the microbiological profile proportions were established.

RESULTS

402 burn patients were included, 234 (58.2%) men and 168 (41.8%) women, aged between 6 days and 83 years, median 12.5 years. The burn agents include scald (52.5%), fire (10.0%), gasoline (9.2%), electricity (7.5%), among others. Burn area ranged from 1% to 80% TBS. Cumulative mortality was 1.5%. 27.8% of burned patients had one or more infections. Identified infections include folliculitis (27.0%), urinary tract infection (19.0%), infection of the burn wound (10.4%), pneumonia (8.6%), Central venous catheter (7.4%), bloodstream infection (7.4%) and skin grafts infection (4.3%) among others. Bacteria were responsible for 88.5% of the cases and fungi 11.5%. The most frequently isolated germs were P. aeruginosa, A. baumannii, E. coli, S. aureus and K. pneumoniae. Most gram-negative bacteria were sensitive to Amikacin, gram positive bacteria were sensitive to multiple antibiotics.

CONCLUSION

Burns is a severe trauma that occurs in adult and pediatric patients, has several causative agents and can compromise the patient's life. The burned patient is at risk for a variety of infections. According to the type of infection it is possible to infer the most common causative organisms and their antibiotic sensitivity/resistance which allow a directed early empiric treatment.

Guidewire Catheter Exchange in Pediatric Oncology: Indications, Postoperative Complications, and Outcomes

BACKGROUND

Maintaining long-term central venous catheters (CVCs) in children undergoing chemotherapy can be challenging. Guidewire catheter exchange (GCE) replaces a CVC without repeat venipuncture. This study evaluated the indications, success rate, and complications of GCE in a large cohort of pediatric cancer patients.

PROCEDURE

Medical records of pediatric cancer patients who underwent GCE at our institution between 2003 and 2013 were retrospectively reviewed. Variables analyzed included gender, age at GCE, primary cancer diagnosis, indication for GCE, absolute neutrophil count (ANC) at GCE, vein used, success rate, and postoperative complications (<30 days after exchange).

RESULTS

A total of 435 GCEs performed in 407 patients (230 males and 177 females) were reviewed. Median age at GCE was 8 years (range, 0.2-24). Acute lymphoblastic leukemia was the most common diagnosis (50.6%). The primary indication for GCE was the desire to have an alternative type of CVC (71%). Other indications included catheter displacement (17%), catheter malfunction (11%), and catheter infection (1%). Median ANC at GCE was 2,581/mm(3) (range, 0-43,400). Left subclavian vein was more commonly used (57.7%). The success rate of GCE was 93.4% (406 of 435 procedures, 95% confidence interval: 91.0-97.5%). A total of 33 (7.5%) postoperative complications occurred including central line associated bloodstream infection (CLABSI) (n = 20, 4.5%), catheter dislodgement (n = 6, 1.4%), and catheter malfunction (n = 7, 1.6%).

CONCLUSIONS

We conclude that GCE in pediatric cancer patients is associated with a high success rate and a low risk of complications. The most common postoperative complication, CLABSI, occurred at a rate significantly lower than following de novo CVC placement.

In situ diagnostic methods for catheter related bloodstream infection in burns patients: A pilot study

BACKGROUND

One of the most common and potentially fatal complications in critically ill burns patients is catheter related bloodstream infection (CR-BSI). Lack of in situ diagnostic techniques requires device removal if CR-BSI is suspected with 75-85% of catheters withdrawn unnecessarily.

AIMS

To assess the sensitivity, specificity and accuracy of two in situ diagnostic methods for CR-BSI in an adult ICU burns population: Differential Time to Positivity (DTP) and Semi-Quantitative Superficial Cultures (SQSC).

METHODS

Both arterial (AC) and central venous (CVC) catheters were studied. On clinicians' suspicion of CR-BSI, the CVC and AC were removed. Superficial semi-quantitative cultures were taken by removing the dressings and swabbing within a 3cm radius of the CVC and AC insertion sites, as well as inside each hub of the CVC and AC. Peripheral blood was taken for qualitative culture and the catheter tip sent for semi-quantitative culture. DTP was considered positive if culture of lumen blood became positive at least 120min before peripheral blood with an identical pathogen. Superficial and tip cultures were identified as positive if ≥15 CFUs were grown. CR-BSI was confirmed when both catheter tip culture and peripheral blood culture were positive with the same micro-organism.

RESULTS

Sixteen patients (88% male) with an APACHE II score of 22.0 (7.3) were enrolled. The mean age was 45.7 (16.9) years with mean total burn surface area 32.9 (19.4)%. Fifty percent had airway burns. ICU stay was 19.9 (11.1) days. All 16 survived ICU discharge with a hospital survival of 93%. There were 20 episodes of CR-BSI in these 16 patients. For these 20 episodes the exposure time (line days) was 113.15. The CR-BSI rate was 15.6 per 1000 catheter days (95% CI 1.9-56.4). For diagnosis of CR-BSI in either AC and CVC, SQSC had a sensitivity of 50% [95% CI 3-97], specificity 83.3% [95% CI 67-93], PPV 14.3 [95% CI 1-58], NPV 96.8 [95% CI 81-100], accuracy of 81.6% [95%CI 65-92] and diagnostic odds ratio 5.0 [95% CI 0.3-91.5]. To diagnose tip colonisation (>15CFU), sensitivity of SQSC was 75% [95% CI 22-99], specificity 88.2% [95%CI 72-96], PPV 42.7 [95% CI 12-80], NPV96.8% [95% CI 81-100], accuracy 86.8% [95% CI 71-95] and diagnostic odds ratio 22.5 [95% CI 1.9-271.9]. For combined DTP blood cultures, sensitivity for CR-BSI was 50% [95% CI 3-97], with specificity 97% [95% CI 82-100], PPV 50% [5% CI 3-97%], NPV 97% [95% CI 82-100], accuracy 94.3% 95% CI 79-99] and diagnostic odds ratio 32 [95% CI 1.1-970.8].

CONCLUSION

Both DTP and SQSC displayed high specificity, NPV and accuracy in a population of adult burns patients. These features may make these tests useful for ruling out CR-BSI in this patient group. This study was limited by a low number of events and further research is required.

Peripherally inserted central venous catheter safety in burn care: a single-center retrospective cohort review

The use of peripherally inserted central catheter (PICC) line for central venous access in thermally injured patients has increased in recent years despite a lack of evidence regarding safety in this patient population. A recent survey of invasive catheter practices among 44 burn centers in the United States found that 37% of burn units use PICC lines as part of their treatment protocol. The goal of this study was to compare PICC-associated complication rates with the existing literature in both the critical care and burn settings. The methodology involved is a single institution retrospective cohort review of patients who received a PICC line during admission to a regional burn unit between 2008 and 2013. Fifty-three patients were identified with a total of seventy-three PICC lines. The primary outcome measurement for this study was indication for PICC line discontinuation. The most common reason for PICC line discontinuation was that the line was no longer indicated (45.2%). Four cases of symptomatic upper extremity deep vein thrombosis (5.5%) and three cases of central line-associated bloodstream infection (4.3%, 2.72 infections per 1000 line days) were identified. PICC lines were in situ an average of 15 days (range 1 to 49 days). We suggest that PICC line-associated complication rates are similar to those published in the critical care literature. Though these rates are higher than those published in the burn literature, they are similar to central venous catheter-associated complication rates. While PICC lines can be a useful resource in the treatment of the thermally injured patient, they are associated with significant and potentially fatal risks.

Survey of central line-associated bloodstream infection prevention practices across american burn association-certified adult burn units

Central line–associated bloodstream infections (CLABSIs) have a considerable impact on morbidity, length of stay, and potential mortality. The estimated per-case cost of CLABSIs is $11,000–$56,167, and there is consensus that most are preventable. Publicly reported CLABSI data are also now used as a metric to compare hospitals.

There are published guidelines for the prevention of central line–associated infections, but these practices have not been studied in burn patients. Patients with severe burns pose unique and specific challenges and differ substantially from the typical medical or surgical intensive care unit (ICU) patient. Our objective was to assess CLABSI prevention practices in burn units.

We identified all American Burn Association (ABA)–certified adult burn centers through the ABA website (http://www.ameriburn.org) and contacted nursing leadership of each burn intensive care unit to conduct a telephone survey of CLABSI prevention practices in March 2012. The survey project was approved by the Johns Hopkins institutional review board.

We had 100% survey participation. There was substantial variation among burn units in the number of beds, the mix of patients, and the acuity of patients' illness. Bed size varied from 4 to 38. Eight units stated that their burn unit incorporated a step-down unit or floor-status beds in their bed count. Thirty (58.8%) of the 51 units defined themselves as mixed burn/surgical or trauma units. The percentage of burned patients seen in the burn units varied from 10% to 100%, with 8 (15.4%) of 51 units stating that their census consisted of fewer than 30% burned patients in their burn ICU.

Infections in Burns

Infections remain a leading cause of death in burn patients. This is as a result of loss of the environmental barrier function of the skin predisposing these patients to microbial colonization leading to invasion. Therefore, reconstitution of the environmental barrier by debriding the devitalized tissue and wound closure with application of allograft versus autograft is of optimal importance.

Femoral central venous catheters are not associated with higher rates of infection in the pediatric critical care population

BACKGROUND

Adult data show a difference in central venous catheter (CVC) infection rates between 3 major sites: subclavian (SC), internal jugular (IJ), and femoral veins. We hypothesized that in patients in pediatric intensive care units (PICUs), there is no difference in rates of CVC infection among these three sites, but specifically the femoral compared to all other sites.

METHODS

In this retrospective cohort study, data from January 1999 to January 2008 were collected prospectively for internal review and quality assurance. All PICU patients with a CVC were enrolled. The rate of CVC infection was determined using Cox regression survival analysis to account for various durations of CVC placement at the various sites, then adjusted for severity of illness, number of lumens, and patient age. Mortality was compared in patients with a CVC infection versus those without.

RESULTS

A total of 4,512 patients with a CVC were enrolled. No site was associated with an increased risk of infection compared with the other sites, with hazard ratios of 0.951 (95% confidence interval [CI], 0.612-1.478) for the SC site, 0.956 (95% CI, 0.593-1.541) for the IJ site, and 1.120 (95% CI, 0.753-1.665) for the femoral site. No significant association between mortality and presence of CVC infection was found when adjusted for age, severity of illness, and duration of CVC placement. An association was found between the presence of a CVC infection and prolonged PICU length of stay (3.98 days longer; P < .001).

CONCLUSION

Femoral CVCs are not associated with higher rates of infection in the PICU. In addition, the presence of CVC infection does not affect mortality, but is associated with longer PICU admission.

Complications associated with 2 different types of percutaneously inserted central venous catheters in very low birth weight infants

OBJECTIVE

To identify the prevalence and risk factors for complications associated with percutaneously inserted central venous catheters (PICCs) and evaluate the effect of different catheter types and their indwelling time on catheter-related complications.

DESIGN

Retrospective cohort study.

SETTING

A 49-bed neonatal intensive-care teaching hospital in Taiwan.

PATIENTS

Between 2004 and 2007, 518 single-lumen PICCs (defined as "old type") and 290 PICCs with a stiffening stylet and a thicker introducer ("new type") were inserted in a total of 534 neonates with a birth body weight of 1,500 g or less.

RESULTS

Independent risk factors of catheter-related sepsis (CRS) were longer duration for PICC placement and PICC inserted at femoral site (compared with nonfemoral sites) (odds ratio [OR], 1.53 [95% confidence interval {CI}, 1.07-2.25]; P = .044). An independent predictor of catheter-related noninfectious complications was time spent for PICC insertion of more than 60 minutes (compared with less than 30 minutes) (OR, 1.96 [95% CI, 1.08-3.53]; P = .026). New-type PICCs were significantly associated with a higher rate of femoral site insertion, catheter-related noninfectious complications, and longer time for successful insertion than old-type PICCs. The hazard rates of CRS according to indwelling time, determined over 5-day periods by survival analysis, showed 0.05% for catheters in place for 4 days or less; 0.27% for 5-9 days; 0.40% for 10-14 days; 0.68% for 15-19 days; 1.18% for 20-24 days; 3.96% for 25-29 days; and 10.45% for 30 or more days.

CONCLUSIONS

Different catheters do influence the complication rates. Spending more than 60 minutes for successful PICC insertion and PICCs indwelling for more than 30 days are associated with higher rates of catheter-related complications.

Sepsis in burns: a review of current practice and future therapies

Sepsis is a major cause of death worldwide and remains the subject of much research and debate within the critical care community. Despite advances in burn prevention, treatment, and rehabilitation, sepsis remains a common cause of death in patients who have sustained a severe burn injury. The unique physical, metabolic, and physiologic changes seen after major thermal injury mean that the management of sepsis in burns poses a particular challenge and differs in many respects to the management of sepsis in the general critical care population. This article describes current issues in the prevention, diagnosis, and treatment of sepsis in burns with a review of the associated literature. In addition, we discuss possible future therapies for managing this condition.

Risk factors and prognosis of catheter-related bloodstream infection in critically ill patients: a multicenter study

OBJECTIVE

To assess the risk factors associated with CR-BSI development in critically ill patients with non-tunneled, non-cuffed central venous catheters (CVC) and the prognosis of the episodes of CR-BSI. Design and setting; prospective, observational, multicenter study in nine Spanish Hospitals.

PATIENTS

All subjects admitted to the participating ICUs from October 2004 to June 2005 with a CVC.

INTERVENTIONS

None.

MEASUREMENT AND RESULTS

Overall, 1,366 patients were enrolled and 2,101 catheters were analyzed. Sixty-six episodes of CR-BSI were diagnosed. The incidence of CR-BSI was significantly higher in CVC compared with peripherically inserted central venous catheters (PICVC) without significant differences among the three locations of CVC. In the multivariate analysis, duration of catheterization and change over a guidewire were the independent variables associated with the development of CR-BSI whereas the use of a PICVC was a protective factor. Excluding PICVC, 1,598 conventional CVC were analyzed. In this subset, duration of catheterization, tracheostomy and change over a guidewire were independent risk factors for CR-BSI. A multivariate analysis of predictors for mortality among 66 patients with CRSI showed that early removal of the catheter was a protective factor and APACHE II score at the admission was a strong determinant of in-hospital mortality.

CONCLUSIONS

Peripherically inserted central venous catheters is associated with a lower incidence of CR-BSI in critically ill patients. Exchange over a guidewire of CVC and duration of catheterization are strong contributors to CR-BSI. Our results reinforce the importance of early catheter removal in critically ill patients with CR-BSI.