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Torres-Flores J, Espinoza-Zamora R, Garcia-Mendez J, Cervera-Ceballos E, Sosa-Espinoza A, Zapata-Canto N. Treatment-Related Mortality From Infectious Complications in an Acute Leukemia Clinic. J Hematol 2020; 9:123-131. [PMID: 33224392 PMCID: PMC7665858 DOI: 10.14740/jh751] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 10/29/2020] [Indexed: 12/01/2022] Open
Abstract
Background The main causes of mortality in patients with acute leukemia are the infectious complications. The author wanted to know the induction-related mortality and treatment-related mortality in the acute leukemia patients at the Instituto Nacional de Cancerologia (INCan), Mexico. Also the author is interested in finding out the micro-organism and the main site of infection to make some changes in the management of patients in these clinics. Primary objective was induction chemotherapy-related mortality and treatment-related mortality. Secondary objective was to determine the site of infection, micro-organism, type of chemotherapy related with more mortality and relapse mortality. Methods This was a retrospective case-series analysis of all patients who were admitted to the INCan Acute Leukemia Clinic between January 2012 and December 2015 with febrile neutropenic complications. We reviewed the case histories of all patients, including those with acute lymphoblastic leukemia (ALL), acute myeloblastic leukemia (AML), acute biphenotypic leukemia and acute promyelocytic leukemia, regardless of disease status (newly diagnosed or relapsed) at the time of clinic attendance. Patients who died as the result of an infectious complication during the analysis window were identified, and their demographics, disease characteristics, treatment history (chemotherapy within 45 days of date of death) and details of the infectious complication resulting in death were collected. Results Of the 313 patients studied during that time period, 84 (27%) died as a result of infectious complications. Lung infections were the most common, accounting for 67% of all deaths from infectious complications. Escherichia coli producing extended-spectrum beta-lactamases was the most frequently isolated infectious organism (12 patients; 14%). The majority of deaths occurred during either induction therapy (27 patients; 32%) or treatment for a first relapse (25 patients; 30%). Hyperfractionated cyclophosphamide, vincristine, doxorubicin and dexamethasone (hyper-CVAD) was the chemotherapy regimen most commonly received within 45 days prior to death (17 patients; 20%). Conclusions Our findings suggest a need for long-term management and supportive care to prevent infectious complication-associated fatalities during both initial chemotherapy and subsequent disease relapse in patients with acute leukemia. The use of prophylaxis will help patients to prevent complications.
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Affiliation(s)
- Jorge Torres-Flores
- Hematology Department, Instituto Nacional de Cancerologia Mexico (INCan), Mexico City, Mexico
| | - Ramiro Espinoza-Zamora
- Hematology Department, Instituto Nacional de Cancerologia Mexico (INCan), Mexico City, Mexico
| | - Jorge Garcia-Mendez
- Infectious Diseases Department, Instituto Nacional de Cancerologia Mexico (INCan), Mexico City, Mexico
| | | | | | - Nidia Zapata-Canto
- Hematology Department, Instituto Nacional de Cancerologia Mexico (INCan), Mexico City, Mexico
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Initial Management of Fever and Neutropenia: A Practical Approach. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kethireddy S, Safdar N. Urokinase Lock or Flush Solution for Prevention of Bloodstream Infections Associated with Central Venous Catheters for Chemotherapy: A Meta-Analysis of Prospective Randomized Trials. J Vasc Access 2018. [DOI: 10.1177/112972980800900109] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Intravascular devices (IVDs) carry significant risk of device-associated bloodstream infection (BSI). Catheter thrombosis increases the likelihood of microbial colonization of the catheter and BSI. Urokinase has been studied for the prevention of BSI associated with IVDs. We undertook a systematic review to determine the efficacy of urokinase-heparin lock or flush solution compared with heparin alone in preventing IVD-associated BSI. Methods Computerized databases were searched for relevant publications in English from January 1966 to 1 January 2007. We identified randomized controlled trials comparing a urokinase-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term IVDs. Summary effect sizes were calculated with assessment of heterogeneity. Results Five randomized, controlled trials involving a total of 991 patients being treated with IVDs met the inclusion criteria; all five studies were conducted among patients with cancer; three of these studies were undertaken in children and two in adults. The summary risk ratio with a urokinase-heparin lock solution for IVD-associated BSI was 0.77 (95% confidence interval [CI], 0.60–0.98; p=0.01). Results of the test for heterogeneity were not statistically significant (p=0.53). Conclusions Use of a urokinase lock solution in high-risk patient populations being treated with long-term central IVDs may reduce the risk of BSI. However, there are few randomized trials and methodologic limitations of these preclude more robust recommendations regarding the use of urokinase to prevent BSI. Further adequately powered studies should seek to evaluate the efficacy of urokinase and optimize dosage and instillation regimen.
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Affiliation(s)
- S. Kethireddy
- Section of Infectious Diseases, Department of
Medicine, University of Wisconsin Medical School, Madison, WI - USA
| | - N. Safdar
- Section of Infectious Diseases, Department of
Medicine, University of Wisconsin Medical School, Madison, WI - USA
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Krzywda EA, Andris DA, Edmiston CE. Catheter Infections: Diagnosis, Etiology, Treatment, and Prevention. Nutr Clin Pract 2016. [DOI: 10.1177/088453369901400405] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Schiavetti A, Ventriglia F. Contrast echocardiography test for intrapleural extravasation by central venous catheter. ACTA ACUST UNITED AC 2014. [DOI: 10.2217/iim.13.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
The introduction of totally implantable subcutaneous devices in the early 1980s provided patients with secure, reliable venous access and also gave them the ability to move more freely and have a more normal lifestyle with these devices in place. The most common totally implantable device used today is the subcutaneous port. These ports consist of an injection port connected to a catheter. Ports provide a number of advantages compared with other venous catheters; the most important is the reduced risk of infection. These devices have significantly lower rates of infection than nontunneled and tunneled catheters. Additional advantages include less frequent irrigation and minimal home care, and they are less prone to environmental or cutaneous contamination when not being accessed. This article will focus on the placement of these ports.
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Affiliation(s)
- Shaun J Gonda
- Division of Interventional Radiology, Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR 77205, USA.
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Di Carlo I, Toro A, Pulvirenti E, Palermo F, Scibilia G, Cordio S. Could antibiotic prophylaxis be not necessary to implant totally implantable venous access devices? Randomized prospective study. Surg Oncol 2011; 20:20-5. [DOI: 10.1016/j.suronc.2009.09.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2009] [Revised: 08/26/2009] [Accepted: 09/05/2009] [Indexed: 10/20/2022]
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Senturk E, Telli M, Sen S, Cokpinar S. Thoracic catheter-related infections. J Bras Pneumol 2011; 36:753-8. [PMID: 21225179 DOI: 10.1590/s1806-37132010000600013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Accepted: 07/08/2010] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To determine the incidence of local and systemic infection in a sample of patients catheterized with thoracic catheters (TCs) and to identify the prognostic factors for catheter-related infection. METHODS A retrospective study involving 48 patients (17 females and 31 males) catheterized with TCs between December of 2008 and March of 2009 in the Thoracic Surgery Department of the Adnan Menderes University Hospital, located in Aydin, Turkey. Blood samples for culture were collected from the distal end of each TC and from each of the 48 patients. We looked for correlations between positive culture and possible prognostic factors for catheter-related infection. RESULTS Culture results were positive in TC samples only for 3 patients, in blood samples only for 2, and in both types of samples for another 2. Advanced age correlated significantly with positive culture in TC samples and in blood samples (r = 0.512 and r = 0.312, respectively; p < 0.05 for both), as did prolonged catheterization (r = 0.347 and r = 0.372, respectively; p < 0.05). There was a significant correlation between having undergone surgery and positive culture in TC samples only (p < 0.05). However, having an inoperable malignancy correlated with bacterial growth in blood and in TC samples alike (p < 0.05 for both). CONCLUSIONS Risk factors, such as advanced age, prolonged catheterization, comorbidities, and inoperable malignancy, increase the risk of catheter-related infection. It is imperative that prophylaxis with broad-spectrum antibiotics be administered to patients who present with these risk factors and might be catheterized with a TC.
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Affiliation(s)
- Ekrem Senturk
- Departamento de Microbiologia Médica, Hospital Universitário, Faculdade de Medicina, Universidade Adnan Menderes, Aydin, Turquia.
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Svanberg A, Ohrn K, Birgegård G. Oral cryotherapy reduces mucositis and improves nutrition - a randomised controlled trial. J Clin Nurs 2010; 19:2146-51. [PMID: 20659194 DOI: 10.1111/j.1365-2702.2010.03255.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM AND OBJECTIVE To investigate if oral cryotherapy during myeloablative therapy may influence frequency and severity of mucositis, nutritional status and infection rate after bone marrow transplantation. BACKGROUND Patients treated with intensive myeloablative treatment before bone marrow transplantation are all at risk to develop mucositis. Oral mucositis causes severe pain and oral dysfunction, which can contribute to local and systemic infections and bleeding; it may even interrupt cancer therapy. Oral mucositis also decreases the oral food intake, which increases the risk for malnutrition and infection. Reduced food intake, loss of fat and muscles, alterations in energy and substrate metabolism leads to malnutrition. DESIGN A randomised controlled trial with a random assignment to experimental or control group. METHOD A stratified randomisation was used with regard to the type of transplantation. Mucositis was measured on WHO mucositis scale. Number of days of total parenteral nutrition, infection rate, weight, albumin levels and days at hospital was compared. RESULTS There were significantly fewer patients in the experimental group with mucositis grade 3-4 than in the control group and significantly lower number of days in the hospital (allogeneic patients). Less total parenteral nutrition was needed in the experimental group in both settings, and the S-albumin level was significantly better preserved. No significant difference could be found with regard to infection rate. CONCLUSION Oral cryotherapy reduced mucositis, number of hospital days, the need for total parenteral nutrition and resulted in a better nutritional status. RELEVANCE TO CLINICAL PRACTICE Nurses caring for patients treated with myeloablative therapy should place high priority to prevent oral mucositis and hereby reduce its side effects.
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Affiliation(s)
- Anncarin Svanberg
- Institute for Medical Sciences, Faculty of Medicine, Uppsala University, Uppsala, Sweden.
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Nosari AM, Nador G, Gasperi AD, Ortisi G, Volonterio A, Cantoni S, Nichelatti M, Marbello L, Mazza E, Mancini V, Ravelli E, Ricci F, Ciapanna D, Garrone F, Gesu G, Morra E. Prospective monocentric study of non-tunnelled central venous catheter-related complications in hematological patients. Leuk Lymphoma 2009; 49:2148-55. [DOI: 10.1080/10428190802409930] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Catheter-related bloodstream infection is one of the most serious complications of central venous access devices. Antimicrobial-coated catheters represent one novel strategy to prevent catheter-related bloodstream infection. A comprehensive economic evaluation is essential to guide informed decision-making regarding the adoption of this technology and its expected benefits in healthcare institutions.
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Affiliation(s)
- Nasia Safdar
- Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, H4/572, Madison, WI 53792, USA.
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Wolf HH, Leithäuser M, Maschmeyer G, Salwender H, Klein U, Chaberny I, Weissinger F, Buchheidt D, Ruhnke M, Egerer G, Cornely O, Fätkenheuer G, Mousset S. Central venous catheter-related infections in hematology and oncology. Ann Hematol 2008; 87:863-76. [DOI: 10.1007/s00277-008-0509-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Accepted: 05/10/2008] [Indexed: 10/21/2022]
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Gil L, Styczynski J, Komarnicki M. Infectious complication in 314 patients after high-dose therapy and autologous hematopoietic stem cell transplantation: risk factors analysis and outcome. Infection 2007; 35:421-7. [PMID: 17926001 DOI: 10.1007/s15010-007-6350-2] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2006] [Accepted: 06/27/2007] [Indexed: 01/01/2023]
Abstract
BACKGROUND Infectious complications occur in most of the patients receiving high-dose therapy (HDT) and autologous hematopoietic stem cell transplantation (HSCT). The objective of the study was to analyze of the type and incidence of infectious complications during neutropenia after HDT and autologous HSCT with respect to risk factors related to stem cell transplant setting in patients treated for hematological malignancies in a single center. PATIENTS AND METHODS A total number of 314 patients diagnosed for Hodgkin's disease (HD), non-Hodgkin's lymphoma (NHL), acute myeloid leukemia (AML), multiple myeloma (MM) or acute lymphoblastic leukemia (ALL) were included in the study. Analysis of risk factors and outcome of infections after HDT and autologous HSCT was performed. RESULTS Infectious complications during neutropenia after HDT occurred in 92.3% patients. Microbiologically documented infections (MDI) accounted for 38.9% of febrile episodes, clinically documented infections (CDI) for 9.3%, and fever of unknown origin (FUO) for 51.7% cases. Median time to defervescence with antibiotic therapy was seven days for FUO and nine days for documented infections (p < 0.001). Duration of infection correlated with the length of very severe neutropenia (p < 0.001). Response to first-line antibiotic therapy was seen in 34% patients. Infections were fatal in 12 (3.8%) patients. The highest probability of infection was observed for ALL and AML patients, especially these conditioned with total body irradiation (TBI). CONCLUSION Patients at high risk of infection after autologous HSCT were identified as those with acute leukemia and those after conditioning with TBI, all with prolonged neutropenia. We suggest that newer prophylactic strategies should be administered to these groups of patients.
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Affiliation(s)
- L Gil
- Department of Hematology, University of Medical Sciences, ul. Szamarzewskiego 84, 60-569, Poznan, Poland.
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Camp-Sorrell D. Eye Infection: what's the culprit? Clin J Oncol Nurs 2007; 11:189-90. [PMID: 17573267 DOI: 10.1188/07.cjon.189-190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Safdar N, Maki DG. Use of Vancomycin-Containing Lock or Flush Solutions for Prevention of Bloodstream Infection Associated with Central Venous Access Devices: A Meta-Analysis of Prospective, Randomized Trials. Clin Infect Dis 2006; 43:474-84. [PMID: 16838237 DOI: 10.1086/505976] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Accepted: 04/18/2006] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Prolonged exposure to central venous access devices carries significant risk of device-associated bloodstream infection (BSI), which is associated with morbidity, added health care costs, and attributable mortality. We aimed to determine the efficacy of vancomycin-heparin lock or flush solution in preventing BSI in patients being treated with long-term central venous intravascular devices (IVDs). METHODS We collected data from January 1966 to January 2006 from multiple computerized databases and compiled reference lists of identified articles. We identified prospective, randomized controlled trials comparing a vancomycin-heparin lock or flush solution with heparin alone for prevention of BSI associated with long-term central venous IVDs. Using a standardized form, we abstracted data regarding study quality, patient characteristics, and incidence of BSI. RESULTS Seven randomized, controlled trials involving a total of 463 patients being treated with IVDs met the inclusion criteria; 5 studies were conducted among patients with cancer, 1 among a critically ill neonatal population, and 1 among patients with cancer or who required parenteral nutrition. We could not detect publication bias. The summary risk ratio with a vancomycin heparin-lock solution for IVD-associated BSI was 0.49 (95% confidence interval [CI], 0.26-0.95; P = .03). Results of the test for heterogeneity were statistically significant; however, when a single study was removed from the analysis, heterogeneity was no longer present. Use of vancomycin as a true lock solution--instilling it for a defined period, rather than simply flushing it directly through the device--conferred a much greater benefit, with a risk ratio of 0.34 (95% CI, 0.12-0.98; P = .04). The 2 studies that performed prospective surveillance cultures to identify colonization or infection by vancomycin-resistant organisms did not find an increased risk. CONCLUSIONS Use of a vancomycin lock solution in high-risk patient populations being treated with long-term central IVDs reduces the risk of BSI. The use of an anti-infective lock solution warrants consideration for patients who require central access but who are at high risk of BSI, such as patients with malignancy or low-birthweight neonates.
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Affiliation(s)
- Nasia Safdar
- Section of Infectious Diseases, Department of Medicine, University of Wisconsin Medical School, Madison, WI, USA
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Pracchia LF, Dias LCS, Dorlhiac-Llacer PE, Chamone DDAF. Comparison of catheter-related infection risk in two different long-term venous devices in adult hematology-oncology patients. ACTA ACUST UNITED AC 2004; 59:291-5. [PMID: 15543402 DOI: 10.1590/s0041-87812004000500012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE: Infection is the leading complication of long-term central venous catheters, and its incidence may vary according to catheter type. The objective of this study was to compare the frequency and probability of infection between two types of long-term intravenous devices. METHODS: Retrospective study in 96 onco-hematology patients with partially implanted catheters (n = 55) or completely implanted ones (n = 42). Demographic data and catheter care were similar in both groups. Infection incidence and infection-free survival were used for the comparison of the two devices. RESULTS: In a median follow-up time of 210 days, the catheter-related infection incidence was 0.2102/100 catheter-days for the partially implanted devices and 0.0045/100 catheter-days for the completely implanted devices; the infection incidence rate was 46.7 (CI 95% = 6.2 to 348.8). The 1-year first infection-free survival ratio was 45% versus 97%, and the 1-year removal due to infection-free survival ratio was 42% versus 97% for partially and totally implanted catheters, respectively (P <.001 for both comparisons). CONCLUSION: In the present study, the infection risk was lower in completely implanted devices than in partially implanted ones.
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Affiliation(s)
- Luís Fernando Pracchia
- Department of Hematology and Hemotherapy, Hospital das Clínicas, Faculty of Medicine, University of São Paulo and the Pró-Sangue Foundation - São Paulo/SP, Brazil.
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Aliff TB, Maslak PG, Jurcic JG, Heaney ML, Cathcart KN, Sepkowitz KA, Weiss MA. Refractory Aspergillus pneumonia in patients with acute leukemia: successful therapy with combination caspofungin and liposomal amphotericin. Cancer 2003; 97:1025-32. [PMID: 12569602 DOI: 10.1002/cncr.11115] [Citation(s) in RCA: 189] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pulmonary aspergillosis and other invasive fungal infections (IFIs) commonly complicate the management of patients with acute leukemia. Standard amphotericin-based therapies may be ineffective for many patients and the available salvage agents (itraconazole and caspofungin) are reported to possess only moderate activity against resistant infections. Laboratory evidence suggests a synergistic interaction between amphotericin and caspofungin. The authors treated a group of patients with amphotericin-refractory IFIs with the combination of caspofungin and amphotericin (or liposomal amphotericin). METHODS A retrospective evaluation of patients with amphotericin-resistant IFIs was conducted. Diagnosis was based on clinical, radiographic, and when available, microbiologic data. Response to combination antifungal therapy was graded as either favorable or unfavorable. Favorable responses included improvement of both clinical and radiographic signs of fungal pneumonia. All other responses were graded as unfavorable. RESULTS Thirty patients were included in this analysis. Twenty-six patients had acute leukemia. Based on recently published criteria, the IFIs were classified as proven in 6 patients, probable in 4 patients, and possible in 20 patients. The median duration and dose of amphotericin monotherapy were 12 days (range, 4-65 days) and 7.8 mg/kg (range, 4.2-66.1 mg/kg), respectively. The median duration of combination therapy was 24 days (range, 3-74 days). Eighteen patients (60%) experienced a favorable antifungal response. Twenty patients with acute leukemia received combination therapy for fungal pneumonias arising during intensive chemotherapy treatments. Favorable responses were observed in 15 of these patients (75%), and antifungal response did not depend on the response of the underlying leukemia. Survival to hospital discharge was significantly better (P < 0.001) in patients having a favorable response. Mild to moderate nephrotoxicity was noted in 50% of patients, necessitating the substitution of liposomal amphotericin. Mild elevation of alkaline phosphatase levels occurred in 30% of patients. Caspofungin was temporarily withheld from one patient who developed moderate but reversible biochemical hepatotoxicity. CONCLUSIONS The antifungal combination of caspofungin and amphotericin can be administered safely to high-risk patients with hematologic malignancies. Although an absolute assessment of efficacy is limited by the design of this study, encouraging outcomes were noted for many patients. The authors plan to evaluate this regimen further in a randomized clinical trial.
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Affiliation(s)
- Timothy B Aliff
- Leukemia Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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Aquino VM, Sandler ES, Mustafa MM, Steele JW, Buchanan GR. A prospective double-blind randomized trial of urokinase flushes to prevent bacteremia resulting from luminal colonization of subcutaneous central venous catheters. J Pediatr Hematol Oncol 2002; 24:710-3. [PMID: 12468909 DOI: 10.1097/00043426-200212000-00005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE This study was undertaken to determine if central venous catheter (CVC)-related infection in children with cancer could be prevented by monthly flushing of the catheter with urokinase. PATIENTS AND METHODS Between August 1994 and July 1998, 103 patients with cancer were randomized at the time of subcutaneous CVC placement to receive monthly flushing of their catheters with either 5000 IU of urokinase-heparin or heparin alone. Patients subsequently had blood cultures taken from their CVCs during an episode of fever. RESULTS Seventy-four of the 103 patients (72%) enrolled in the study received at least 6 catheter flushes: 40 with urokinase-heparin and 34 with heparin. The median number of flushes was 9.5 in the urokinase-heparin group and 10.2 in the heparin-only group (P = 0.62). There were 5 positive blood cultures in the urokinase-heparin group and seven in patients receiving heparin alone (P = 0.27). Staphylococcus epidermidis was isolated from the blood of 3 patients receiving urokinase-heparin and 6 in those receiving heparin alone (P = 0.17). CONCLUSION Prophylactic monthly catheter flushes with 5000 IU urokinase did not significantly decrease the number of documented bacteremic events in children with cancer who have CVCs.
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Affiliation(s)
- Victor M Aquino
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
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Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore) 2002; 81:466-79. [PMID: 12441903 DOI: 10.1097/00005792-200211000-00007] [Citation(s) in RCA: 203] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Strategies for preventing central venous catheter (CVC)-related bloodstream infection are most likely to be effective if guided by an understanding of the risk factors associated with these infections. In this critical review of published studies of risk factors for CVC-related bloodstream infection that were prospective and used multivariable techniques of data analysis or that were randomized trials of a preventive measure, a significantly increased risk of catheter-related bloodstream infection was associated with inexperience of the operator and nurse-to-patient ratio in the intensive care unit, catheter insertion with less than maximal sterile barriers, placement of a CVC in the internal jugular or femoral vein rather than subclavian vein, placement in an old site by guidewire exchange, heavy colonization of the insertion site or contamination of a catheter hub, and duration of CVC placement > 7 days. Prospective studies or randomized trials of control measures focusing on these risk factors have been shown to reduce risk significantly: formal training in CVC insertion and care, use of maximal sterile barriers at insertion, use of chlorhexidine rather than povidone-iodine for cutaneous antisepsis, applying a topical anti-infective cream or ointment or a chlorhexidine-impregnated dressing to the insertion site, and the use of novel catheters with an anti-infective surface or a contamination resistant hub. Better prospective studies of sufficient size to address all potential risk factors, including insertion site and hub colonization, insertion technique, and details of follow-up care, would enhance our understanding of the pathogenesis of CVC-related bloodstream infection and guide efforts to develop more effective strategies for prevention.
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Affiliation(s)
- Nasia Safdar
- Department of Medicine, University of Wisconsin Medical School and University of Wisconsin Hospitals and Clinics, Madison, 53792, USA
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Kurul S, Saip P, Aydin T. Totally implantable venous-access ports: local problems and extravasation injury. Lancet Oncol 2002; 3:684-92. [PMID: 12424071 DOI: 10.1016/s1470-2045(02)00905-1] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Totally implantable venous-access ports (TIVAPs) are valuable instruments for long-term intravenous treatment of patients with cancer, but implantation and use of these devices are each associated with complications. In addition to the perioperative problems, long-term complications can arise; these can be classified in five categories-catheter malfunction, catheter-related venous thrombosis, catheter-related infection, port-related complications, and extravasation injury. Such complications reduce the benefits of reliable access to the venous system in patients with malignant tumours. The vast majority of such disadvantages are attributable to inexpert handling of ports and, therefore, should be avoidable. TIVAP placement procedures and TIVAP complications are discussed in this review, with special emphasis on local problems and extravasation injuries. To obtain maximum benefit from TIVAPs, all health-care personnel must be familiar with the use and routine maintenance procedures of the devices and treatment options for catheter-related complications.
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Affiliation(s)
- Sidika Kurul
- Division of Surgical Oncology at the Istanbul University Institute of Oncology, Istanbul, Turkey.
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Abstract
Central venous catheters represent a major source of nosocomial bloodstream infections, which cause considerable excess morbidity. It is currently unknown to what extent these infections contribute to mortality. Most catheter-related infections (CRIs) are caused by Gram-positive organisms (mainly coagulase-negative staphylococci). Definite diagnosis of CRI necessitates removal of the catheter in most cases. However, the recently described technique of differential time to positivity may allow diagnosis of CRI with the catheter left in place. Removal of the catheter has been standard clinical practice for the management of CRI in the past and is still recommended in many cases. In specific situations, such as infections of implanted catheters with coagulase-negative staphylococci, a trial of catheter salvage may be justified. In catheter-related bloodstream infection Staphylococcus aureus and Candida spp., the catheter should be removed immediately, due to the high risk of metastatic infection and increased mortality. A clinical work-up for the detection of additional foci (including transesophageal echocardiography in S. aureus infections) is advisable in these cases. All CRIs should be treated with antibiotics to which the causative agent has been shown to be susceptible. In addition to systemic antimicrobial therapy, antibiotic lock therapy may be applied, especially in patients with implanted long-term catheters if catheter salvage is attempted.
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Affiliation(s)
- G Fätkenheuer
- Department of Internal Medicine, University of Cologne, Germany Department of Microbiology, Hygiene and Medical Immunology, University of Cologne, Germany.
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22
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Bow EJ, Laverdière M, Lussier N, Rotstein C, Cheang MS, Ioannou S. Antifungal prophylaxis for severely neutropenic chemotherapy recipients: a meta analysis of randomized-controlled clinical trials. Cancer 2002; 94:3230-46. [PMID: 12115356 DOI: 10.1002/cncr.10610] [Citation(s) in RCA: 176] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The overall clinical efficacy of the azoles antifungal agents and low-dose intravenous amphotericin B for antifungal chemoprophylaxis in patients with malignant disease who have severe neutropenia remains unclear. METHODS Randomized-controlled trials of azoles (fluconazole, itraconazole, ketoconazole, and miconazole) or intravenous amphotericin B formulations compared with placebo/no treatment or polyene-based controls in severely neutropenic chemotherapy recipients were evaluated using meta-analytical techniques. RESULTS Thirty-eight trials that included 7014 patients (study agents, 3515 patients; control patients, 3499 patients) were analyzed. Overall, there were reductions in the use of parenteral antifungal therapy (prophylaxis success: odds ratio [OR], 0.57; 95% confidence interval [95% CI], 0.48-0.68; relative risk reduction [RRR], 19%; number requiring treatment for this outcome [NNT], 10 patients), superficial fungal infection (OR, 0.29; 95% CI, 0.20-0.43; RRR, 61%; NNT, 12 patients), invasive fungal infection (OR, 0.44; 95% CI, 0.35-0.55; RRR, 56%; NNT, 22 patients), and fungal infection-related mortality (OR, 0.58; 95% CI, 0.41-0.82; RRR, 47%; NNT, 52 patients). Invasive aspergillosis was unaffected (OR, 1.03; 95% CI, 0.62-1.44). Although overall mortality was not reduced (OR, 0.87; 95% CI, 0.74-1.03), subgroup analyses showed reduced mortality in studies of patients who had prolonged neutropenia (OR, 0.72; 95% CI, 0.55-0.95) or who underwent hematopoietic stem cell transplantation (HSCT) (OR, 0.77; 95% CI, 0.59-0.99). The multivariate metaregression analyses identified HSCT, prolonged neutropenia, acute leukemia with prolonged neutropenia, and higher azole dose as predictors of treatment effect. CONCLUSIONS Antifungal prophylaxis reduced morbidity, as evidenced by reductions in the use of parenteral antifungal therapy, superficial fungal infection, and invasive fungal infection, as well as reducing fungal infection-related mortality. These effects were most pronounced in patients with malignant disease who had prolonged neutropenia and HSCT recipients.
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Affiliation(s)
- Eric J Bow
- Department of Internal Medicine, the University of Manitoba and CancerCare Manitoba, Winnipeg, Manitoba, Canada.
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23
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Moran AB, Camp-Sorrell D. Maintenance of venous access devices in patients with neutropenia. Clin J Oncol Nurs 2002; 6:126-30. [PMID: 11998604 DOI: 10.1188/02.cjon.126-130] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Neutropenia is a common complication in patients with cancer who are undergoing chemotherapy. Because of treatment frequency, potential chemotherapy damage to peripheral veins and tissues, and pain from multiple venipunctures, venous access devices (VADs) often are used in the oncology setting. Although VADs have been used for 30 years, no sufficient scientific data exist to support the best care and maintenance strategies for their use in patients with neutropenia. Understanding the etiology and pathogenesis of VAD-related infections (VAD-RI) and the proper steps to prevent or quickly treat it can decrease the likelihood that patients with neutropenia will have a fatal response. This article describes the differences between VADs, the most common sources of VAD-RI, and the treatment of such infections and suggests nursing interventions to help prevent VAD-RI.
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24
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Jeng MR, Feusner J, Skibola C, Vichinsky E. Central venous catheter complications in sickle cell disease. Am J Hematol 2002; 69:103-8. [PMID: 11835345 DOI: 10.1002/ajh.10047] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
A review of patients with sickle cell disease (SCD) and central venous catheters (CVCs) was performed to evaluate the frequency of catheter complications (infections, thrombotic events, and premature CVC removal. Fifteen evaluable patients were identified during our review of a 7.5-year period. The median age was 18 years (range, 1.5-30 years); 14 were African American, and 1 was Latino; 5 were male, and 10 were female. Forty-one CVCs were placed (36 Mediport and 5 Broviac catheters) for a total of 12,120 CVC days. We observed a median of 2 CVCs per patient (range, 1-8 CVCs per patient) with 67 discrete episodes of CVC-associated infection (range, 0-18 per patient) involving 10 patients. The rate of CVC-associated infection for patients with SCD at our institution was 5.5 infections per 1,000 CVC days; this rate was significantly higher than the rate of CVC-associated infection in our patients with cancer (P < 0.001). We also determined that the rate of CVC-associated thrombosis was 0.99 events per 1,000 CVC days and involved 33% of the patients with SCD; the rate of premature CVC removal was 3.15 per 1,000 CVC days, and 78% of CVCs were removed prematurely. We conclude that patients with SCD are at high risk for CVC-related complications, and improved care and close monitoring of CVCs should be encouraged to decrease morbidity in these chronically ill patients.
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Affiliation(s)
- Michael R Jeng
- Department of Hematology and Oncology, Children's Hospital Oakland, Oakland, California, USA.
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26
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Abstract
The increasing trend of a multimodal therapeutic approach in gynecologic oncology in the last few years has markedly changed the nature, frequency, and clinical presentation of infectious diseases. Despite the improved diagnostic tools, refined surgical technique, and routine use of prophylactic antibiotics, the morbidity and mortality of infectious complications remain significant. The rational use of available treatment resources, the recognition of risk factors, and increased awareness of host-cancer interactions should reduce the incidence of these serious infectious complications. The improved prevention and more efficient treatment of infections in the gynecologic oncology patient will not only improve prognosis but also have a significant economic impact as well.
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Affiliation(s)
- R A Adam
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia 30303, USA.
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27
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Wang CC, Mattson D, Wald A. Corynebacterium jeikeium bacteremia in bone marrow transplant patients with Hickman catheters. Bone Marrow Transplant 2001; 27:445-9. [PMID: 11313675 DOI: 10.1038/sj.bmt.1702808] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2000] [Accepted: 12/08/2000] [Indexed: 11/09/2022]
Abstract
Prior studies suggest that Corynebacterium jeikeium bacteremia in immunocompromised patients results in frequent morbidity that may be decreased by prompt removal of the indwelling catheter. To summarize recent experience, charts of 53 bone marrow transplant recipients with Hickman catheters and C. jeikeium bacteremia were reviewed. Forty-one patients were treated with vancomycin without catheter removal and 10 patients underwent catheter removal with subsequent vancomycin therapy. No patient in either group died with C. jeikeium bacteremia as the proximate cause. Salvage of the intravascular catheter was successful in 38 of 41 (93%) attempts. Three patients (7%) in the catheter-salvage group and one patient (10%) in the catheter-removal group experienced recurrent bacteremia. In both catheter-salvage and catheter-removal groups, median time to negative blood culture was 2 days. Thus, time to clearance of bacteremia and patient clinical outcome did not differ between treatment groups. In many patients with Hickman catheters, C. jeikeium bacteremia may be treated successfully with vancomycin and without removal of the catheter.
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Affiliation(s)
- C C Wang
- Department of Medicine, University of Washington, USA
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28
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Domingo P, Fontanet A. Management of complications associated with totally implantable ports in patients with AIDS. AIDS Patient Care STDS 2001; 15:7-13. [PMID: 11177583 DOI: 10.1089/108729101460056] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Morbidity associated with totally implantable ports is common in patients with acquired immune deficiency syndrome (AIDS). More than half of the implanted devices will have at least one complication before its removal or the patient's death. Infectious complications are the most frequent. Two patients are reported here in whom staphylococcal infection of the totally implantable port occurred; one of the devices could be saved through the antibiotic lock technique. Infectious complications of totally implantable ports occur more commonly in patients who are neutropenic or who have low CD4 cell counts (<25 cells per microliter). When patients have chamber infection (the most frequent infectious complication) with or without secondary bacteremia, the antibiotic lock technique has proven useful for device sterilization.
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Affiliation(s)
- P Domingo
- Department of Internal Medicine (Infectious Diseases Unit), Hospital de la Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
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29
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Worthington P, Gilbert KA, Wagner BA. Parenteral nutrition for the acutely ill. AACN CLINICAL ISSUES 2000; 11:559-79; quiz 634-6. [PMID: 11288419 DOI: 10.1097/00044067-200011000-00008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Parenteral nutrition (PN) is one of the most sophisticated forms of intravenous therapy in use today. Intravenous feeding is a life-saving technology for patients unable to maintain their nutritional status using the gastrointestinal tract. Although PN has become an integral component of patient care, the risks associated with this therapy must be weighed against the potential benefits. Comprehensive clinical management includes selection of candidates, implementation and monitoring of therapy, and ensuring a seamless transition when PN is no longer required. Optimal parenteral nutrition demands expertise in caring for vascular access devices. A collaborative approach to care minimizes the risks associated with PN and ensures positive patient outcomes.
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Affiliation(s)
- P Worthington
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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30
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Maroulis J, Kalfarentzos F. Complications of parenteral nutrition at the end of the century. Clin Nutr 2000; 19:295-304. [PMID: 11031066 DOI: 10.1054/clnu.1999.0089] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- J Maroulis
- Surgical Department, University Hospital of Patras Rio, Patras, Greece
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31
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Zuger A. Antimicrobial therapy in immunocompromised patients: infectious complications of solid tumors. Cancer Invest 1999; 17:220-2. [PMID: 10099662 DOI: 10.3109/07357909909021425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- A Zuger
- Albert Einstein College of Medicine, Bronx, New York, USA
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32
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Abstract
The treatment of fever and neutropenia following chemotherapy lends itself well to outpatient parenteral antimicrobial therapy (OPAT). Patients prefer to be at home rather than hospitalized again. There is a clear cost advantage of outpatient therapy. With a quality program and careful patient selection, OPAT can be provided effectively and safely. The chances of an infection due to resistant bacteria also appear to be reduced. There are an increasing number of studies that support the use of empiric antibiotic therapy for the first fever in neutropenic patients. The choice of antimicrobial, dose, as well as vascular access and infusion devices must be tailored to the individual patient needs and circumstances.
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Affiliation(s)
- A D Tice
- Department of Medicine, University of Washington School of Medicine, Seattle, USA
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Affiliation(s)
- C Yip
- McMaster Medical Unit, Henderson Site, Hamilton Health Sciences Corperation, Ontario, Canada
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Abstract
Catheter-related infection (CRI) accounts for a large percentage of nosocomial infections, and related bacteremia is a common complication. Bacteremia arises in approximately 1 of 15 episodes of CRI and causes considerable morbidity and occasional mortality, as well as increased medical costs. The diagnosis of CRI and catheter-related bacteremia (CRB) is still a challenge for practitioners treating catheterized patients. Semiquantitative tip culture by the roll-plate method is the cornerstone for diagnosis of CRI in routine practice. However, there is a great deal of interest in the alternative methods for diagnosing CRI without catheter withdrawal, since treatment of the patient can be successfully completed with the infected device maintained in place. The conservative management of CRI includes perfusion of antibiotics through the infected catheter and the antibiotic-lock technique (ALT). Catheter-related infection prevention is accomplished mainly by strict adherence to hygienic practices in insertion and manipulation of the catheter. However, knowledge of the pathophysiology of CRI has led to the development of new sophisticated catheters and hubs that incorporate mechanical and antibacterial barriers.
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Affiliation(s)
- J A Capdevila
- Servei de Malalties Infeccioses, Hospital General Vall d'Hebrón, Barcelona, Spain
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35
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Andris DA, Krzywda EA. CENTRAL VENOUS ACCESS. Nurs Clin North Am 1997. [DOI: 10.1016/s0029-6465(22)02687-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Brzozowski D, Ross DC. Upper limb Escherichia coli cellulitis in the immunocompromised. JOURNAL OF HAND SURGERY (EDINBURGH, SCOTLAND) 1997; 22:679-80. [PMID: 9752934 DOI: 10.1016/s0266-7681(97)80376-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The neutropenic state characteristic of acute lymphoblastic leukaemia (ALL) predisposes to infections involving Gram-negative bacilli. An Escherichia coli cellulitis originating in the first web space of the hand is described in a patient undergoing reinduction chemotherapy for ALL. Proximal extension of the infection progressed at a very rapid rate and required a forequarter amputation as a life saving measure. Due to the blunted inflammatory response in neutropenic patients, the need for close monitoring and quick intervention is stressed.
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Affiliation(s)
- D Brzozowski
- Hand and Upper Limb Centre and Division of Plastic Surgery, University of Western Ontario, London, Canada
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