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Oladapo-Shittu O, Cosgrove SE, Rock C, Hsu YJ, Klein E, Harris AD, Mejia Chew C, Saunders H, Ching PR, Gadala A, Mayoryk S, Pineles L, Maragakis LL, Salinas AB, Helsel T, Keller SC. CLABSIs aren't just for inpatients: the need to identify CLABSI burden among outpatients. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2024; 4:e132. [PMID: 39290627 PMCID: PMC11406563 DOI: 10.1017/ash.2024.384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/09/2024] [Accepted: 07/09/2024] [Indexed: 09/19/2024]
Affiliation(s)
| | - Sara E Cosgrove
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Clare Rock
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yea-Jen Hsu
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Eili Klein
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anthony D Harris
- University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Public Health, Baltimore, MD, USA
| | | | | | - Patrick R Ching
- Washington University School of Medicine, St. Louis, MO, USA
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Avi Gadala
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stephanie Mayoryk
- University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Public Health, Baltimore, MD, USA
| | - Lisa Pineles
- University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Public Health, Baltimore, MD, USA
| | - Lisa L Maragakis
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Taylor Helsel
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sara C Keller
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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2
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Devautour C, Poey N, Lagier J, Launay E, Cerdac A, Vergnaud N, Berneau P, Parize P, Ferroni A, Tzaroukian L, Pinhas Y, Pinquier D, Lorrot M, Dubos F, Caseris M, Ouziel A, Chalumeau M, Cohen JF, Toubiana J. Salvage strategy for long-term central venous catheter-associated Staphylococcus aureus infections in children: a multi-centre retrospective study in France. J Hosp Infect 2024; 150:125-133. [PMID: 38880286 DOI: 10.1016/j.jhin.2024.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/28/2024] [Accepted: 04/29/2024] [Indexed: 06/18/2024]
Abstract
OBJECTIVES Catheter removal is recommended in adults with Staphylococcus aureus central-line-associated bloodstream infection (CLABSI) but is controversial in children with long-term central venous catheters (LTCVC). We evaluated the occurrence of catheter salvage strategy (CSS) in children with S. aureus LTCVC-associated CLABSI and assessed determinants of CSS failure. METHODS We retrospectively included children (<18 years) with an LTCVC and hospitalized with S. aureus CLABSI in eight French tertiary-care hospitals (2010-2018). CSS was defined as an LTCVC left in place ≥72 h after initiating empiric antibiotic treatment for suspected bacteraemia. Characteristics of patients were reviewed, and multi-variable logistic regression was performed to identify factors associated with CSS failure (i.e., persistence, recurrence or complications of bacteraemia). RESULTS We included 273 episodes of S. aureus LTCVC-associated CLABSI. CSS was chosen in 194 out of 273 (71%) cases and failed in 74 of them (38%). The main type of CSS failure was the persistence of bacteraemia (39 of 74 cases, 53%). Factors independently associated with CSS failure were: history of catheter infection (adjusted odds ratio (aOR) 3.18, 95% confidence interval (CI) 1.38-7.36), CLABSI occurring on an implantable venous access device (aOR 7.61, 95% CI 1.98-29.20) when compared with tunnelled-cuffed CVC, polymicrobial CLABSI (aOR 3.45, 95% CI 1.25-9.50), and severe sepsis at the initial stage of infection (aOR 4.46, 95% CI 1.18-16.82). CONCLUSIONS CSS was frequently chosen in children with S. aureus LTCVC-associated CLABSI, and failure occurred in one-third of cases. The identified risk factors may help clinicians identify children at risk for CSS failure.
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Affiliation(s)
- C Devautour
- Department of General Pediatrics and Infectious Diseases, Necker-Enfants Malades University Hospital, AP-HP, Université Paris Cité, Paris, France
| | - N Poey
- Department of General Pediatrics and Infectious Diseases, Robert Debré University Hospital, AP-HP, Université Paris Cité, Paris, France
| | - J Lagier
- Department of Pediatrics, Hospices Civils de Lyon, Lyon, France
| | - E Launay
- Department of Pediatrics, CHU Nantes, Nantes, France
| | - A Cerdac
- Pediatric Emergency Medicine & Infectious Diseases, CHU Lille, Lille, France
| | - N Vergnaud
- Department of General Pediatrics, Trousseau University Hospital, AP-HP, Pierre et Marie Curie University, Sorbonne Paris, Paris, France
| | - P Berneau
- Department of Pediatrics, Centre Hospitalier de Rennes, Rennes, France
| | - P Parize
- Department of Infectious Diseases and Tropical Medicine, Necker-Enfants Malades University Hospital, AP-HP, Université Paris Cité, Paris, France
| | - A Ferroni
- Department of Clinical Microbiology, Necker-Enfants Malades University Hospital, AP-HP, Université Paris Cité, Paris, France
| | - L Tzaroukian
- Department of Neonatal Pediatrics and Intensive Care and Neuropediatrics, Charles Nicolle University Hospital, Rouen, France
| | - Y Pinhas
- Department of General Pediatrics and Infectious Diseases, Necker-Enfants Malades University Hospital, AP-HP, Université Paris Cité, Paris, France
| | - D Pinquier
- Department of Neonatal Pediatrics and Intensive Care and Neuropediatrics, Charles Nicolle University Hospital, Rouen, France
| | - M Lorrot
- Department of General Pediatrics, Trousseau University Hospital, AP-HP, Pierre et Marie Curie University, Sorbonne Paris, Paris, France
| | - F Dubos
- Pediatric Emergency Medicine & Infectious Diseases, CHU Lille, Lille, France
| | - M Caseris
- Department of General Pediatrics and Infectious Diseases, Robert Debré University Hospital, AP-HP, Université Paris Cité, Paris, France
| | - A Ouziel
- Department of Pediatrics, Hospices Civils de Lyon, Lyon, France
| | - M Chalumeau
- Department of General Pediatrics and Infectious Diseases, Necker-Enfants Malades University Hospital, AP-HP, Université Paris Cité, Paris, France
| | - J F Cohen
- Department of General Pediatrics and Infectious Diseases, Necker-Enfants Malades University Hospital, AP-HP, Université Paris Cité, Paris, France
| | - J Toubiana
- Department of General Pediatrics and Infectious Diseases, Necker-Enfants Malades University Hospital, AP-HP, Université Paris Cité, Paris, France.
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Joslyn D, Saber DA, Miles P. Predictors of Central Vascular Access Device Bloodstream Infections in Patients With Acute Leukemia and Neutropenia: A Retrospective Case-Control Chart Review. JOURNAL OF INFUSION NURSING 2023; 46:139-148. [PMID: 37104689 DOI: 10.1097/nan.0000000000000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Central vascular access devices (CVADs) are standard for the treatment of leukemia. The objectives of this study were to examine predictors for central line-associated bloodstream infection (CLABSI) and causative microorganisms. A retrospective case/control design was used to examine electronic health records (EHRs) of patients with acute leukemia, a CVAD, and neutropenia. Variables were examined for differences between those who developed bacteremia (cases: n = 10) and those who did not (controls: n = 13). Variables included conditions of health (eg, patient history, laboratory results at the time of nadir, nutritional intake during hospitalization, and CVAD care practices). Fisher exact and Mann-Whitney U tests were used for comparison. Nine organisms were identified, including viridans group streptococci (20%) and Escherichia coli (20%). No statistical differences in variables were found between groups. However, over 50% of the nutritional intake data was missing due to lack of documentation. These findings indicate that further study is needed to examine barriers for electronic documentation. The data collection site found opportunities to improve patient care that included education regarding the daily care of CVADs, collaboration with nutritional services to ensure accurate assessments, and coordination with clinical information systems to improve clinical documentation compliance.
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Affiliation(s)
- Delight Joslyn
- Northern Light Eastern Maine Medical Center, Bangor, Maine (Ms Joslyn, Dr Saber, Ms Miles); University of Maine School of Nursing and University of Maine Senator George J. Mitchell Center for Sustainability Solutions, Orono, Maine (Dr Saber)
- Delight Joslyn, MSN, RN, OCN®, CRNI®, CPHON, is a staff nurse III at Northern Light Eastern Maine Medical Center on an inpatient acute care medical-surgical unit with a primary specialty focus in respiratory and oncology care. She received her BSN and MS in nursing education from the University of Maine School of Nursing. As a registered nurse, she has spent 28 years in various capacities at the medical center to include prior experience as manager of infusion services. Her most recent roles include bedside nurse, charge nurse, and staff nurse III. In her capacity as staff nurse III, her responsibilities include staff education and participation in quality and performance projects such as central line-associated bloodstream infection prevention. She has held certification in oncology nursing for over 10 years and the designation of Certified Registered Nurse Infusion (CRNI) since 2015. Deborah A. Saber, PhD, RN, CCRN-K, is an associate professor at the University of Maine School of Nursing and the director of nursing research and evidence-based practice at Northern Light Eastern Maine Medical Center. She received her BSN from Vanderbilt University, MS in nursing administration from DePaul University, and PhD in nursing from the University of Central Florida. As a registered nurse (RN), she spent 25 years in clinical practice in a variety of intensive care units (eg, surgical, medical, pediatric). As the director of nursing research, she assists nursing staff in conducting research and evidence-based practice projects. Her field of research has focused on the nursing work environment, and health care waste resulting from food and solid waste, which has resulted in the publication of articles in peer reviewed journals and presentations at both regional and international conferences. Patricia Miles, MSN, RN, OCN®, is a nurse manager at Northern Light Eastern Maine Medical Center on an inpatient acute care medical-surgical unit with a primary specialty focus in respiratory and oncology care. She received her BSN and MS in nursing education from the University of Maine School of Nursing. As a registered nurse, she has spent 22 years in various capacities on the oncology unit to include bedside nurse, charge nurse, and nurse manager. In her capacity as nurse manager, her responsibilities include oversight of quality and performance improvement on the unit. She has held certification in oncology nursing for 20 years
| | - Deborah A Saber
- Northern Light Eastern Maine Medical Center, Bangor, Maine (Ms Joslyn, Dr Saber, Ms Miles); University of Maine School of Nursing and University of Maine Senator George J. Mitchell Center for Sustainability Solutions, Orono, Maine (Dr Saber)
- Delight Joslyn, MSN, RN, OCN®, CRNI®, CPHON, is a staff nurse III at Northern Light Eastern Maine Medical Center on an inpatient acute care medical-surgical unit with a primary specialty focus in respiratory and oncology care. She received her BSN and MS in nursing education from the University of Maine School of Nursing. As a registered nurse, she has spent 28 years in various capacities at the medical center to include prior experience as manager of infusion services. Her most recent roles include bedside nurse, charge nurse, and staff nurse III. In her capacity as staff nurse III, her responsibilities include staff education and participation in quality and performance projects such as central line-associated bloodstream infection prevention. She has held certification in oncology nursing for over 10 years and the designation of Certified Registered Nurse Infusion (CRNI) since 2015. Deborah A. Saber, PhD, RN, CCRN-K, is an associate professor at the University of Maine School of Nursing and the director of nursing research and evidence-based practice at Northern Light Eastern Maine Medical Center. She received her BSN from Vanderbilt University, MS in nursing administration from DePaul University, and PhD in nursing from the University of Central Florida. As a registered nurse (RN), she spent 25 years in clinical practice in a variety of intensive care units (eg, surgical, medical, pediatric). As the director of nursing research, she assists nursing staff in conducting research and evidence-based practice projects. Her field of research has focused on the nursing work environment, and health care waste resulting from food and solid waste, which has resulted in the publication of articles in peer reviewed journals and presentations at both regional and international conferences. Patricia Miles, MSN, RN, OCN®, is a nurse manager at Northern Light Eastern Maine Medical Center on an inpatient acute care medical-surgical unit with a primary specialty focus in respiratory and oncology care. She received her BSN and MS in nursing education from the University of Maine School of Nursing. As a registered nurse, she has spent 22 years in various capacities on the oncology unit to include bedside nurse, charge nurse, and nurse manager. In her capacity as nurse manager, her responsibilities include oversight of quality and performance improvement on the unit. She has held certification in oncology nursing for 20 years
| | - Patricia Miles
- Northern Light Eastern Maine Medical Center, Bangor, Maine (Ms Joslyn, Dr Saber, Ms Miles); University of Maine School of Nursing and University of Maine Senator George J. Mitchell Center for Sustainability Solutions, Orono, Maine (Dr Saber)
- Delight Joslyn, MSN, RN, OCN®, CRNI®, CPHON, is a staff nurse III at Northern Light Eastern Maine Medical Center on an inpatient acute care medical-surgical unit with a primary specialty focus in respiratory and oncology care. She received her BSN and MS in nursing education from the University of Maine School of Nursing. As a registered nurse, she has spent 28 years in various capacities at the medical center to include prior experience as manager of infusion services. Her most recent roles include bedside nurse, charge nurse, and staff nurse III. In her capacity as staff nurse III, her responsibilities include staff education and participation in quality and performance projects such as central line-associated bloodstream infection prevention. She has held certification in oncology nursing for over 10 years and the designation of Certified Registered Nurse Infusion (CRNI) since 2015. Deborah A. Saber, PhD, RN, CCRN-K, is an associate professor at the University of Maine School of Nursing and the director of nursing research and evidence-based practice at Northern Light Eastern Maine Medical Center. She received her BSN from Vanderbilt University, MS in nursing administration from DePaul University, and PhD in nursing from the University of Central Florida. As a registered nurse (RN), she spent 25 years in clinical practice in a variety of intensive care units (eg, surgical, medical, pediatric). As the director of nursing research, she assists nursing staff in conducting research and evidence-based practice projects. Her field of research has focused on the nursing work environment, and health care waste resulting from food and solid waste, which has resulted in the publication of articles in peer reviewed journals and presentations at both regional and international conferences. Patricia Miles, MSN, RN, OCN®, is a nurse manager at Northern Light Eastern Maine Medical Center on an inpatient acute care medical-surgical unit with a primary specialty focus in respiratory and oncology care. She received her BSN and MS in nursing education from the University of Maine School of Nursing. As a registered nurse, she has spent 22 years in various capacities on the oncology unit to include bedside nurse, charge nurse, and nurse manager. In her capacity as nurse manager, her responsibilities include oversight of quality and performance improvement on the unit. She has held certification in oncology nursing for 20 years
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Linder LA, Gerdy C, Jo Y, Stark C, Wilson A. Changes in Central Line–Associated Bloodstream Infection (CLABSI) Rates Following Implementation of Levofloxacin Prophylaxis for Children and Adolescents With High-Risk Leukemia. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2022; 40:69-81. [PMID: 36358024 DOI: 10.1177/27527530221122683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: Despite initiatives to reduce central line–associated bloodstream infection (CLABSI), children and adolescents with hematologic malignancies, as well as those with relapsed disease, remain at the greatest risk for infection. This single-institution project evaluated changes in CLABSI rates following implementation of antibacterial prophylaxis with levofloxacin for patients with high-risk hematologic malignancies. Methods: Positive blood culture events meeting National Health Safety Network surveillance criteria to be classified as CLABSIs from January 1, 2006, to December 31, 2019, were included. Data were organized into four time periods for comparison based on implementation of CLABSI-reduction interventions. Conditional Poisson regression models were used to evaluate the effect of time (intervention period) on CLABSI rates with post hoc Tukey pairwise comparisons between each of the four time periods. Results: From 2006 and 2019, 227 patients experienced 310 CLABSIs. Clinically important decreases in CLABSI rates from baseline (4.84 per 1,000 line days) occurred with implementation of Children's Hospital Association (CHA) bundles (3.29 per 1,000 line days); however, this difference was not significant ( p = .16). CLABSI rates decreased from baseline with the addition of formalized supportive cares (2.66 per 1,000 line days; incidence rate ratio [IRR] = 0.60; p < .01), and with the use of antibacterial prophylaxis (1.66 per 1,000 line days; IRR = 0.35; p < .01). Post hoc comparisons indicated decreased CLABSI rates with the use of antibacterial prophylaxis compared with CHA bundles alone (IRR = 0.49; p = .011) and CHA bundles plus formalized supportive cares (IRR = 0.58; p = .046). Discussion: Results demonstrate sustained success using a practice-based evidence approach to guide CLABSI-reduction interventions. Follow-up research, applying machine learning algorithms, may identify additional risk factors and inform future interventions.
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Affiliation(s)
- Lauri A. Linder
- University of Utah College of Nursing, Salt Lake City, UT, USA
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Cheryl Gerdy
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Yeonjung Jo
- Huntsman Cancer Institute, Salt Lake City, UT, USA
- University of Utah School of Medicine, Population Health Sciences, Salt Lake City, UT, USA
| | - Crystal Stark
- Primary Children’s Hospital, Center for Cancer and Blood Disorders, Salt Lake City, UT, USA
| | - Andrew Wilson
- Parexel, Durham, NC, USA
- University of Utah Department of Family and Preventive Medicine, Salt Lake City, UT, USA
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Abstract
PURPOSE OF REVIEW Pediatric oncology patients frequently experience episodes of prolonged neutropenia which puts them at high risk for infection with significant morbidity and mortality. Here, we review the data on infection prophylaxis with a focus on both pharmacologic and ancillary interventions. This review does not include patients receiving hematopoietic stem cell transplantation. RECENT FINDINGS Patients with hematologic malignancies are at highest risk for infection. Bacterial and fungal prophylaxis decrease the risk of infection in certain high-risk groups. Ancillary measures such as ethanol locks, chlorhexidine gluconate baths, GCSF, IVIG, and mandatory hospitalization do not have enough data to support routine use. There is limited data on risk of infection and role of prophylaxis in patients receiving immunotherapy and patients with solid tumors. Patients with Down syndrome and adolescent and young adult patients may benefit from additional supportive care measures and protocol modifications. Consider utilizing bacterial and fungal prophylaxis in patients with acute myeloid leukemia or relapsed acute lymphoblastic leukemia. More research is needed to evaluate other supportive care measures and the role of prophylaxis in patients receiving immunotherapy.
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Affiliation(s)
- Stephanie Villeneuve
- Paediatric Haemotology/Oncology, Dalhousie University and the IWK Health Centre, 5850/5980 University Avenue, Halifax, NS, B3K 6R8, Canada
| | - Catherine Aftandilian
- Pediatric Hematology/Oncology, Stanford University, 1000 Welch Rd, Palo Alto, CA, 94304, USA.
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High Rates of Central Venous Line Replacement or Revision in Children With Cancer at US Children's Hospitals. J Pediatr Hematol Oncol 2022; 44:43-46. [PMID: 33633028 DOI: 10.1097/mph.0000000000002098] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 01/14/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Most children with cancer utilize a central venous line (CVL) for treatment. Complications often necessitate early replacement, revision, or addition (RRA), but the rate of these procedures is not known. This study sought to determine rates of RRA in pediatric oncology patients, and associated risk factors. MATERIALS AND METHODS Data queried from the Pediatric Health Information System including patients ≤18 years old with malignancy and CVL placement. Analysis included: first CVL placement of the calendar year and subsequent procedures for 6 months thereafter. RESULTS A total of 6553 children met inclusion criteria (55.9% male, median age 6 years, interquartile range: 2 to 12). RRA within 6 months was required in 25.6% of patients, with 1.7% requiring 5 or more lines. Patients with Central Line-Associated Bloodstream Infection (CLABSI) were 2.78 times more likely to require RRA within 6 months of initial CVL placement, but accounted for only 16% of RRA patients. Factors associated with RRA were age below 1 year, CLABSI, hematologic malignancy, malnutrition, clotting disorder, deep vessel thromboembolism, and obesity. Patients with implantable ports as initial CVL (42%) were less likely to need RRA. CONCLUSION Twenty-five percent require at least 1 RRA within 6 months, with associated morbidity and costs. Though strongly associated, most revisions were not related to CLABSI episodes.
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Woods-Hill CZ, Xie A, Lin J, Wolfe HA, Plattner AS, Malone S, Chiotos K, Szymczak JE. Numbers and narratives: how qualitative methods can strengthen the science of paediatric antimicrobial stewardship. JAC Antimicrob Resist 2022; 4:dlab195. [PMID: 35098126 PMCID: PMC8794647 DOI: 10.1093/jacamr/dlab195] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Antimicrobial and diagnostic stewardship initiatives have become increasingly important in paediatric settings. The value of qualitative approaches to conduct stewardship work in paediatric patients is being increasingly recognized. This article seeks to provide an introduction to basic elements of qualitative study designs and provide an overview of how these methods have successfully been applied to both antimicrobial and diagnostic stewardship work in paediatric patients. A multidisciplinary team of experts in paediatric infectious diseases, paediatric critical care and qualitative methods has written a perspective piece introducing readers to qualitative stewardship work in children, intended as an overview to highlight the importance of such methods and as a starting point for further work. We describe key differences between qualitative and quantitative methods, and the potential benefits of qualitative approaches. We present examples of qualitative research in five discrete topic areas of high relevance for paediatric stewardship work: provider attitudes; provider prescribing behaviours; stewardship in low-resource settings; parents' perspectives on stewardship; and stewardship work focusing on select high-risk patients. Finally, we explore the opportunities for multidisciplinary academic collaboration, incorporation of innovative scientific disciplines and young investigator growth through the use of qualitative research in paediatric stewardship. Qualitative approaches can bring rich insights and critically needed new information to antimicrobial and diagnostic stewardship efforts in children. Such methods are an important tool in the armamentarium against worsening antimicrobial resistance, and a major opportunity for investigators interested in moving the needle forward for stewardship in paediatric patients.
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Affiliation(s)
- Charlotte Z. Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 733 N Broadway, Baltimore, MD 21205, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, 750 E Pratt St., Baltimore, MD 21202, USA
| | - John Lin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Heather A. Wolfe
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Alex S. Plattner
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Sara Malone
- Division of Pediatric Infectious Disease, Department of Pediatrics, Washington University School of Medicine, 660 S Euclid Ave, St Louis, MO 63110, USA
| | - Kathleen Chiotos
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
- University of Pennsylvania Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Julia E. Szymczak
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk # 210, Philadelphia, PA 19104, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA
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8
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Sick-Samuels AC, Woods-Hill C. Diagnostic Stewardship in the Pediatric Intensive Care Unit. Infect Dis Clin North Am 2022; 36:203-218. [PMID: 35168711 PMCID: PMC8865365 DOI: 10.1016/j.idc.2021.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In the pediatric intensive care unit (PICU), clinicians encounter complex decision making, balancing the need to treat infections promptly against the potential harms of antibiotics. Diagnostic stewardship is an approach to optimize microbiology diagnostic test practices to reduce unnecessary antibiotic treatment. We review the evidence for diagnostic stewardship of blood, endotracheal, and urine cultures in the PICU. Clinicians should consider 3 questions applying diagnostic stewardship: (1) Does the patient have signs or symptoms of an infectious process? (2) What is the optimal diagnostic test available to evaluate for this infection? (3) How should the diagnostic specimen be collected to optimize results?
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Affiliation(s)
- Anna C. Sick-Samuels
- The Johns Hopkins University School of Medicine, Department of Pediatrics, Division of Infectious Diseases, Baltimore, MD,The Johns Hopkins Hospital, Department of Hospital Epidemiology and Infection Control, Baltimore, MD
| | - Charlotte Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Postoperative Rather Than Preoperative Neutropenia Is Associated With Early Catheter-related Bloodstream Infections in Newly Diagnosed Pediatric Cancer Patients. Pediatr Infect Dis J 2022; 41:133-139. [PMID: 34596627 DOI: 10.1097/inf.0000000000003315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The relationship of early catheter-related bloodstream infections (CRBSIs) with perioperative neutropenia and antibiotic prophylaxis is not well established. We sought to evaluate perioperative factors associated with early CRBSIs in newly diagnosed pediatric cancer patients, particularly hematologic indices and antibiotic use. METHODS We retrospectively reviewed national registry records of newly diagnosed pediatric cancer patients with port-a-caths inserted using standardized perioperative protocols where only antibiotic use was not regulated. Thirty-day postoperative CRBSI incidence was correlated with preoperative factors using logistic regression and with postoperative blood counts using linear trend analysis. RESULTS Among 243 patients, 17 CRBSIs (7.0%) occurred at median 14 (range, 8-28) postoperative days. Early CRBSIs were significantly associated with cancer type [acute myeloid leukemia and other leukemias (AML/OLs) vs. solid tumors and lymphomas (STLs): odds ratio (OR), 5.09; P = 0.0036; acute lymphoblastic leukemia vs. STL: OR 0.83; P = 0.0446] but not preoperative antibiotics, absolute neutrophil counts and white blood cell counts. Thirty-day postoperative absolute neutrophil counts and white blood cell trends differed significantly between patients with acute lymphoblastic leukemia and STLs (OR 0.83, P < 0.05) and between AML/OLs and STLs (OR 5.09, P < 0.005), with AML/OL patients having the most protracted neutropenia during this period. CONCLUSIONS Contrary to common belief, low preoperative absolute neutrophil counts and lack of preoperative antibiotics were not associated with higher early CRBSI rates. Instead, AML/OL patients, particularly those with prolonged neutropenia during the first 30 postoperative days, were at increased risk. Our findings do not support the use of empirical preoperative antibiotics and instead identify prolonged postoperative neutropenia as a major contributing factor for early CRBSI.
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10
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Low Risk of Central Line-associated Bloodstream Infections in Pediatric Hematology/Oncology Patients. Pediatr Infect Dis J 2021; 40:827-831. [PMID: 33990520 DOI: 10.1097/inf.0000000000003177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Central venous lines (CVLs) are essential for standard care of pediatric hematology/oncology patients providing safe administration of cytotoxic drugs and pain-free blood sampling. Central line-associated bloodstream infections (CLABSIs) cause significant morbidity. This study describes the epidemiology, microbiology, and risk factors for CLABSI in all children with malignancies in Iceland. METHODS All children that were diagnosed with malignancy in Iceland and received a CVL during 2008-2017 were included in the study. Characteristics of CVLs and patients were registered, information on risk factors, and microbiology was collected. International standards were used for CLABSI definition. RESULTS One hundred forty-three CVLs were placed in 94 children. Acute lymphoblastic leukemia was the most common underlying disease (31/94). Median age was 7 years. Implantable ports were the most commonly placed CVLs (82/143, 57%), tunneled lines were 39 (27%). Overall CLABSI rate was 0.24 infections/1000 line-days (14 episodes in 58,830 line-days), with little fluctuations. No CLABSI episodes occurred for 4 consecutive years (2012-2015). Staphylococci (of which 7 Staphylococcus aureus) were the cause of 10/14 episodes. Nine CLABSI episodes led to line removal, but no deaths were linked to CLABSIs. CONCLUSION We report very low CLABSI rates over a 9-year period at our hospital, with 4 consecutive CLABSI-free years. Even with the addition of episodes of possible CLABSI, rates were still very low and lower than most published reports.
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Woods-Hill CZ, Koontz DW, Voskertchian A, Xie A, Shea J, Miller MR, Fackler JC, Milstone AM. Consensus Recommendations for Blood Culture Use in Critically Ill Children Using a Modified Delphi Approach. Pediatr Crit Care Med 2021; 22:774-784. [PMID: 33899804 PMCID: PMC8416691 DOI: 10.1097/pcc.0000000000002749] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Blood cultures are fundamental in evaluating for sepsis, but excessive cultures can lead to false-positive results and unnecessary antibiotics. Our objective was to create consensus recommendations focusing on when to safely avoid blood cultures in PICU patients. DESIGN A panel of 29 multidisciplinary experts engaged in a two-part modified Delphi process. Round 1 consisted of a literature summary and an electronic survey sent to invited participants. In the survey, participants rated a series of recommendations about when to avoid blood cultures on five-point Likert scale. Consensus was achieved for the recommendation(s) if 75% of respondents chose a score of 4 or 5, and these were included in the final recommendations. Any recommendations that did not meet these a priori criteria for consensus were discussed during the in-person expert panel review (Round 2). Round 2 was facilitated by an independent expert in consensus methodology. After a review of the survey results, comments from round 1, and group discussion, the panelists voted on these recommendations in real-time. SETTING Experts' institutions; in-person discussion in Baltimore, MD. SUBJECTS Experts in pediatric critical care, infectious diseases, nephrology, oncology, and laboratory medicine. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 27 original recommendations, 18 met criteria for achieving consensus in Round 1; some were modified for clarity or condensed from multiple into single recommendations during Round 2. The remaining nine recommendations were discussed and modified until consensus was achieved during Round 2, which had 26 real-time voting participants. The final document contains 19 recommendations. CONCLUSIONS Using a modified Delphi process, we created consensus recommendations on when to avoid blood cultures and prevent overuse in the PICU. These recommendations are a critical step in disseminating diagnostic stewardship on a wider scale in critically ill children.
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Affiliation(s)
- Charlotte Z Woods-Hill
- Division of Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Danielle W Koontz
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annie Voskertchian
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Judy Shea
- Division of General Internal Medicine, Department of Medicine and Leonard Davis Institute of Health Economics
| | - Marlene R Miller
- Rainbow Babies and Children’s Hospital
- Case Western Reserve University School of Medicine
- Johns Hopkins Bloomberg School of Public Health
| | - James C Fackler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Aaron M Milstone
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
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12
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Milford K, von Delft D, Majola N, Cox S. Long-term vascular access in differently resourced settings: a review of indications, devices, techniques, and complications. Pediatr Surg Int 2020; 36:551-562. [PMID: 32200406 DOI: 10.1007/s00383-020-04640-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 11/26/2022]
Abstract
Central venous access is frequently essential for the management of many acute and chronic conditions in children. Millions of central venous access devices (CVADs) are placed each year. In this review article, we discuss the indications for long-term vascular access, the types of devices available, the state of the art of central venous cannulation and device placement, and the complications of long-term central venous access. We pay a special attention to the challenges of, and options for long-term central venous access, also those in developing countries, with limited financial, human, and material resources.
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Affiliation(s)
- Karen Milford
- The Division of Urology, The Hospital for Sick Children, The University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Dirk von Delft
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Nkululeko Majola
- Department of Paediatric Surgery, Frere Hospital, Walter Sisulu University, East London, South Africa
| | - Sharon Cox
- Division of Paediatric Surgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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13
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Akinboyo IC, Young RR, Spees LP, Heston SM, Smith MJ, Chang YC, McGill LE, Martin PL, Jenkins K, Lugo DJ, Hazen KC, Seed PC, Kelly MS. Microbiology and Risk Factors for Hospital-Associated Bloodstream Infections Among Pediatric Hematopoietic Stem Cell Transplant Recipients. Open Forum Infect Dis 2020; 7:ofaa093. [PMID: 32284949 PMCID: PMC7141603 DOI: 10.1093/ofid/ofaa093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/12/2020] [Indexed: 12/02/2022] Open
Abstract
Background Children undergoing hematopoietic stem cell transplantation (HSCT) are at high risk for hospital-associated bloodstream infections (HA-BSIs). This study aimed to describe the incidence, microbiology, and risk factors for HA-BSI in pediatric HSCT recipients. Methods We performed a single-center retrospective cohort study of children and adolescents (<18 years of age) who underwent HSCT over a 20-year period (1997–2016). We determined the incidence and case fatality rate of HA-BSI by causative organism. We used multivariable Poisson regression to identify risk factors for HA-BSI. Results Of 1294 patients, the majority (86%) received an allogeneic HSCT, most commonly with umbilical cord blood (63%). During the initial HSCT hospitalization, 334 HA-BSIs occurred among 261 (20%) patients. These were classified as gram-positive bacterial (46%), gram-negative bacterial (24%), fungal (12%), mycobacterial (<1%), or polymicrobial (19%). During the study period, there was a decline in the cumulative incidence of HA-BSI (P = .021) and, specifically, fungal HA-BSIs (P = .002). In multivariable analyses, older age (incidence rate ratio [IRR], 1.03; 95% confidence interval [CI], 1.01–1.06), umbilical cord blood donor source (vs bone marrow; IRR, 1.69; 95% CI, 1.19–2.40), and nonmyeloablative conditioning (vs myeloablative; IRR, 1.85; 95% CI, 1.21–2.82) were associated with a higher risk of HA-BSIs. The case fatality rate was higher for fungal HA-BSI than other HA-BSI categories (21% vs 6%; P = .002). Conclusions Over the past 2 decades, the incidence of HA-BSIs has declined among pediatric HSCT recipients at our institution. Older age, umbilical cord blood donor source, and nonmyeloablative conditioning regimens are independent risk factors for HA-BSI among children undergoing HSCT.
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Affiliation(s)
- Ibukunoluwa C Akinboyo
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebecca R Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael J Smith
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Yeh-Chung Chang
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Lauren E McGill
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA.,Division of Pediatric Blood and Marrow Transplantation, Duke University Medical Center, Durham, North Carolina, USA
| | - Paul L Martin
- Division of Pediatric Blood and Marrow Transplantation, Duke University Medical Center, Durham, North Carolina, USA
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Debra J Lugo
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin C Hazen
- Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Patrick C Seed
- Division of Pediatric Infectious Diseases, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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Baier C, Linke L, Eder M, Schwab F, Chaberny IF, Vonberg RP, Ebadi E. Incidence, risk factors and healthcare costs of central line-associated nosocomial bloodstream infections in hematologic and oncologic patients. PLoS One 2020; 15:e0227772. [PMID: 31978169 PMCID: PMC6980604 DOI: 10.1371/journal.pone.0227772] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/27/2019] [Indexed: 12/28/2022] Open
Abstract
Non-implanted central vascular catheters (CVC) are frequently required for therapy in hospitalized patients with hematological malignancies or solid tumors. However, CVCs may represent a source for bloodstream infections (central line-associated bloodstream infections, CLABSI) and, thus, may increase morbidity and mortality of these patients. A retrospective cohort study over 3 years was performed. Risk factors were determined and evaluated by a multivariable logistic regression analysis. Healthcare costs of CLABSI were analyzed in a matched case-control study. In total 610 patients got included with a CLABSI incidence of 10.6 cases per 1,000 CVC days. The use of more than one CVC per case, CVC insertion for conditioning for stem cell transplantation, acute myeloid leukemia, leukocytopenia (≤ 1000/μL), carbapenem therapy and pulmonary diseases were independent risk factors for CLABSI. Hospital costs directly attributed to the onset of CLABSI were 8,810 € per case. CLABSI had a significant impact on the overall healthcare costs. Knowledge about risk factors and infection control measures for CLABSI prevention is crucial for best clinical practice.
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Affiliation(s)
- Claas Baier
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Lena Linke
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Matthias Eder
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Frank Schwab
- Institute of Hygiene and Environmental Medicine, Charité - University Medicine, Berlin, Germany
| | - Iris Freya Chaberny
- Institute of Hygiene, Hospital Epidemiology and Environmental Medicine, Leipzig University Hospital, Leipzig, Germany
| | - Ralf-Peter Vonberg
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
| | - Ella Ebadi
- Institute for Medical Microbiology and Hospital Epidemiology, Hannover Medical School, Hannover, Germany
- * E-mail:
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15
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Nassar R, Hazan G, Leibovitz E, Ling G, Lazar I, Khalaila A, Fruchtman Y, Yerushalmi B. Central venous catheter-associated bloodstream infections in children diagnosed with intestinal failure in Southern Israel. Eur J Clin Microbiol Infect Dis 2019; 39:517-525. [PMID: 31768705 DOI: 10.1007/s10096-019-03753-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 10/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To study the clinical, epidemiological, and microbiological associations between intestinal failure (IF) and central line-associated infections (CLABSI) in patients with central vein catheters (CVCs) during 2005-2016. METHODS We compared retrospectively CLABSI rates according to background disease, type of line access, pathogen distribution, and antibiotic susceptibilities. RESULTS One hundred and fourteen children (64.1% < 4 years) were enrolled. Main diagnoses were persistent diarrhea (20, 17.5%), short bowel syndrome (13, 11.4%), continuous-TPN w/o diarrhea (11, 9.7%), very early-onset inflammatory bowel disease (VEO-IBD, 8, 7%), Hirschsprung's disease (3, 2.6%), non-oncologic hematologic conditions (13, 11.4%), and other diseases (46, 40.4%). 152.749 catheter days were recorded; 71.1% had Hickman's catheters. Two hundred and nine CLABSI episodes were recorded in 58 patients (82% with IF, 13.7 and 8.2/1000 catheter days in IF, and non-gastrointestinal conditions, P = 0.09). More CLABSI were recorded in continuous TPN vs. VEO-IBD or persistent diarrhea (38.8 vs.15.8 and 12.8/1000 catheter days, P < 0.004). Among patients with Hickman in jugular vein, highest CLBSI incidence was in continuous TPN, VEO-IBD, and persistent diarrhea (29.9, 15.84, and 12.49 episodes/1000 catheter days, respectively). CVCs were removed in 38.8% CLABSI. Two hundred and thirty-five pathogens were isolated (Enterobacteriaceae spp. in 39% of IF patients, mostly in persistent diarrhea and short bowel syndrome patients, 47.6% and 34.8%, respectively). Coagulase-negative Staphylococcus was the commonest pathogen in continuous TPN, VEO-IBD, and Hirschsprung's (71.4%, 55.6% and 46.1%, respectively). CONCLUSIONS CLABSI rates in IF patients were among the highest reported. We reported a "hierarchy" in CLABSI incidence among patients with IF and showed that CLABSI incidence and etiology were different as function of background diseases and CVC insertion site.
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Affiliation(s)
- Raouf Nassar
- Pediatric Division, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, 84101, Be'er Sheva, Israel
| | - Guy Hazan
- Pediatric Division, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, 84101, Be'er Sheva, Israel
| | - Eugene Leibovitz
- Pediatric Division, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, 84101, Be'er Sheva, Israel.
| | - Galina Ling
- Pediatric Gastroenterology Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University, Be'er Sheva, Israel
| | - Isaac Lazar
- Pediatric Division, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, 84101, Be'er Sheva, Israel
| | - Aya Khalaila
- Pediatric Division, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, 84101, Be'er Sheva, Israel
| | - Yariv Fruchtman
- Pediatric Division, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 151, 84101, Be'er Sheva, Israel
| | - Baruch Yerushalmi
- Pediatric Gastroenterology Unit, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University, Be'er Sheva, Israel
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16
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Mantegazza C, Landy N, Zuccotti GV, Köglmeier J. Indications and complications of inpatient parenteral nutrition prescribed to children in a large tertiary referral hospital. Ital J Pediatr 2018; 44:66. [PMID: 29880053 PMCID: PMC5992672 DOI: 10.1186/s13052-018-0505-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/25/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Parenteral Nutrition (PN) is prescribed to children with intestinal failure. Although life saving, complications are common. Recommendations for indications and constituents of PN are made in the 2005 guidelines by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). The aim of this study was to establish if the indications for prescribing PN in a tertiary children's hospital were appropriate, and to identify complications encountered. Data were compared to those published by the National Confidential Enquiry into patient outcome and death (NCEPOD) carried out in the United Kingdom in 2010. METHODS Children and newborns receiving inpatient PN over a 6 months period were entered into the study and data was collected prospectively. The appropriate indications for the use of PN were based on the ESPGHAN guidelines. Recorded complications were divided into metabolic, central venous catheter (CVC) related, hepatobiliary and nutritional. RESULTS A total of 303 children (67 newborns) were entered into the study. The main indications for the start of PN were critical illness (66/303), surgery (63/303) and bone marrow transplantation (28/303). The ESPGHAN recommendations were followed in 91.7% (278/303) of cases (95.5% of newborns, 90.7% of children). PN was considered inappropriate in 12/303 patients and equivocal in 13. The mean PN duration was 18 days (1-160) and the incidence of complications correlated to the length of PN prescribed. Metabolic, hepatobiliary and CVC related complications affected 74.6, 24.4, 16.4% of newborns and 76.7, 37.7 and 24.6% of children respectively. In relation to the appropriate indications for the start of PN our results mirrored those reported by the NCEPOD audit (92.4% of newborns and 88.6% children). However, the incidence of metabolic disturbances was higher in our cohort (74.6% vs 30.4% in children, 76.7% vs 14.3% in newborns) but CVC related complications lower amongst our newborns (16,4% vs 25%). CONCLUSIONS Although the indications for inpatient PN in children is mostly justified, there is still a proportion who is receiving PN unnecessarily. PN related complications remain common. There is a need for better education amongst health professionals prescribing PN and access to nutritional support teams to reduce unwanted side effects.
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Affiliation(s)
- C. Mantegazza
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Pediatrics, University of Milan, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - N. Landy
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - G. V. Zuccotti
- Department of Pediatrics, University of Milan, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - J. Köglmeier
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Clinical Characteristics and Risk Factors of Long-term Central Venous Catheter-associated Bloodstream Infections in Children. Pediatr Infect Dis J 2018; 37:401-406. [PMID: 29194165 DOI: 10.1097/inf.0000000000001849] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central line-associated bloodstream infections (CLABSIs) account for significant morbidity and mortality in patients with long-term central venous catheters (CVCs). This study was performed to identify the characteristics and risk factors of CLABSIs among children with long-term CVCs. METHODS A retrospective review of children who had a long-term CVC in Seoul National University Children's Hospital between 2011 and 2015 was performed. Data on patient demographics, the isolated pathogens and the status of CVC placement were collected. Clinical variables were compared between subjects with and without CLABSIs to determine the risk factors for CLABSIs. RESULTS A total of 629 CVCs were inserted in 499 children during the 5-year period. The median age at insertion was 6.0 years (14 days-17.9 years), and hemato-oncologic disease was the most common underlying condition (n = 497, 79.0%). A total of 235 CLABSI episodes occurred in 155 children, with a rate of 0.93 per 1,000 catheter days. The most common pathogens were Klebsiella pneumoniae (n = 64, 27.2%), coagulase-negative staphylococci (n = 40, 17.0%) and Staphylococcus aureus (n = 28, 12.0%). In the univariate analysis, the gender, underlying disease, catheter characteristics and insertion technique did not increase the risk for CLABSI. In both the univariate and logistic regression analyses, patients with prior BSIs (odds ratio 1.66; 95% confidence interval: 1.090-2.531; P = 0.018) were more likely to have a CLABSI. CONCLUSIONS CLABSI prevention is of particular concern for children with a prior BSI. Furthermore, the antimicrobial resistance of major pathogens should be monitored to enable the empiric selection of appropriate antibiotics in patients with long-term CVCs.
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18
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Linder LA, Gerdy C, Jo Y, Wilson A. Changes in Central Line-Associated Bloodstream Infection Rates Among Children With Immune Compromised Conditions: An 11-Year Review. J Pediatr Oncol Nurs 2018; 35:382-391. [PMID: 29665727 DOI: 10.1177/1043454218767885] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This article describes changes in central line-associated bloodstream infection (CLABSI) rates among common causative organisms over an 11-year period on a pediatric inpatient unit prior to and following CLABSI reduction strategies. The setting for this descriptive cohort design study was a 32-bed inpatient unit in a tertiary pediatric hospital serving children with immune compromised conditions, including cancer and recipients of hematopoietic stem cell and solid organ transplants. Between January 2006 and December 2016, 265 CLABSIs involving 189 patients were reported. Data were organized into three time periods: 5-year preintervention baseline (2006-2010), implementation of maintenance care bundles (2011-2012), and addition of formalized supportive care practices to the maintenance care bundles (2013-2016). Organisms were categorized into four groups based on the National Health Safety Network organism list. Time-by-class Poisson regression models evaluated changes in CLABSI rates. Characteristics of patients who developed CLABSIs were unchanged. Infections occurred most frequently among patients with hematologic malignancies and neutropenia. Significant log rate decreases in CLABSI rates were observed with the implementation of maintenance care bundles plus enhanced supportive cares compared to preintervention baseline for the following organisms: (1) common commensal organisms (-1.05, p = .005), (2) mucosal barrier injury (MBI) organisms common to the mouth (-.708, p = .007), and (3) other noncommensal/non-MBI pathogens (-.77, p = .005). Rates were unchanged for MBI organisms common to the lower gastrointestinal tract. Central line maintenance care bundles and formalized supportive care practices resulted in sustained decreased CLABSI rates. Additional interventions are needed to reduce CLABSIs involving MBI-associated organisms common to the lower gastrointestinal tract.
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Affiliation(s)
- Lauri A Linder
- 1 University of Utah, Salt Lake City, UT, USA.,2 Primary Children's Hospital, Salt Lake City, UT, USA
| | - Cheryl Gerdy
- 2 Primary Children's Hospital, Salt Lake City, UT, USA
| | - Yeonjung Jo
- 1 University of Utah, Salt Lake City, UT, USA
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19
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Devrim İ, Oruç Y, Demirağ B, Kara A, Düzgöl M, Uslu S, Yaşar N, Aydın Köker S, Töret E, Bayram N, Vergin C. Central line bundle for prevention of central line-associated bloodstream infection for totally implantable venous access devices (ports) in pediatric cancer patients. J Vasc Access 2018; 19:358-365. [PMID: 29926785 DOI: 10.1177/1129729818757955] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE The clinical impact of central line bundle programs for central line-associated bloodstream infections has been well demonstrated in intensive care units. However, the experience of central line bundle programs in totally implantable venous access devices (ports) in pediatric-hematology patients was limited. METHODS A retrospective study was designed to compare and evaluate the clinical impact of implementing a central line bundle for a 2-year 5-month period, including 10 months of prebundle period, 11 months of central line bundle (that includes needleless split-septum devices), and finally 8 months of central line bundle period in which single-use prefilled flushing devices were added to the previous central line bundle. RESULTS During the prebundle period, the rate of 14.5 central line-associated bloodstream infections per 1000 CL-days had decreased to 5.49 CLABSIs per 1000 CL-days in the first bundle period. The incidence rate ratio with these two groups was 0.379, indicating a relative risk reduction of 62% ( p = 0.005). By the addition of single-use prefilled flushing devices to the first bundle program, the central line-associated bloodstream infection rate decreased to 2.63 per 1000 CL-days. Port removal rate due to central line-associated bloodstream infections was 0.46 per 1000 catheter days in the bundle period, which was significantly lower than in the prebundle period in which port removal rate was 4.5 per 1000 catheter days ( p < 0.001). CONCLUSION Central line bundle programs were found to be effective in decreasing central line-associated bloodstream infection rates, improving patients' quality of life by preventing ports removal due in pediatric cancer patients.
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Affiliation(s)
- İlker Devrim
- 1 Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Yeliz Oruç
- 2 Department of Infection Control Committee, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Bengü Demirağ
- 3 Department of Pediatric Hematology and Oncology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Ahu Kara
- 1 Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Mine Düzgöl
- 1 Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Selma Uslu
- 3 Department of Pediatric Hematology and Oncology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Nevbahar Yaşar
- 2 Department of Infection Control Committee, Dr. Behçet Uz Children's Hospital, Izmir, Turkey
| | - Sultan Aydın Köker
- 3 Department of Pediatric Hematology and Oncology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Ersin Töret
- 3 Department of Pediatric Hematology and Oncology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Nuri Bayram
- 1 Department of Pediatric Infectious Diseases, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
| | - Canan Vergin
- 3 Department of Pediatric Hematology and Oncology, Dr. Behçet Uz Children's Hospital, İzmir, Turkey
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20
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Heiser Rosenberg CE, Terhaar MF, Ascenzi JA, Walbert A, Kokoszka KM, Perretta JS, Miller MR. Becoming Parent and Nurse: High-Fidelity Simulation in Teaching Ambulatory Central Line Infection Prevention to Parents of Children with Cancer. Jt Comm J Qual Patient Saf 2017; 43:251-258. [PMID: 28434459 DOI: 10.1016/j.jcjq.2017.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Ambulatory central-line infections in children with cancer are life-threatening. Infections are two to three times more frequent in outpatients than inpatients, for whom evidence-based bundles have decreased morbidity. Most cancer care now takes place at home, where parents perform many of the same tasks as nurses. However, parents often feel stressed and unprepared. To address this, high-fidelity simulation, which has been effective for teaching novice nurses, was evaluated for parent central-line education. METHODS In a feasibility study using a pretest/posttest design, after completion of usual central-line education, parents participated in a high-fidelity simulation practice session. Parents were assessed in three domains: (1) knowledge of infection prevention; (2) psychomotor skill competence; and (3) ability to recognize health care provider nonadherence to best practices. Parents also completed a 5-point Likert simulation experience survey. RESULTS A convenience sample of 17 parents participated between December 2015 and March 2016. Knowledge median scores increased from pre- to posttest from 10 to 15 of 16 points possible (p ≤ 0.001; Wilcoxon signed rank test). Median skills scores increased from pre- to posttest from 8 to 12 points of 12 possible (p ≤ 0.001). Following simulation, median recognition scores increased from 3 to 6 with 6 points possible (p ≤ 0.001). For the parent experience survey, 100% of participants strongly agreed or agreed that simulation was meaningful for learning central-line care. CONCLUSIONS As an adjunct to usual care central-line education, translation of high-fidelity simulation to parent education is a novel approach that shows promise for improving central-line care at home in children with cancer.
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Bacterial bloodstream infections in the allogeneic hematopoietic cell transplant patient: new considerations for a persistent nemesis. Bone Marrow Transplant 2017; 52:1091-1106. [PMID: 28346417 DOI: 10.1038/bmt.2017.14] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/20/2016] [Accepted: 01/12/2017] [Indexed: 12/14/2022]
Abstract
Bacterial bloodstream infections (BSI) cause significant transplant-related morbidity and mortality following allogeneic hematopoietic cell transplantation (allo-HCT). This manuscript reviews the risk factors for and the bacterial pathogens causing BSIs in allo-HCT recipients in the contemporary transplant period. In addition, it offers insight into emerging resistant pathogens and reviews clinical management considerations to treat and strategies to prevent BSIs in allo-HCT patients.
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Rogers AEJ, Eisenman KM, Dolan SA, Belderson KM, Zauche JR, Tong S, Gralla J, Hilden JM, Wang M, Maloney KW, Dominguez SR. Risk factors for bacteremia and central line-associated blood stream infections in children with acute myelogenous leukemia: A single-institution report. Pediatr Blood Cancer 2017; 64. [PMID: 27616655 DOI: 10.1002/pbc.26254] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/10/2016] [Indexed: 11/05/2022]
Abstract
BACKGROUND Central line-associated blood stream infections (CLABSIs) are a source of high morbidity and mortality in children with acute myelogenous leukemia (AML). PROCEDURE To understand the epidemiology and risk factors associated with the development of CLABSI in children with AML. METHODS We retrospectively reviewed all patients with AML over a 5-year period between 2007 and 2011 at the Children's Hospital Colorado. Cases and controls were classified on the basis of the presence of a CLABSI as defined by the National Healthcare Safety Network. RESULTS Of 40 patients in the study, 25 (62.5%) developed at least one CLABSI during therapy. The majority of CLABSIs were due to oral or gastrointestinal organisms (83.0%). Skin organisms accounted for 8.5%. In a multivariable analysis, the strongest risk factors associated with CLABSI were diarrhea (odds ratio [OR] 6.7, 95% confidence interval [CI] 1.6-28.7), receipt of blood products in the preceding 4-7 days (OR 10.0, 95%CI 3.2-31.0), not receiving antibiotics (OR 8.3, 95%CI 2.8-25.0), and chemotherapy cycle (OR 3.5, 95%CI 1.4-8.9). CLABSIs led to increased morbidity, with 13 cases (32.5%) versus two controls (1.9%) requiring transfer to the pediatric intensive care unit (P < 0.001). Three (7.5%) of 40 CLABSI events resulted in or contributed to death. CONCLUSIONS Intensified line care efforts cannot eliminate all CLABSIs in the patients with AML. Exploring the role of mucosal barrier breakdown and/or the use of antibiotic prophylaxis may be effective strategies for further prevention of CLABSIs, supporting ongoing trials in this patient population.
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Affiliation(s)
- Ashley E J Rogers
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kristen M Eisenman
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Susan A Dolan
- Department of Epidemiology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kristin M Belderson
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Jocelyn R Zauche
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Suhong Tong
- Department of Pediatrics, Biostatistics and Informatics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Jane Gralla
- Department of Pediatrics, Biostatistics and Informatics, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Joanne M Hilden
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Michael Wang
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Kelly W Maloney
- Department of Pediatric Oncology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
| | - Samuel R Dominguez
- Department of Epidemiology, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado.,Department of Infectious Disease, University of Colorado Denver School of Medicine and Children's Hospital Colorado, Aurora, Colorado
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Thurman CB, Abbott M, Liu J, Larson E. Risk for Health Care-Associated Bloodstream Infections in Pediatric Oncology Patients With Various Malignancies. J Pediatr Oncol Nurs 2016; 34:196-202. [PMID: 28038498 DOI: 10.1177/1043454216680596] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This was a retrospective cohort study to identify the rates, predictors, and outcomes of health care-associated bloodstream infections (HA-BSI) among children with solid tumors, lymphoma, lymphoid leukemia, and myeloid leukemia. The study population included 4500 children ≤18 years old at a pediatric hospital in New York City from 2006 to 2014. A total of 147 HA-BSI cases were identified; using multivariable logistic regression modeling, children with a hematologic diagnosis (lymphoma, lymphoid leukemia, myeloid leukemia) were at greater risk for HA-BSI than those with a solid tumor diagnosis (all P values <.0001). The odds of mortality for patients with HA-BSI were 6.98 (95% confidence interval 3.02-16.10) times that of those without HA-BSI. Although malignancy type was identified as risk factor for HA-BSI, there was no significant difference in overall mortality from HA-BSI by tumor type ( P = .51).
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Linder LA, Gerdy C, Abouzelof R, Wilson A. Using Practice-Based Evidence to Improve Supportive Care Practices to Reduce Central Line–Associated Bloodstream Infections in a Pediatric Oncology Unit. J Pediatr Oncol Nurs 2016; 34:185-195. [DOI: 10.1177/1043454216676838] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Children with cancer are a subset of patients with central lines with distinct risk factors for infection including periods of prolonged neutropenia and compromised mucous membrane integrity. This article relates the implementation of principles of practice-based evidence to identify interventions in addition to best practice maintenance care bundles to reduce central line–associated bloodstream infections involving viridans group streptococci and coagulase-negative staphylococci on an inpatient pediatric oncology unit. Review of individual events combined with review of current clinical practice guided the development of structured protocols emphasizing routine oral care and general supportive cares. Key principles of the protocols emphasized a 1-2-3 mnemonic and included daily bathing, twice daily oral care, and out-of-bed activity 3 times daily. Poisson regression identified a significant main effect for time period for central line–associated bloodstream infection rates involving both viridans group streptococci and coagulase-negative staphylococci. Significant differences were present between the preintervention baseline and implementation of the supportive care protocols. Project outcomes demonstrate the added value of using principles of practice-based evidence to guide the development of interventions to improve clinical care when evidence-based sources are limited.
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Affiliation(s)
- Lauri A. Linder
- University of Utah College of Nursing, Salt Lake City, UT, USA
- Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Cheryl Gerdy
- Primary Children’s Hospital, Salt Lake City, UT, USA
| | | | - Andrew Wilson
- University of Utah College of Nursing, Salt Lake City, UT, USA
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Abstract
OBJECTIVE Although management algorithms for fever and central venous catheters (CVCs) have been implemented for pediatric oncology (PO) patients, management of pediatric outpatients with noncancer diagnoses and CVCs lacks clear protocols. The aim of the study was to assess outcomes for pediatric outpatients with gastrointestinal disorders presenting with fever and CVC. METHODS Using a microbiology database and emergency department records, we created a database of pediatric gastroenterology (PGI) and PO outpatients with fever and a CVC who presented to our emergency department or clinics from January 2010 through December 2012. We excluded patients who had severe neutropenia (absolute neutrophil count, <500/mm). We performed chart reviews to assess demographic and clinical characteristics. RESULTS A total of 334 episodes in 144 patients were evaluated. Fifty-three percent (95% confidence interval, 38%-68%) of PGI patients had a bloodstream infection, whereas only 9% (95% confidence interval, 5%-14%) of PO patients had a bloodstream infection (P < 0.001). Among patients with a bloodstream infection, the PGI patients were more likely than the PO patients to have polymicrobial infections (46% vs 15%), gram-negative infections (57% vs 27%), and/or infection with enteric organisms (61% vs 23%). The PGI patients had higher rates of CVC removal (19% vs 4%) but no statistical difference in intensive care unit needs (11% vs 4%). CONCLUSIONS Pediatric gastroenterology outpatients with fever and a CVC have a high prevalence of bloodstream infection. Algorithms for management need to be subspecialty specific. Pediatric gastroenterology patients presenting to emergency departments or clinics with fever and CVC require admission for monitoring and management.
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Simon A, Furtwängler R, Graf N, Laws HJ, Voigt S, Piening B, Geffers C, Agyeman P, Ammann RA. Surveillance of bloodstream infections in pediatric cancer centers - what have we learned and how do we move on? GMS HYGIENE AND INFECTION CONTROL 2016; 11:Doc11. [PMID: 27274442 PMCID: PMC4886351 DOI: 10.3205/dgkh000271] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pediatric patients receiving conventional chemotherapy for malignant disease face an increased risk of bloodstream infection (BSI). Since BSI may represent an acute life-threatening event in patients with profound immunosuppression, and show further negative impact on quality of life and anticancer treatment, the prevention of BSI is of paramount importance to improve and guarantee patients' safety during intensive treatment. The great majority of all pediatric cancer patients (about 85%) have a long-term central venous access catheter in use (type Broviac or Port; CVAD). Referring to the current surveillance definitions a significant proportion of all BSI in pediatric patients with febrile neutropenia is categorized as CVAD-associated BSI. This state of the art review summarizes the epidemiology and the distinct pathogen profile of BSI in pediatric cancer patients from the perspective of infection surveillance. Problems in executing the current surveillance definition in this patient population are discussed and a new concept for the surveillance of BSI in pediatric cancer patients is outlined.
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Affiliation(s)
- Arne Simon
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Rhoikos Furtwängler
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Norbert Graf
- Pädiatrische Onkologie und Hämatologie, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Hans Jürgen Laws
- Klinik für Pädiatrische Onkologie, Hämatologie und Immunologie, Universitätskinderklinik, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Sebastian Voigt
- Klinik für Pädiatrie m. S. Onkologie / Hämatologie / Stammzelltransplantation, Charité – Universitätsmedizin Berlin, Germany
| | - Brar Piening
- Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Germany
| | - Christine Geffers
- Institut für Hygiene und Umweltmedizin, Charité – Universitätsmedizin Berlin, Germany
| | - Philipp Agyeman
- Pädiatrische Infektiologie und Pädiatrische Hämatologie-Onkologie, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Switzerland
| | - Roland A. Ammann
- Pädiatrische Infektiologie und Pädiatrische Hämatologie-Onkologie, Universitätsklinik für Kinderheilkunde, Inselspital, Bern, Switzerland
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Furtwängler R, Laux C, Graf N, Simon A. Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients. GMS HYGIENE AND INFECTION CONTROL 2015; 10:Doc15. [PMID: 26605135 PMCID: PMC4657435 DOI: 10.3205/dgkh000258] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: During intensive chemotherapy, bloodstream infection (BSI) represents an important complication in paediatric cancer patients. Most patients carry a long-term central venous access device (CVAD). Improved maintenance care of these vascular catheters may decrease the risk of BSI. Methods: Intervention study (adapted CVAD prevention protocol) with two observation periods (P1: 09-2009 until 05-2011; P2: 09-2011 until 05-2013); prospective surveillance of all laboratory confirmed BSIs. In P2, ready to use sterile NaCl 0.9% syringes were used for CVAD flushing and octenidine/isopropanol for the disinfection of catheter hubs and 3-way stopcocks. Results: During P1, 84 patients were included versus 81 patients during P2. There were no significant differences between the two patient populations in terms of median age, gender, underlying malignancy or disease status (first illness or relapse). Nearly all CVADs were Broviac catheters. The median duration from implantation to removal of the CVAD was 192 days (Inter-quartile-range (IQR); 110–288 days) in P1 and 191 days (IQR; 103–270 days) in P2. 28 BSI were diagnosed in 22 patients in P1 (26% of all patients experienced at least one BSI) and 15 BSI in 12 patients in P2 (15% of all patients). The corresponding results for incidence density (ID) were 0.44 (CI95 0.29–0.62) for P1 vs. 0.34 (0.19–0.53) BSI per 100 inpatient days for P2 and for incidence rate (IR) 7.76 (5.16–10.86) in P1 vs. 4.75 (2.66–7.43) BSI per 1,000 inpatient CVAD utilization days. In P1, 9 BSI were caused by CoNS vs. only 2 in P2 (IR 2.49; CI95 0.17–4.17 vs. 0.63; CI95 0.08–1.72). In P1 two BSI (7%) lead to early removal of the device. During P2 one CVAD was prematurely removed due to a Broviac-related BSI (6.7%). Conclusion: The preventive protocol investigated in this study led to a reduction of BSI in paediatric cancer patients. This result was clinically relevant but – due to insufficient power in a single centre observation – the difference did not reach statistical significance. The most pronounced trend in BSI reduction was observed for CoNS infections. Thus, improving maintenance care of the CVAD may result in lower CVAD-linked infection rates. The higher acquisition cost of the ready to use NaCl 0.9% flushing syringes and octenidine/propanol hub disinfection were probably balanced by cost savings in the intervention period.
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Affiliation(s)
- Rhoikos Furtwängler
- Department of Paediatric Oncology and Haematology, University Hospital, Homburg/Saar, Germany
| | - Carolin Laux
- Department of Paediatric Oncology and Haematology, University Hospital, Homburg/Saar, Germany
| | - Norbert Graf
- Department of Paediatric Oncology and Haematology, University Hospital, Homburg/Saar, Germany
| | - Arne Simon
- Department of Paediatric Oncology and Haematology, University Hospital, Homburg/Saar, Germany
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Abstract
PURPOSE OF REVIEW Compared with adults, neonatal and pediatric populations are especially vulnerable patients who have specific diagnostic and therapeutic differences; therefore, the standard infection control practices designed for adults are sometimes not effective or need modifications to work. This review focuses on the recent literature addressing the challenges and successes in preventing healthcare-associated infections (HAIs) in children. RECENT FINDINGS Improving the implementation of pediatric versions of preventive bundles focusing on proper catheter insertion and maintenance, mainly as a part of a larger multimodal strategy, is effective in reducing the central-line-associated bloodstream infections in neonatal and pediatric populations including oncology patients. Appropriate feeding, antimicrobial stewardship, and infection control measures should be combined in reducing necrotizing enterocolitis in preterm neonates. Implementing a multimodal bundle strategy adapted for pediatric population is successful in preventing ventilator-associated pneumonia. Appropriate use of antimicrobial prophylaxis remains the cornerstone for preventing surgical-site infections irrespective of age, with few additional effective adjuvant preventive practices in specific pediatric patients. SUMMARY Several evidence-based practices are effective in reducing the incidence and the impact of HAIs in children; however, proper implementation remains a challenge. Additionally, several adult preventive practices are still unestablished in children and need further thorough examination.
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Ammann RA, Laws HJ, Schrey D, Ehlert K, Moser O, Dilloo D, Bode U, Wawer A, Schrauder A, Cario G, Laengler A, Graf N, Furtwängler R, Simon A. Bloodstream infection in paediatric cancer centres--leukaemia and relapsed malignancies are independent risk factors. Eur J Pediatr 2015; 174:675-86. [PMID: 25804192 DOI: 10.1007/s00431-015-2525-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 03/12/2015] [Accepted: 03/13/2015] [Indexed: 01/05/2023]
Abstract
UNLABELLED In a prospective multicentre study of bloodstream infection (BSI) from November 01, 2007 to July 31, 2010, seven paediatric cancer centres (PCC) from Germany and one from Switzerland included 770 paediatric cancer patients (58% males; median age 8.3 years, interquartile range (IQR) 3.8-14.8 years) comprising 153,193 individual days of surveillance (in- and outpatient days during intensive treatment). Broviac catheters were used in 63% of all patients and Ports in 20%. One hundred forty-two patients (18%; 95% CI 16 to 21%) experienced at least one BSI (179 BSIs in total; bacteraemia 70%, bacterial sepsis 27%, candidaemia 2%). In 57%, the BSI occurred in inpatients, in 79% after conventional chemotherapy. Only 56 % of the patients showed neutropenia at BSI onset. Eventually, patients with acute lymphoblastic leukaemia (ALL) or acute myeloblastic leukaemia (AML), relapsed malignancy and patients with a Broviac faced an increased risk of BSI in the multivariate analysis. Relapsed malignancy (16%) was an independent risk factor for all BSI and for Gram-positive BSI. CONCLUSION This study confirms relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. On a unit level, data on BSIs in this high-risk population derived from prospective surveillance are not only mandatory to decide on empiric antimicrobial treatment but also beneficial in planning and evaluating preventive bundles. WHAT IS KNOWN • Paediatric cancer patients face an increased risk of nosocomial bloodstream infections (BSIs). • In most cases, these BSIs are associated with the use of a long-term central venous catheter (Broviac, Port), severe and prolonged immunosuppression (e.g. neutropenia) and other chemotherapy-induced alterations of host defence mechanisms (e.g. mucositis). What is New: • This study is the first multicentre study confirming relapsed malignancy as an independent risk factor for BSIs in paediatric cancer patients. • It describes the epidemiology of nosocomial BSI in paediatric cancer patients mainly outside the stem cell transplantation setting during conventional intensive therapy and argues for prospective surveillance programmes to target and evaluate preventive bundle interventions.
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Affiliation(s)
- R A Ammann
- Department of Paediatrics, University of Bern, Bern, Switzerland,
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Madenci AL, Lehmann LE, Weldon CB. Surgical consultation and intervention during pediatric hematopoietic stem cell transplantation. Pediatr Transplant 2014; 18:875-81. [PMID: 25224384 DOI: 10.1111/petr.12360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2014] [Indexed: 11/29/2022]
Abstract
Children undergoing HSCT are at risk for complications due to immune system impairment, toxicity from prior therapies and conditioning regimens, and long-term use of indwelling catheters. These problems may require assessment by the surgical team. We sought to characterize the role of surgical consultation during primary hospital stay for HSCT. We retrospectively reviewed the records of consecutive patients undergoing HSCT between September 2010 and September 2012. One hundred and seventy-three patients underwent 189 HSCTs. General surgery consultations occurred during 33% (n = 62) of primary hospitalizations for HSCT, with a total of 85 consults. Sixty-three (73%) consults resulted in an intervention in the operating room or at the bedside. The majority of consults were for CVL issues (59%, n = 50), followed by abdominal complaints (16%, n = 14). Patients requiring surgical consultation had significantly higher in-hospital mortality (16% vs. 2%, p < 0.01) and 100-day TRM (10% vs. 2%, p < 0.01), compared with those not requiring consultation. Patients undergoing HSCT often require surgical consultation, most commonly for line-related issues. Surgical consultation heralded an increased risk of in-hospital and 100-day TRM. Issues among this high-risk cohort of children who have undergone HSCT must be familiar to the general surgeon and oncologist alike.
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Affiliation(s)
- Arin L Madenci
- Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA; Department of Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Wilson MZ, Rafferty C, Deeter D, Comito MA, Hollenbeak CS. Attributable costs of central line-associated bloodstream infections in a pediatric hematology/oncology population. Am J Infect Control 2014; 42:1157-60. [PMID: 25444262 DOI: 10.1016/j.ajic.2014.07.025] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 07/23/2014] [Accepted: 07/24/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Although several studies have estimated the attributable cost and length of stay (LOS) of central line-associated bloodstream infections (CLABSIs) in the pediatric intensive care unit setting, little is known about the attributable costs and LOS of CLABSIs in the vulnerable pediatric hematology/oncology population. METHODS We studied a total of 1562 inpatient admissions for 291 pediatric hematology/oncology patients at a single tertiary care children's hospital in the mid-Atlantic region between January 2008 and May 2011. Costs were normalized to year 2011 dollars. Propensity score matching was used to estimate the effect of CLABSIs on total cost and LOS while controlling for other covariates. RESULTS Sixty CLABSIs occurred during the 1562 admissions. Compared with the patients without a CLABSI, those who developed a CLABSI tended to be older (9.0 years vs 7.5 years; P = .026) and to have a tunneled catheter (46.7% vs 27.0%) and a peripherally inserted central catheter (20.0% vs 11.2%) as opposed to other types of catheters (P < .0001). Propensity score matching yielded matched groups without significant differences in patient characteristics. In the propensity score analysis, the attributable LOS of a CLABSI was 21.2 days (P < .0001), and the attributable cost of a CLABSI was $69,332 (P < .0001). CONCLUSIONS Among pediatric hematology/oncology patients, CLABSI was associated with an additional LOS of 21 days and increased costs of nearly $70,000. These findings may inform decisions regarding the value of investing in efforts to prevent CLABSIs in this vulnerable population.
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Tavadze M, Rybicki L, Mossad S, Avery R, Yurch M, Pohlman B, Duong H, Dean R, Hill B, Andresen S, Hanna R, Majhail N, Copelan E, Bolwell B, Kalaycio M, Sobecks R. Risk factors for vancomycin-resistant enterococcus bacteremia and its influence on survival after allogeneic hematopoietic cell transplantation. Bone Marrow Transplant 2014; 49:1310-6. [PMID: 25111516 DOI: 10.1038/bmt.2014.150] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 05/28/2014] [Accepted: 06/02/2014] [Indexed: 11/09/2022]
Abstract
Vancomycin-resistant enterococcus (VRE) is a well-known infectious complication among immunocompromised patients. We performed a retrospective analysis to identify risk factors for the development of VRE bacteremia (VRE-B) within 15 months after allogeneic hematopoietic cell transplantation (alloHCT) and to determine its prognostic importance for other post-transplant outcomes. Eight hundred consecutive adult patients who underwent alloHCT for hematologic diseases from 1997 to 2011 were included. Seventy-six (10%) developed VRE-B at a median of 46 days post transplant. Year of transplant, higher HCT comorbidity score, a diagnosis of ALL, unrelated donor and umbilical cord blood donor were all significant risk factors on multivariable analysis for the development of VRE-B. Sixty-seven (88%) died within a median of 1.1 months after VRE-B, but only four (6%) of these deaths were attributable to VRE. VRE-B was significantly associated with worse OS (hazard ratio 4.28, 95% confidence interval 3.23-5.66, P<0.001) in multivariable analysis. We conclude that the incidence of VRE-B after alloHCT has increased over time and is highly associated with mortality, although not usually attributable to VRE infection. Rather than being the cause, this may be a marker for a complicated post-transplant course. Strategies to further enhance immune reconstitution post transplant and strict adherence to infection prevention measures are warranted.
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Affiliation(s)
- M Tavadze
- Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - L Rybicki
- Quantitative Health Sciences, Cleveland Clinic Lerner Research Institute, Cleveland, OH, USA
| | - S Mossad
- Department of Infectious Diseases, Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - R Avery
- Division of Infectious Diseases (Transplant/Oncology), John Hopkins, Baltimore, MD, USA
| | - M Yurch
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - B Pohlman
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - H Duong
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - R Dean
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - B Hill
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - S Andresen
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - R Hanna
- Department of Pediatric Hematology and Oncology, Cleveland Clinic, Cleveland, OH, USA
| | - N Majhail
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - E Copelan
- Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA
| | - B Bolwell
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - M Kalaycio
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
| | - R Sobecks
- Hematologic Oncology and Blood Disorders, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA
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Ammann RA, Niggli FK, Leibundgut K, Teuffel O, Bodmer N. Exploring the association of hemoglobin level and adverse events in children with cancer presenting with fever in neutropenia. PLoS One 2014; 9:e101696. [PMID: 25020130 PMCID: PMC4096594 DOI: 10.1371/journal.pone.0101696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 06/10/2014] [Indexed: 11/25/2022] Open
Abstract
Background In children and adolescents with fever in neutropenia (FN) during chemotherapy for cancer, hemoglobin ≥90 g/L at presentation with FN had been associated with adverse events (AE). This analysis explored three hypothetical pathophysiological mechanisms potentially explaining this counterintuitive finding, and further analyzed the statistical association between hemoglobin and AE. Methods Two of 8 centers, reporting on 311 of 421 FN episodes in 138 of 215 patients participated in this retrospective analysis based on prospectively collected data from three databases (SPOG 2003 FN, transfusion and hematology laboratories). Associations with AE were analyzed using mixed logistic regression. Results Hemoglobin was ≥90 g/L in 141 (45%) of 311 FN episodes, specifically in 59/103 (57%) episodes with AE, and in 82/208 (39%) without (OR, 2.3; 99%CI, 1.1–4.9; P = 0.004). In FN with AE, hemoglobin was bimodally distributed with a dip around 85 g/L. There were no significant interactions for center, age and sex. In multivariate mixed logistic regression, AE was significantly and independently associated with leukopenia (leukocytes <0.3 G/L; OR, 3.3; 99%CI, 1.1–99; P = 0.004), dehydration (hemoglobinPresentation/hemoglobin8–72 hours ≥1.10 in untransfused patients; OR, 3.5; 99%CI, 1.1–11.4; P = 0.006) and non-moderate anemia (difference from 85 g/L; 1.6 per 10 g/L; 1.0–2.6; P = 0.005), but not with recent transfusion of packed red blood cells (pRBC), very recent transfusion of pRBC or platelets, or with hemoglobin ≥90 g/L as such. Conclusions Non-moderate anemia and dehydration were significantly and relevantly associated with the risk of AE in children with cancer and FN. These results need validation in prospective cohorts before clinical implementation.
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Affiliation(s)
- Roland A. Ammann
- Department of Pediatrics, University of Bern, Bern, Switzerland
- * E-mail:
| | - Felix K. Niggli
- Division of Oncology, Department of Pediatrics, University of Zurich, Zurich, Switzerland
| | - Kurt Leibundgut
- Department of Pediatrics, University of Bern, Bern, Switzerland
| | - Oliver Teuffel
- Department of Pediatrics, University of Bern, Bern, Switzerland
- Division of Oncology, Medical Services of the Statutory Health Insurance Baden-Württemberg, Tübingen, Germany
| | - Nicole Bodmer
- Division of Oncology, Department of Pediatrics, University of Zurich, Zurich, Switzerland
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Calton EA, Le Doaré K, Appleby G, Chisholm JC, Sharland M, Ladhani SN. Invasive bacterial and fungal infections in paediatric patients with cancer: incidence, risk factors, aetiology and outcomes in a UK regional cohort 2009-2011. Pediatr Blood Cancer 2014; 61:1239-45. [PMID: 24615980 DOI: 10.1002/pbc.24995] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2013] [Accepted: 01/30/2014] [Indexed: 01/06/2023]
Abstract
BACKGROUND Cancer is the second most common cause of childhood deaths in the United Kingdom and infection contributes to a quarter of all cancer-related deaths. This study aimed to estimate the risk, aetiology and outcome of bloodstream bacterial and fungal infections in children with cancer within a geographically defined region in South-West London over a 3-year period. METHODS Web-based questionnaires were completed using case records of children with positive blood cultures admitted to five London hospitals during 2009-2011. RESULTS A total of 112 children with a median age of 5.4 (IQR 3.6-11.2) years had 266 significant blood cultures during 149 infection episodes. Haematological malignancy affected 68 patients (60.7%) and solid tumours 44 (39.3%). The overall bloodstream infection rate was 1.5 episodes per 1,000 days-at-risk (95% CI, 1.2-1.8) and was similar for those with haematological malignancies and solid tumours. Most episodes were attributed to central venous catheter infection (120/149, 80.5%). Coagulase-negative staphylococci were isolated in almost half the bloodstream infections (127/266; 47.7%), while Gram-negative organisms accounted for a further quarter (64/266; 24.1%). Fungal isolates from blood were uncommon (8/112 children, 7.1%) but significantly associated with neutropenia (18/149 [12.1%] vs. 1/114 [0.9%], P = 0.0004). Six children (5.4%) died, including three (2.7%; 95% CI, 0.6-7.6%) whose deaths were infection-related. CONCLUSIONS This study provides an updated risk estimate for bloodstream infections in children with cancer and adds to the framework for developing evidence-based guidance for management of suspected infections in this highly vulnerable group.
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Affiliation(s)
- Elizabeth A Calton
- Paediatric Infectious Diseases Group, St. George's University of London, London, UK
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Sandora TJ, Graham DA, Conway M, Dodson B, Potter-Bynoe G, Margossian SP. Impact of needleless connector change frequency on central line-associated bloodstream infection rate. Am J Infect Control 2014; 42:485-9. [PMID: 24773786 DOI: 10.1016/j.ajic.2014.01.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/23/2014] [Accepted: 01/23/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bloodstream infection is the most common pediatric health care-associated infection and is strongly associated with catheter use. These infections greatly increase the cost of hospital stay. METHODS To assess the association between needleless connector (NC) change frequency and central line-associated bloodstream infection (CLABSI) rate, we modeled monthly pediatric stem cell transplant (SCT) CLABSI rate in 3 periods: baseline period during which NC were changed every 96 hours regardless of infusate (period 1); trial period in which NC were changed every 24 hours with blood or lipid infusions (period 2); and a return to NC change every 96 hours regardless of infusate (period 3). Data on potential confounders were collected retrospectively. Autocorrelated segmented regression models were used to compare SCT CLABSI rates in each period, adjusting for potential confounders. CLABSI rates were also assessed for a nonequivalent control group (oncology unit) in which NC were changed every 24 hours with blood or lipid use in periods 2 and 3. RESULTS SCT CLABSI rates were 0.41, 3.56, and 0.03 per 1,000 central line-days in periods 1, 2, and 3, respectively. In multivariable analysis, the CLABSI rate was significantly higher in period 2 compared with both period 1 (P = .01) and period 3 (P = .003). In contrast, CLABSI rates on the oncology unit were not significantly different among periods. CONCLUSION In pediatric SCT patients, changing needleless connectors every 24 hours when blood or lipids are infused is associated with increased CLABSI rates. National recommendations regarding NC change frequency should be clarified.
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Affiliation(s)
- Thomas J Sandora
- Division of Infectious Diseases, Department of Medicine and Department of Laboratory Medicine, Boston Children's Hospital, Boston, MA.
| | - Dionne A Graham
- Center for Patient Safety and Quality Research, Boston Children's Hospital, Boston, MA
| | - Margaret Conway
- Department of Nursing, Boston Children's Hospital, Boston, MA
| | - Brenda Dodson
- Department of Pharmacy, Boston Children's Hospital, Boston, MA
| | - Gail Potter-Bynoe
- Infection Prevention and Control, Boston Children's Hospital, Boston, MA
| | - Steven P Margossian
- Division of Hematology/Oncology, Department of Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA
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Wilson MZ, Deeter D, Rafferty C, Comito MM, Hollenbeak CS. Reduction of central line-associated bloodstream infections in a pediatric hematology/oncology population. Am J Med Qual 2013; 29:484-90. [PMID: 24226650 DOI: 10.1177/1062860613509401] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study reports the results of an initiative to reduce central line-associated bloodstream infections (CLABSIs) among pediatric hematology/oncology patients, a population at increased risk for CLABSI. The study design was a pre-post comparison of a series of specific interventions over 40 months. Logistic regression was used to determine if the risk of developing CLABSI decreased in the postintervention period, after controlling for covariates. The overall CLABSI rate fell from 9 infections per 1000 line days at the beginning of the study to zero in a cohort of 291 patients encompassing 2107 admissions. Admissions during the intervention period had an 86% reduction in odds of developing a CLABSI, controlling for other factors. At the study team's institution, an initiative that standardized blood culturing techniques, lab draw times, line care techniques, and provided physician and nurse education was able to eliminate CLABSI among pediatric hematology/oncology patients.
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Affiliation(s)
| | - Deana Deeter
- Penn State Milton S. Hershey Medical Center, Hershey, PA
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Rinke ML, Milstone AM, Chen AR, Mirski K, Bundy DG, Colantuoni E, Pehar M, Herpst C, Miller MR. Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors. Pediatr Blood Cancer 2013; 60:1882-9. [PMID: 23881643 PMCID: PMC4559846 DOI: 10.1002/pbc.24677] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 06/06/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND To compare the burden of central line-associated bloodstream infections (CLABSIs) in ambulatory versus inpatient pediatric oncology patients, and identify the epidemiology of and risk factors associated with ambulatory CLABSIs. PROCEDURE We prospectively identified infections and retrospectively identified central line days and characteristics associated with CLABSIs from January 2009 to October 2010. A nested case-control design was used to identify characteristics associated with ambulatory CLABSIs. RESULTS We identified 319 patients with central lines. There were 55 ambulatory CLABSIs during 84,705 ambulatory central line days (0.65 CLABSIs per 1,000 central line days (95% CI 0.49, 0.85)), and 19 inpatient CLABSIs during 8,682 inpatient central line days (2.2 CLABSIs per 1,000 central lines days (95% CI 1.3, 3.4)). In patients with ambulatory CLABSIs, 13% were admitted to an intensive care unit and 44% had their central lines removed due to the CLABSI. A secondary analysis with a sub-cohort, suggested children with tunneled, externalized catheters had a greater risk of ambulatory CLABSI than those with totally implantable devices (IRR 20.6, P < 0.001). Other characteristics independently associated with ambulatory CLABSIs included bone marrow transplantation within 100 days (OR 16, 95% CI 1.1, 264), previous bacteremia in any central line (OR 10, 95% CI 2.5, 43) and less than 1 month from central line insertion (OR 4.2, 95% CI 1.0, 17). CONCLUSIONS In pediatric oncology patients, three times more CLABSIs occur in the ambulatory than inpatient setting. Ambulatory CLABSIs carry appreciable morbidity and have identifiable, associated factors that should be addressed in future ambulatory CLABSI prevention efforts.
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Affiliation(s)
- Michael L. Rinke
- Department of Pediatrics, The Children’s Hospital at Montefiore, Bronx, New York,Correspondence to: Michael L. Rinke, The Children’s Hospital at Montefiore, 3415 Bainbridge Avenue, Bronx, NY 10467.
| | - Aaron M. Milstone
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allen R. Chen
- Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kara Mirski
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David G. Bundy
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Miriana Pehar
- Hospital Epidemiology and Infection Control, Johns Hopkins Hospital, Baltimore, Maryland
| | - Cynthia Herpst
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Marlene R. Miller
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland,Children’s Hospital Association, Alexandria, Virginia
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Microbiology and risk factors for central line-associated bloodstream infections among pediatric oncology outpatients: a single institution experience of 41 cases. J Pediatr Hematol Oncol 2013; 35:e71-6. [PMID: 23412591 PMCID: PMC3574641 DOI: 10.1097/mph.0b013e3182820edd] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Risk factors for central line-associated bloodstream infections (CLABSI) among children with cancer in the outpatient setting remain poorly defined, and the microbiology may differ from hospital-onset CLABSI. MATERIALS AND METHODS We conducted a matched case-control study of oncology patients followed at the Dana Farber/Children's Hospital Cancer Center. Cases (N=41) were patients with CLABSI as per National Healthcare Safety Network criteria who had not been hospitalized in the preceding 48 hours. For each case we randomly selected 2 oncology outpatients with a central venous catheter and a clinic visit within 30 days of the case subject's CLABSI. Multivariate conditional logistic regression models were used to identify independent risk factors for CLABSI. We compared the microbiology to that of 54 hospital-onset CLABSI occurring at our institution during the study period. RESULTS Independent predictors of community-onset CLABSI included neutropenia in the prior week (odds ratio 17.46; 95% confidence interval, 4.71-64.67) and tunneled externalized catheter (vs. implantable port; odds ratio 10.30; 95% confidence interval, 2.42-43.95). Nonenteric gram-negative bacteria were more frequently isolated from CLABSI occurring among outpatients. DISCUSSION Pediatric oncology outpatients with recent neutropenia or tunneled externalized catheters are at increased risk of CLABSI. The microbiology of community-onset CLABSI differs from hospital-onset CLABSI.
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Choi SW, Chang L, Hanauer DA, Shaffer-Hartman J, Teitelbaum D, Lewis I, Blackwood A, Akcasu N, Steel J, Christensen J, Niedner MF. Rapid reduction of central line infections in hospitalized pediatric oncology patients through simple quality improvement methods. Pediatr Blood Cancer 2013; 60:262-9. [PMID: 22522576 PMCID: PMC3720122 DOI: 10.1002/pbc.24187] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 04/05/2012] [Indexed: 11/09/2022]
Abstract
BACKGROUND Pediatric hematology-oncology (PHO) patients are at significant risk for developing central line-associated bloodstream infections (CLA-BSIs) due to their prolonged dependence on such catheters. Effective strategies to eliminate these preventable infections are urgently needed. In this study, we investigated the implementation of bundled central line maintenance practices and their effect on hospital-acquired CLA-BSIs. MATERIALS AND METHODS CLA-BSI rates were analyzed within a single-institution's PHO unit between January 2005 and June 2011. In May 2008, a multidisciplinary quality improvement team developed techniques to improve the PHO unit's safety culture and implemented the use of catheter maintenance practices tailored to PHO patients. Data analysis was performed using time-series methods to evaluate the pre- and post-intervention effect of the practice changes. RESULTS The pre-intervention CLA-BSI incidence was 2.92 per 1,000-patient days (PD) and coagulase-negative Staphylococcus was the most prevalent pathogen (29%). In the post-intervention period, the CLA-BSI rate decreased substantially (45%) to 1.61 per 1,000-PD (P < 0.004). Early on, blood and marrow transplant (BMT) patients had a threefold higher CLA-BSI rate compared to non-BMT patients (P < 0.033). With additional infection control countermeasures added to the bundled practices, BMT patients experienced a larger CLA-BSI rate reduction such that BMT and non-BMT CLA-BSI rates were not significantly different post-intervention. CONCLUSIONS By adopting and effectively implementing uniform maintenance catheter care practices, learning multidisciplinary teamwork, and promoting a culture of patient safety, the CLA-BSI incidence in our study population was significantly reduced and maintained.
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Affiliation(s)
- Sung W Choi
- Pediatric Hematology-Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI 48109-5942, USA.
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Gaur AH, Bundy DG, Gao C, Werner EJ, Billett AL, Hord JD, Siegel JD, Dickens D, Winkle C, Miller MR. Surveillance of hospital-acquired central line-associated bloodstream infections in pediatric hematology-oncology patients: lessons learned, challenges ahead. Infect Control Hosp Epidemiol 2013; 34:316-20. [PMID: 23388370 DOI: 10.1086/669513] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Across 36 US pediatric oncology centers, 576 central line-associated bloodstream infections (CLABSIs) were reported over a 21-month period. Most infections occurred in those with leukemia and/or profound neutropenia. The contribution of viridans streptococci infections was striking. Study findings depict the contemporary epidemiology of CLABSIs in hospitalized pediatric cancer patients.
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Affiliation(s)
- Aditya H Gaur
- St. Jude Children's Research Hospital, Memphis, Tennessee 38105, USA
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41
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Rinke ML, Chen AR, Bundy DG, Colantuoni E, Fratino L, Drucis KM, Panton SY, Kokoszka M, Budd AP, Milstone AM, Miller MR. Implementation of a central line maintenance care bundle in hospitalized pediatric oncology patients. Pediatrics 2012; 130:e996-e1004. [PMID: 22945408 PMCID: PMC3457619 DOI: 10.1542/peds.2012-0295] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To investigate whether a multidisciplinary, best-practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population. METHODS We performed a prospective, interrupted time series study of a best-practice bundle addressing all areas of central line care: reduction of entries, aseptic entries, and aseptic procedures when changing components. Based on a continuous quality improvement model, targeted interventions were instituted to improve compliance with each of the bundle elements. CLABSI rates and epidemiological data were collected for 10 months before and 24 months after implementation of the bundle and compared in a Poisson regression model. RESULTS CLABSI rates decreased from 2.25 CLABSIs per 1000 central line days at baseline to 1.79 CLABSIs per 1000 central line days during the intervention period (incidence rate ratio [IRR]: 0.80, P = .58). Secondary analyses indicated CLABSI rates were reduced to 0.81 CLABSIs per 1000 central line days in the second 12 months of the intervention (IRR: 0.36, P = .091). Fifty-nine percent of infections resulted from Gram-positive pathogens, 37% of patients with a CLABSI required central line removal, and patients with Hickman catheters were more likely to have a CLABSI than patients with Infusaports (IRR: 4.62, P = .02). CONCLUSIONS A best-practice central line maintenance care bundle can be implemented in hospitalized pediatric oncology patients, although long ramp-up times may be necessary to reap maximal benefits. Further research is needed to determine if this CLABSI rate reduction can be sustained and spread.
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Affiliation(s)
| | - Allen R. Chen
- Oncology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Elizabeth Colantuoni
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Lisa Fratino
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; and
| | - Kim M. Drucis
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; and
| | | | - Michelle Kokoszka
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; and
| | - Alicia P. Budd
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland; and
| | | | - Marlene R. Miller
- Departments of Pediatrics, and,Children’s Hospital Association, Alexandria, Virginia
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