Clinical outcome of catheter salvage in neutropenic cancer patients with catheter-related infection

Early removal of a permanent catheter during the acute management of the unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection: a multi-disciplinary survey and review of the literature

There are no guidelines for the optimal manner and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infections (CRBSI). Our goals were to examine current practices of permanent central catheter management and choice of removal in the hemodynamically unstable pediatric patient with suspected CRBSI among practitioners in diverse subspecialties. We performed a literature review on the subject, and conducted a multi-disciplinary survey included pediatric oncologists, pediatric emergency medicine physicians, and pediatric intensive care physicians whom we queried about their choice of permanent central catheter management and removal while treating the hemodynamically unstable pediatric patient with suspected CRBSI. Most of the 78 responders (n = 47, 59%) preferred to utilize the existing permanent central catheter for initial intravenous access rather than an alternative access. There were no significant differences between physician subspecialties (p = 0.29) or training levels (p = 0.14). Significantly more pediatric emergency medicine physicians preferred not to remove the permanent central catheter at any time point compared to the pediatric hemato-oncologists, who preferred to remove it at some point during the acute presentation (44.4% vs. 9.4%, respectively, p = 0.02).

CONCLUSION

Our study findings reflect the need for uniform guidelines on permanent central catheter use and indications for its removal in the hemodynamically unstable pediatric patient. We suggest that permanent central catheter removal should be urgently considered in a deteriorating patient who failed to be stabilized with medical treatment.

WHAT IS KNOWN

• There are no guidelines for the optimal choice and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection (CRBSI).

WHAT IS NEW

• We found variations in practices among pediatricians from diverse subspecialties and conflicting data in the literature. • There is a need for prospective studies to provide uniform guidelines for optimal management of suspected CRBSI in the hemodynamically unstable pediatric patient.

Epidemiology of infections in cancer patients

Although major advances in the care of cancer patients over the past several decades have resulted in improved survival, infectious complications remain a significant cause of morbidity and mortality. To successfully identify, treat, and prevent infections, a comprehensive understanding of risk factors that predispose to infection and of commonly encountered pathogens is necessary. In addition, clinicians must keep abreast of the changing epidemiology of infections in this population. As therapeutic modalities continue to evolve, as established pathogens become increasingly drug resistant, and as new pathogens are discovered, successful management of infections will continue to present challenges in the years to come.

Serum glutamate levels correlate with Gleason score and glutamate blockade decreases proliferation, migration, and invasion and induces apoptosis in prostate cancer cells

PURPOSE

During glutaminolysis, glutamine is catabolized to glutamate and incorporated into citric acid cycle and lipogenesis. Serum glutamate levels were measured in patients with primary prostate cancer or metastatic castrate-resistant prostate cancer (mCRPCa) to establish clinical relevance. The effect of glutamate deprivation or blockade by metabotropic glutamate receptor 1 (GRM1) antagonists was investigated on prostate cancer cells' growth, migration, and invasion to establish biologic relevance.

EXPERIMENTAL DESIGN

Serum glutamate levels were measured in normal men (n = 60) and patients with primary prostate cancer (n = 197) or mCRPCa (n = 109). GRM1 expression in prostatic tissues was examined using immunohistochemistry (IHC). Cell growth, migration, and invasion were determined using cell cytotoxicity and modified Boyden chamber assays, respectively. Apoptosis was detected using immunoblotting against cleaved caspases, PARP, and γ-H2AX.

RESULTS

Univariate and multivariate analyses showed significantly higher serum glutamate levels in Gleason score ≥ 8 than in the Gleason score ≤ 7 and in African Americans than in the Caucasian Americans. African Americans with mCRPCa had significantly higher serum glutamate levels than those with primary prostate cancer or benign prostate. However, in Caucasian Americans, serum glutamate levels were similar in normal research subjects and patients with mCRPC. IHC showed weak or no expression of GRM1 in luminal acinar epithelial cells of normal or hyperplastic glands but high expression in primary or metastatic prostate cancer tissues. Glutamate deprivation or blockade decreased prostate cancer cells' proliferation, migration, and invasion and led to apoptotic cell death.

CONCLUSIONS

Glutamate expression is mechanistically associated with and may provide a biomarker of prostate cancer aggressiveness.

Managing intravascular catheter-related infections in heart transplant patients: how far can we apply IDSA guidelines for immunocompromised patients?

PURPOSE OF REVIEW

This study discusses the applicability to heart transplant patients of recently issued guidelines on the diagnosis, management and prevention of catheter-related bloodstream infections (CR-BSIs). It also updates newly available information of possible interest to the care of heart transplant patients.

RECENT FINDINGS

Catheters remain the leading cause of early bloodstream infections in heart transplant patients. The cause of CR-BSI is mainly attributable to Gram-positive microorganisms. Very frequently, the origin of a bloodstream infection in a heart transplant patient with multiple catheters is not clear, and a precise diagnosis is required. Management without catheter removal may be undertaken when indicated. Empiric therapy should cover Gram-positive, multidrug resistant and Gram-negative bacteria along with Candida. Prolonged antibiotic treatment exceeding 14 days is recommended and should be continued up to 4-6 weeks in the case of Staphylococcus aureus. Prevention measures include education and training, maximal sterile barrier precautions during catheter insertion, a 2% chlorhexidine preparation for skin antisepsis, avoiding routine replacement of catheters and using antimicrobial/antiseptic impregnated short-term central vein catheters (CVCs) and chlorhexidine sponge dressings.

SUMMARY

Until confirmatory data are obtained, present guidelines for diagnosing, managing and preventing CR-BSI can be applied to heart transplant patients. We would nevertheless highlight that the additional precautions should be taken of broader empiric antimicrobial therapy followed by longer duration treatment in these patients.