Incidence of Bacteremia, Infective Endocarditis, or Prosthetic Joint Infection in Dermatologic Surgery: A Systematic Review

BACKGROUND

Prophylactic antibiotic therapy is widely used in dermatologic surgery to prevent surgical site infections and bacteremia, which can lead to prosthetic joint infections (PJI) and infective endocarditis (IE) in high-risk populations.

OBJECTIVE

To evaluate the incidence of bacteremia, PJI, and IE after dermatologic surgery and assess the current evidence for antibiotic prophylaxis.

MATERIALS AND METHODS

A search of the computerized bibliographic databases was performed using key terms from the date of inception to March 21, 2021. Data extraction was performed independently by 2 data extractors.

RESULTS

The review resulted in 9 publications that met inclusion criteria, including 5 prospective cohort studies and 4 case reports or case series. The prospective studies reported a wide range of bacteremia incidence (0%-7%) after dermatologic surgery. No cases of PJI resulting directly from cutaneous surgery were identified, and only 1 case series reported IE after various skin procedures.

CONCLUSION

These findings suggest a low rate of bacteremia and a lack of direct evidence linking dermatologic surgery to PJI or IE. The scarcity of published data on this topic is a limitation, highlighting the need for further research, particularly randomized controlled trials, to guide antibiotic prophylaxis recommendations.

The applicability of the central line-associated bloodstream infection (CLABSI) criteria for the evaluation of bacteremia episodes in pediatric oncology patients

BACKGROUND

The aim of this study was to investigate the applicability of the central line-associated bloodstream infection (CLABSI) criteria of the Centers for Disease Control and Prevention in pediatric oncology patients.

METHODS

Bacteremia episodes from 2020 to 2022 from a prospective cohort of pediatric oncology patients with a central venous catheter were included. Episodes were classified by three medical experts following the CLABSI criteria as either a CLABSI or non-CLABSI (i.e., contamination, other infection source, or mucosal barrier injury-laboratory confirmed bloodstream infection (MBI-LCBI)). Subsequently, they were asked if and why they (dis)agreed with this diagnosis following the criteria. The primary outcome was the percentage of episodes where the experts clinically disagreed with the diagnosis given following the CLABSI criteria.

RESULTS

Overall, 84 bacteremia episodes in 71 patients were evaluated. Following the CLABSI criteria, 34 (40%) episodes were classified as CLABSIs and 50 (60%) as non-CLABSIs. In 11 (13%) cases the experts clinically disagreed with the diagnosis following the CLABSI criteria. The discrepancy between the CLABSI criteria and clinical diagnosis was significant; McNemar's test p < .01. Disagreement by the experts with the CLABSI criteria mostly occurred when the experts found an MBI-LCBI a more plausible cause of the bacteremia than a CLABSI due to the presence of a gram negative bacteremia (Pseudomonas aeruginosa n = 3) and/or mucositis.

CONCLUSIONS

A discrepancy between the CLABSI criteria and the evaluation of the experts was observed. Adding Pseudomonas aeruginosa as an MBI pathogen and incorporating the presence of mucositis in the MBI-LCBI criteria, might increase the applicability.

Risk factors of central catheter bloodstream infections in intensive care units: A systematic review and meta-analysis

BACKGROUND

Central catheter bloodstream infections (CRBSI) is a major cause of healthcare-associated infections. However, few factors are generally accepted and some studies have conflicting finding about some factors, possibly caused by limitation associated with an individual study. This study was to identify risk factors for CRBSI in intensive care units.

METHODS

We searched the PubMed, Cochrane Library, Web of science and EMBASE databases and the 4 top Chinese-language databases, including WanFang data, China National Knowledge Infrastructure (CNKI), and Chinese Science and Technology Journal Database (VIP), China Biology Medicine disc (CBM) as of July 2023. Case control and cohort studies were included. Two authors independently screened the literature and evaluated the quality of the studies using the Newcastle-Ottawa scale (NOS). The pooled effect size was estimated using the odds ratio (OR), and the corresponding 95% confidence interval (CI) was calculated. The Cochrane Q (χ2) and I2 tests were used to assess heterogeneity among studies, and each risk factor was tested for its robustness using fixed- or random-effects models.

FINDINGS

A total of 32 studies enrolled, among which eleven factors were identified, they were divided into two categories: modifiable and unmodifiable factors. Modifiable factors: duration of catheterization (≥ 5d) (OR: 2.07, 95%CI: 1.41-3.03), duration of catheterization (≥ 7d) (OR: 3.62, 95%CI: 2.65-4.97), duration of catheterization (≥ 14d)(OR: 4.85, 95%CI: 3.35-7.01), total parenteral nutrition (OR: 2.27,95%CI: 1.56-3.29), use of multiple-lumen catheters(OR: 3.41, 95%CI: 2.27-5.11), times of tube indwelling (OR: 3.50, 95%CI: 2.93-4.17), length of ICU stay (OR: 4.05, 95%CI: 2.41-6.80), the position of indwelling(OR: 2.41, 95%CI: 2.03-2.85); Unmodifiable factors: APACHEII scores (OR: 1.84, 95%CI: 1.54-2.20), Age≥ 60 years old (OR: 2.19, 95%CI: 1.76-2.73), the extensive use of antibiotic (OR: 3.54, 95%CI: 1.65-7.61), Diabetes mellitus (OR: 3.06, 95%CI: 2.56-3.66), Immunosuppression (OR: 2.87, 95%CI: 2.08-3.95).

CONCLUSIONS

Effective interventions targeting the above modifiable factors may reduce the risk of developing CRBSI in ICU and improve the clinical outcome of patients. Further prospective studies are needed to confirm these findings.

Clinical Adjudication of Hemodialysis Catheter-Related Bloodstream Infections: Findings from the REDUCCTION Trial

Key Points

Background

Hemodialysis catheter-related bloodstream infection (HD-CRBSI) are a significant source of morbidity and mortality among dialysis patients, but benchmarking remains difficult because of varying definitions of HD-CRBSI. This study explored the effect of clinical adjudication process on HD-CRBSI reporting.

Methods

The REDUcing the burden of Catheter ComplicaTIOns: a National approach trial implemented an evidence-based intervention bundle using a stepped-wedge design to reduce HD-CRBSI rates in 37 Australian kidney services. Six New Zealand services participated in an observational capacity. Adult patients with a new hemodialysis catheter between December 2016 and March 2020 were included. HD-CRBSI events reported were compared with the adjudicated outcomes using the end point definition and adjudication processes of the REDUcing the burden of Catheter ComplicaTIOns: a National approach trial. The concordance level was estimated using Gwet agreement coefficient (AC1) adjusted for service-level effects and implementation tranches (Australia only), with the primary outcome being the concordance of confirmed HD-CRBSI.

Results

A total of 744 hemodialysis catheter-related infectious events were reported among 7258 patients, 12,630 catheters, and 1.3 million catheter-exposure days. The majority were confirmed HD-CRBSI, with 77.9% agreement and substantial concordance (AC1=0.77; 95% confidence interval [CI], 0.73 to 0.81). Exit site infections have the highest concordance (AC1=0.85; 95% CI, 0.78 to 0.91); the greatest discordance was in events classified as other (AC1=0.33; 95% CI, 0.16 to 0.49). The concordance of all hemodialysis catheter infectious events remained substantial (AC1=0.80; 95% CI, 0.76 to 0.83) even after adjusting for the intervention tranches in Australia and overall service-level clustering.

Conclusions

There was a substantial level of concordance in overall and service-level reporting of confirmed HD-CRBSI. A standardized end point definition of HD-CRBSI resulted in comparable hemodialysis catheter infection rates in Australian and New Zealand kidney services. Consistent end point definition could enable reliable benchmarking outside clinical trials without the need for independent clinical adjudication.

18F-FDG PET/CT in left ventricular assist device infections: In-depth characterization and clinical implications

BACKGROUND

Previous retrospective studies suggest a good diagnostic performance of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET)/computed tomography (CT) in left ventricular assist device (LVAD) infections. Our aim was to prospectively evaluate the role of PET/CT in the characterization and impact on clinical management of LVAD infections.

METHODS

A total of 40 patients (aged 58 [53-62] years) with suspected LVAD infection and 5 controls (aged 69 [64-71] years) underwent 18F-FDG-PET/CT. Four LVAD components were evaluated: exit site and subcutaneous driveline (peripheral), pump pocket, and outflow graft. The location with maximal uptake was considered the presumed site of infection. Infection was confirmed by positive culture (exit site or blood) and/or surgical findings.

RESULTS

Visual uptake was present in 40 patients (100%) in the infection group vs 4 (80%) control subjects. For each individual component, the presence of uptake was more frequent in the infection than in the control group. The location of maximal uptake was most frequently the pump pocket (48%) in the infection group and the peripheral components (75%) in the control group. Maximum standard uptake values (SUVmax) were higher in the infection than in the control group: SUVmax (average all components): 6.9 (5.1-8.5) vs 3.8 (3.7-4.3), p = 0.002; SUVmax (location of maximal uptake): 10.6 ± 4.0 vs 5.4 ± 1.9, p = 0.01. Pump pocket infections were more frequent in patients with bacteremia than without bacteremia (79% vs 31%, p = 0.011). Pseudomonas (32%) and methicillin-susceptible Staphylococcus aureus (29%) were the most frequent pathogens and were associated with pump pocket infections, while Staphylococcus epidermis (11%) was associated with peripheral infections. PET/CT affected the clinical management of 83% of patients with infection, resulting in surgical debridement (8%), pump exchange (13%), and upgrade in the transplant listing status (10%), leading to 8% of urgent transplants.

CONCLUSIONS

18F-FDG-PET/CT enables the diagnosis and characterization of the extent of LVAD infections, which can significantly affect the clinical management of these patients.

Pantoea agglomerans bacteraemia after uterine artery embolisation: an unusual pathogen

A woman in her 40s presented to the emergency department (ED) with a 3-week history of nausea, vomiting and diarrhoea. Blood cultures were positive for Serratia and Pantoea agglomerans spp. One month before her ED visit, she underwent targeted uterine artery embolisation with particles by an interventional radiologist. Uterine artery embolisation is considered a safe alternative to surgical removal of fibroids or hysterectomy. The patient was initially treated with targeted antibiotics for a large infected uterine fibroid but ultimately required a hysterectomy for source control. To our knowledge, this is the first documented case of P. agglomerans infecting a uterine fibroid.

Epidemiology and outcomes associated with enterococcal blood stream infection among liver and kidney transplant recipients

Bloodstream infections (BSIs) account for 18% of bacterial infections in the first year after solid organ transplantation (SOT). Enterococcus accounts for up to 20% of BSIs in this population, with vancomycin-resistant enterococcus (VRE) posing a particular risk. This is a retrospective, case-control study of adult liver and kidney transplant recipients between 01/01/2016 and 06/30/2021 that characterizes the epidemiology and outcomes of enterococcal BSIs in liver and kidney transplantations at a single institution. Subjects with an enterococcal BSI within the first 6 months post-transplant were compared to those with non-enterococcal BSIs in the same period. We identified 26 subjects with enterococcal BSIs and 28 controls with non-enterococcal BSIs (n = 54; 10.3%). Cases were mostly liver transplant recipients (n = 20; 77%) with a median MELD at transplant of 33 (range 14-43); controls included 14 KT recipients (50%). Groups differed significantly (all p < .05) by factors including perioperative transfusion requirements, need for reoperation, and number of interventions post-transplant. Cases had a median time of 25.5 days to infection and controls 100.5 days (p < .0001). There were no differences in 1-year mortality between the groups. Enterococcus faecium was the predominant species of Enterococcus (n = 23; 88.5%), with a majority (91.3%) of the isolates being VRE. In our liver and kidney transplants, enterococcal BSIs occurred early among liver transplant recipients. The high incidence of VRE among E. faecium isolates in this population warrants further investigation into the optimal approach to empiric antimicrobials for bacteremia in the early post-transplant period.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Systematic scoping review of automated systems for the surveillance of healthcare-associated bloodstream infections related to intravascular catheters

INTRODUCTION

Intravascular catheters are crucial devices in medical practice that increase the risk of healthcare-associated infections (HAIs), and related health-economic adverse outcomes. This scoping review aims to provide a comprehensive overview of published automated algorithms for surveillance of catheter-related bloodstream infections (CRBSI) and central line-associated bloodstream infections (CLABSI).

METHODS

We performed a scoping review based on a systematic search of the literature in PubMed and EMBASE from 1 January 2000 to 31 December 2021. Studies were included if they evaluated predictive performance of automated surveillance algorithms for CLABSI/CRBSI detection and used manually collected surveillance data as reference. We assessed the design of the automated systems, including the definitions used to develop algorithms (CLABSI versus CRBSI), the datasets and denominators used, and the algorithms evaluated in each of the studies.

RESULTS

We screened 586 studies based on title and abstract, and 99 were assessed based on full text. Nine studies were included in the scoping review. Most studies were monocentric (n = 5), and they identified CLABSI (n = 7) as an outcome. The majority of the studies used administrative and microbiological data (n = 9) and five studies included the presence of a vascular central line in their automated system. Six studies explained the denominator they selected, five of which chose central line-days. The most common rules and steps used in the algorithms were categorized as hospital-acquired rules, infection rules (infection versus contamination), deduplication, episode grouping, secondary BSI rules (secondary versus primary BSI), and catheter-associated rules.

CONCLUSION

The automated surveillance systems that we identified were heterogeneous in terms of definitions, datasets and denominators used, with a combination of rules in each algorithm. Further guidelines and studies are needed to develop and implement algorithms to detect CLABSI/CRBSI, with standardized definitions, appropriate data sources and suitable denominators.

Etiology and utility of hospital-onset bacteremia as a safety metric for targeted harm reduction

BACKGROUND

Hospital acquired infections (HAIs) are a major driver of morbidity and cost in health systems. Central line-associated bloodstream infections (CLABSIs) require intensive surveillance and review. All-cause hospital-onset bacteremia (HOB) may be a simpler reporting metric, correlates with CLABSI, and is viewed positively by HAI experts. Despite the ease in the collection, the proportion of HOBs that are actionable and preventable is unknown. Moreover, quality improvement strategies targeting it may be more challenging. In this study, we describe the bedside provider-perceived sources of HOB in order to provide insight into this new metric as a target for HAI prevention.

METHODS

All cases of HOBs in 2019 from an academic tertiary care hospital were retrospectively reviewed. Information was collected to assess provider-perceived etiology and associated clinical factors (microbiology, severity, mortality, and management). HOB was categorized as preventable or not preventable based on the perceived source from the care team and management decisions. Preventable causes included device-associated bacteremias, pneumonias, surgical complications, and contaminated blood cultures.

RESULTS

Of the 392 instances of HOB, 56.0% (n = 220) had episodes that were determined not preventable by providers. Excluding blood culture contaminates, the most common cause of preventable HOB was secondary to CLABSIs (9.9%, n = 39). Of the HOBs that were not preventable, the most common sources were gastrointestinal and abdominal (n = 62), neutropenic translocation (n = 37), and endocarditis (n = 23). Patients with HOB were generally medically complex with an average Charlson comorbidity index of 4.97. This translated into a higher average length of stay (29.23 vs 7.56, P < .001) and higher inpatient mortality (odds ratio 8.3, confidence interval [6.32-10.77]) when compared to admissions without HOB.

CONCLUSIONS

The majority of HOBs were not preventable and the HOB metric may be a marker of a sicker patient population making it a less actionable target for quality improvement. Standardization across the patient mix is important if the metric becomes linked to reimbursement. If the HOB metric were to be used in lieu of CLABSI, large tertiary care health systems that house sicker patients may be unfairly financially penalized for caring for more medically complex patients.

[Recurrent Bacteremia after Cyanoacrylate Sclerotherapy of Ectopic Duodenal Varices]

Sclerotherapy with N-butyl-2-cyanoacrylate is the first-line endoscopic approach for gastric and ectopic variceal bleeding, but it can be associated with local or systemic complications. Episodes of transient bacteremia after the procedure are frequent, but documented cases of recurrent bacteremia are rare. The authors report a 47-year-old female patient with liver cirrhosis who underwent duodenal sclerotherapy with cyanoacrylate after upper gastrointestinal bleeding. Subsequently, she developed five episodes of bacteremia with unknown origin. A definitive diagnosis of recurrent bacteremia due to cyanoacrylate was only possible after an exhaustive study to exclude other infectious foci. This case highlights a rare complication in an unusual topography (ectopic varices) and with a high number of episodes of bacteremia. A multidisciplinary management was paramount due to the patient's high surgical and anesthetic risk, comorbidities, and surgical aggressiveness.

Clinical presentation and outcome of hemodialysis tunneled catheter-related bloodstream infection in older persons

BACKGROUND

The use of a tunneled catheter as the primary vascular access among old hemodialysis patients is frequent. Catheter-related bloodstream infection (CRBSI) is a common complication, associated with increased mortality. Data regarding the clinical presentation and outcomes of CRBSI among old hemodialysis patients is limited.

METHODS

All chronic hemodialysis patients hospitalized between 2010 and 2022 with CRBSI were included. Patients were classified into two groups: old adults (≥ 75) and younger patients. Clinical, microbiological, and outcome data were collected and analyzed.

RESULTS

One hundred and fifty-four patients with CRBSI were identified. Fifty-seven were aged ≥ 75 years. Mean age in the older and younger groups was 81.2 ± 5 and 59.7 ± 12.7, respectively. Male gender was predominant (64%). Charlson comorbidity score and Pitt bacteremia score were comparable among both groups. Norton score < 14 was more common among old persons (n = 24, 67% versus n = 21, 31%, p < 0.001), as well as nursing-home residence. Gram-negative pathogens and Staphylococcus aureus were common in both groups. The frequency of inappropriate empirical antimicrobial treatment was higher among older persons. Overall, in-hospital and 90-day mortality was high (age ≥ 75, 36.8%, age < 75, 24.7%, p = 0.14). Age was not significantly associated with mortality after adjustment for low Norton score, residence, and inappropriate antimicrobial therapy as well as resistance patterns of bloodstream isolates [OR = 1.2 (95% CI 0.4-3.3), p = 0.76].

CONCLUSIONS

Clinical characteristics and outcomes of CRBSI were comparable among old and young hemodialysis patients. However, the high mortality rate in this cohort suggests that the use of tunneled catheters as a permanent vascular access should be discouraged in both patient groups.

Epidemiology of bloodstream infections and the impact of antimicrobial resistance in pediatric hematopoietic cell transplant

Bloodstream infections (BSI) pose a substantial threat to the well-being and survival of patients undergoing hematopoietic stem cell transplantation (HSCT). Risk factors for these infections vary across the different post-HSCT phases. In the pre-engraftment period, patients are particularly susceptible to infection due to prolonged neutropenia, mucosal damage, and extensive use of central venous line (CVL). In the post-engraftment phase, the emergence of graft versus host diseases further compounds the risk. The epidemiology of these infections has undergone notable changes over the years due to multifactorial reasons, including the evolution of protocols that intensify immunosuppression. In this context, the emergence of multi-drug resistance (MDR) microorganisms can be a challenge due to the elevated risk of mortality in these vulnerable patients. Unfortunately, there is a lack of comprehensive data on this topic, particularly in pediatrics. This article aims to provide a summary of the epidemiology of BSI in the different post-transplant phases and the impact of MDR pathogens. Having knowledge about the local epidemiology of BSI can be instrumental in tailoring targeted therapies, leading to improved survival rates in HSCT recipients.

Impact of preoperative bloodstream infection on outcomes of pediatric liver transplant recipients treated for acute liver failure

BACKGROUND

Acute liver failure (ALF) is a component of multisystem organ failure that causes severe liver dysfunction in patients without underlying chronic liver disease. The patients with ALF are prone to have infections, including bacteremia. However, studies of the infectious impact for post liver transplantation (LT) in pediatric ALF are limited. We aimed to evaluate our current practice for pediatric LT cases of ALF with preoperative bacteremia.

METHODS

The records of all patients under 18 years old undergoing LT for ALF in our center from November 2005 to December 2021 were collected. They were divided into two groups: those with a preoperative bloodstream infection (BSI) and those without (NBSI). We compared the preoperative status and also reviewed the details of the BSI group. Intraoperative course and postoperative outcomes were also compared.

RESULTS

There were 19 BSI patients and 66 NBSI patients. One BSI case was detected on the day of LT. This patient had no changes in vital signs and general condition. After evaluation and therapeutic intervention by pediatric infectious disease specialists, LT was performed on the same day. Five cases developed septic shock at the time of detection of BSI. All BSI patients were in stable condition on the operation day with proper interventions. There were no significant differences in mortality and hospital stay between both groups.

CONCLUSIONS

LT might be able to be performed for pediatric ALF even with positive blood cultures. In addition, appropriate therapeutic intervention by specialists and patient's stable condition before LT are essential.

The association between maternal colonization with Group B Streptococcus and infectious morbidity following transcervical Foley catheter-assisted labor induction

OBJECTIVES

To determine whether maternal colonization with Group B Streptococcus increases the risk for infectious morbidity following transcervical Foley catheter-assisted cervical ripening.

METHODS

A retrospective cohort study comparing infectious morbidity and other clinical outcomes by Group B Streptococcus colonization status between all women with singleton pregnancies who underwent Foley catheter-assisted cervical ripening labor induction at a single tertiary medical center during 2011-2021. Multivariable logistic regression explored the relationship between Group B Streptococcus colonization to adverse outcomes while adjusting for relevant clinical variables.

RESULTS

A total of 4,409 women were included of whom 886 (20.1 %) were considered Group B Streptococcus carriers and 3,523 (79.9 %) were not. Suspected neonatal sepsis rate was similar between Group B Streptococcus carriers and non-carriers (5.2 vs. 5.0 %, respectively, p=0.78). Neonatal sepsis was confirmed in 7 (0.02 %) cases, all born to non-carriers. Group B Streptococcus carriers had a higher rate of maternal bacteremia compared to non-carriers (1.2 vs. 0.5 %, respectively, p=0.01). Group B Streptococcus colonization was independently associated with maternal bacteremia (adjusted odds ratio 3.05; 95 %CI 1.39, 6.66).

CONCLUSIONS

Group B Streptococcus colonization among women undergoing Foley catheter-assisted cervical ripening does not seem to increase the risk for neonatal infection. However, higher rates of maternal bacteremia were detected.

Blood stream Infections in chronic hemodialysis patients - characteristics and outcomes

INTRODUCTION

Bloodstream Infections (BSI) are a major cause of death and hospitalization among hemodialysis (HD) patients. The rates of BSI among HD patients vary and are influenced by local patient and pathogen characteristics. Modifications in local infection prevention protocols in light of active surveillance of BSI has been shown to improve clinical outcomes. The aim of this study was to further explore factors associated with BSI in a contemporary cohort of HD patients at a public teaching hospital dialysis center in Israel.

METHODS

This was a retrospective cohort study of HD patients with a BSI in the years 2014 to 2018. The primary outcome was the occurrence of BSI. Secondary outcomes were to describe the causative pathogens of BSI, and to assess for risk factors for BSI, and mortality.

RESULTS

Included were 251 patients. The mean age was 68.5 ± 13.4 years, 66.9% were male. The mean time from initiation of dialysis was 34.76 ± 40.77 months, interquartile range (IQR) 1-47.5 months and the follow up period of the cohort was 25.17 ± 15.9 months. During the observation period, 44 patients (17.5%) developed 54 BSI events, while 10 of them (3.9% of the whole cohort) developed recurrent BSI events. Gram-negative microorganisms caused 46.3% of all BSI events. 31.4% of these BSI were caused by resistant bacteria. In a multivariate logistic regression analysis, patients receiving dialysis through a central line had a significantly increased risk for BSI adjusted Odds Ratio (aOR) 3.907, p = 0.005, whereas patients' weight was mildly protective (aOR 0.971, p = 0.024).

CONCLUSIONS

We noted an increased prevalence of gram-negative pathogens in the etiology of BSI in HD patients. Based on our findings, additional empirical antibiotics addressing gram negative bacteria have been added to our empirical treatment protocol. Our findings highlight the need to follow local epidemiology for implementing appropriate preventative measures and for tailoring appropriate empiric antibiotic therapy.

An Emerging Issue: Carbapenem-Resistant Enterobacteriaceae in Solid-Organ Transplantation

OBJECTIVES

Bloodstream infections caused by carbapenem-resistant bacteria have increased globally. Solid-organ transplant recipients are more prone to these infections. This study aimed to compare the clinical courses of carbapenem-susceptible and carbapenem-resistant Enterobacteriaceae bloodstream infections and to identify risk factors for carbapenem resistance in solid-organ transplant recipients.

MATERIALS AND METHODS

For this retrospective descriptive study, data for solid-organ transplant recipients (age ≥18) treated from 2015 to 2022 were obtained from medical records. Enterobacteriaceaepositive blood culture was screened from laboratory data.

RESULTS

Among 72 patients, there were 100 bacteremia episodes. Patients included 40 kidney (55.6%), 21 liver (29.2%), 7 heart (9.7%), and 4 combined liver and kidney (5.6%) transplant recipients. Fifty-seven bacteremia episodes were recorded between 2015 and 2020, and 43 bacteremia episodes were recorded between 2020 and 2022. Carbapenem resistance was reported in 15.8% of patients before 2020, whereas this rate increased to 39.5% after 2020 (P = .007). Pitt bacteremia score ≥4 (P < .001), Charlson comorbidity index ≥4 (P = .021), chronic liver disease (P = .015), septic shock at admission (P = .001), hypotension at admission (P = .006), bacteremia episodes 48 hours after hospitalization (P = .004), hospitalization in the past 3 months (P = .004), and prior invasive procedure (P = .043) were significant factors for carbapenem resistance. Logistic regression analysis showed that bacteremia 48 hours after hospitalization (P = .002) and hospitalization in the past 3 months (P = .006) were independent risk factors.

CONCLUSIONS

Carbapenem resistance increased significantly over the years. Bacteremia 48 hours after hospitalization and hospitalization within the past 3 months were determined to be risk factors for carbapenem resistance. Carbapenem-resistant infections are still nosocomial infections. Patients should be hospitalized for as a short time as possible, and both patients and their physicians should follow infection control and prevention methods.

Characteristics, costs, and outcomes associated with central-line-associated bloodstream infection and hospital-onset bacteremia and fungemia in US hospitals

OBJECTIVES

To compare characteristics and outcomes associated with central-line-associated bloodstream infections (CLABSIs) and electronic health record-determined hospital-onset bacteremia and fungemia (HOB) cases in hospitalized US adults.

METHODS

We conducted a retrospective observational study of patients in 41 acute-care hospitals. CLABSI cases were defined as those reported to the National Healthcare Safety Network (NHSN). HOB was defined as a positive blood culture with an eligible bloodstream organism collected during the hospital-onset period (ie, on or after day 4). We evaluated patient characteristics, other positive cultures (urine, respiratory, or skin and soft-tissue), and microorganisms in a cross-sectional analysis cohort. We explored adjusted patient outcomes [length of stay (LOS), hospital cost, and mortality] in a 1:5 case-matched cohort.

RESULTS

The cross-sectional analysis included 403 patients with NHSN-reportable CLABSIs and 1,574 with non-CLABSI HOB. A positive non-bloodstream culture with the same microorganism as in the bloodstream was reported in 9.2% of CLABSI patients and 32.0% of non-CLABSI HOB patients, most commonly urine or respiratory cultures. Coagulase-negative staphylococci and Enterobacteriaceae were the most common microorganisms in CLABSI and non-CLABSI HOB cases, respectively. In case-matched analyses, CLABSIs and non-CLABSI HOB, separately or combined, were associated with significantly longer LOS [difference, 12.1-17.4 days depending on intensive care unit (ICU) status], higher costs (by $25,207-$55,001 per admission), and a >3.5-fold increased risk of mortality in patients with an ICU encounter.

CONCLUSIONS

CLABSI and non-CLABSI HOB cases are associated with significant increases in morbidity, mortality, and cost. Our data may help inform prevention and management of bloodstream infections.

Incidence, Etiology, Risk Factors, and Outcomes of Bloodstream Infection after a Second Hematopoietic Stem Cell Transplantation

Objective Infections after a second hematopoietic stem cell transplantation (HSCT) occur commonly and are associated with high mortality. However, studies on bloodstream infection (BSI) after a second HSCT are lacking. We therefore evaluated the details of BSI after a second HSCT. Methods We retrospectively evaluated the incidence, etiology, risk factors, and outcomes of BSI after a second HSCT. Patients Fifty-two adult patients with hematological malignancies who underwent allogeneic HSCT, including cord blood transplantation (CBT; n=33), as the second transplantation were enrolled. The second transplantation was limited to allogeneic HSCT. Patients who underwent HSCT for graft failure were excluded. Results The median HSCT interval was 438 (range: 39-3,893) days. Overall, 31 (59.6%) patients received autologous HSCT as the first HSCT. The cumulative incidence of BSI was 40.4% at 100 days after the second HSCT, with Gram-positive bacteria accounting for the majority (30.8%) of pathogens. Overall, 92.0% of BSIs occurred during the pre-engraftment period, and Enterococcus faecium accounted for 29.6% of pathogens. On a multivariate analysis, CBT was most closely associated with pre-engraftment BSI after the second HSCT (hazard ratio: 3.43, 95% confidence interval: 1.05-11.23, p=0.042). The 1-year survival rate after the second HSCT was lower in patients with BSI than in patients without BSI (p=0.10). Conclusion BSI is common after a second HSCT, especially with CBT. During the pre-engraftment period, BSI caused by pathogens such as E. faecium should be anticipated and appropriately treated to improve transplant outcomes.

Infective endocarditis: prevention strategy and risk factors in an animal model

INTRODUCTION

Infective endocarditis is a serious infection of the endocardium, especially the heart valves, which is associated with a high mortality rate. It generally occurs in patients with altered and abnormal cardiac architecture combined with exposure to bacteria from trauma and other potentially high-risk activities with transient bacteremia.

Risk factors for catheter-related bloodstream infections in patients with intestinal failure undergoing home parenteral nutrition: a single-center study

PURPOSE

The incidence and risk factors of catheter-related bloodstream infections (CRBSI) in patients with intestinal failure (IF) have not been established, partly because catheter management methods vary from different facilities. This study aimed to identify the risk factors and incidence rate of CRBSIs in patients with IF who were given prophylactic treatment.

METHODS

Sixteen patients with IF who required home parenteral nutrition were enrolled in this study. Prophylactic management of CRBSI included monthly ethanol lock therapy and standardized infection prevention education. The outcomes included the incidence and risk factors of CRBSI.

RESULTS

The median incidence rate of CRBSI was 1.2 per 1000 catheter days. Univariate analysis showed that the risk of developing CRBSI was significantly associated with short bowel syndrome (< 30 cm) (p = 0.016). Other relevant findings included a significant negative correlation between serum albumin and CRBSI rate (r = - 0.505, p = 0.046), and past history of mixed bacterial infections was significantly associated with increased CRBSI rate (p = 0.013).

CONCLUSION

CRBSIs can still develop despite undergoing prophylactic management. Risk factors for CRBSI include the residual intestinal length, nutritional status, and susceptibility to certain microorganisms.

Catheter-Related Bloodstream Infections among patients on maintenance haemodialysis: a cross-sectional study at a tertiary hospital in Ghana

BACKGROUND

Catheter-Related Bloodstream Infections (CRBSIs) are notable complications among patients receiving maintenance haemodialysis. However, data on the prevalence of CRBSIs is lacking. This study was conducted to determine the prevalence and factors associated with CRBSIs among patients receiving haemodialysis in the renal unit of the largest tertiary hospital in Ghana.

METHODS

A hospital-based cross-sectional study was conducted on patients receiving maintenance haemodialysis via central venous catheters (CVC) between September 2021 and April 2022. Multivariate analysis using logistic regression was used to determine the risk factors that were predictive of CRBSI. Analysis was performed using SPSS version 23 and a p-value<0.05 was statistically significant.

RESULTS

The prevalence of CRBSI was 34.2% (52/152). Of these, more than half of them (53.9%(28/52)) had Possible CRBSI while 11.5% (6/52) had Definite CRBSI. Among the positive cultures, 62% (21/34) were from catheter sites whilst the rest were from peripheral blood. Gram-negative cultures made up 53% (18/34) of positive cultures with the rest being Gram positive cultures. Acinetobacter baumannii (33.3% (6/18)) was the commonest organism isolated among Gram-negative cultures whilst Coagulase negative Staphylococci (43.7% (7/16)) was the commonest organism isolated among Gram-positve cultures. Gram-negative bacilli were more predominant in this study making up 52.9% of the total bacteria cultured. Sex, duration of maintenance dialysis, underlying cause of End-stage kidney disease, mean corpuscular haemoglobin (MCH), neutrophil count and lymphocyte count were significantly predictive of CRBSI status (p<0.05).

CONCLUSION

There was a high prevalence of CRBSI among patients undergoing haemodialysis. The commonest causative agent was Coagulase negative Staphylococci, however there was a predominance of Gram-negative bacilli as compared to Gram positive cocci. There is a need to set up infection surveillance unit in the renal unit to track CRBSI and put in place measures to reduce these CRBSI.

[Analysis of Pathogenic Bacterial Spectrum, Drug Resistance and Risk Factors for Mortality of Bloodstream Infection in Patients with Hematologic Diseases]

OBJECTIVE

To analyze the pathogenic bacterial spectrum, drug resistance, and risk factors associated with multidrug-resistant bacterial infection and mortality in patients with hematologic diseases complicated by bloodstream infections, so as to provide reference for rational drug use and improving prognosis.

METHODS

Positive blood culture specimens of patients with hematologic diseases in two Class A tertiary hospitals of Shanxi province from January 2019 to December 2021 were retrospectively analyzed. Pathogen distribution, drug resistance and outcomes of patients with bloodstream infection were investigated, then the multivariate logistic analysis was performed to analyze the risk factors of multidrug-resistant bacterial infection and factors affecting prognosis.

RESULTS

203 strains of pathogens were identified, mainly Gram-negative bacteria (GNB) (69.46%, 141/203), of which Escherichia coli (E.coli) had the highest incidence (41.13%, 58/141), followed by Klebsiella pneumoniae (20.57%, 29/141) and Pseudomonas aeruginosa (12.77%, 18/141). Extended-spectrum beta-lactamase (ESBL)-producing E.coli and Klebsiella pneumoniae were 46.55% (27/58) and 37.93% (11/29), respectively. Carbapenem-resistant Gram-negative bacteria accounted for 10.64% (15/141). And Gram-positive bacteria accounted for 27.59% (56/203), Staphylococcus epidermidis, Streptococcus pneumoniae, and Staphylococcus aureus were the most frequently isolated pathogen among Gram-positive bacteria (14.29%, 12.50% and 10.71%, respectively), of which methicillin-resistant Staphylococcus aureus accounted for 33.33% (2/6), coagulase-negative staphylococci accounted for 87.50% (7/8), without vancomycin- or linezolid-resistant strain. Additionally, fungi accounted for 2.95% (6/203), all of which were Candida. Multidrug-resistant Gram-negative bacteria (MDR-GNB) accounted for 53.90% (76/141). Duration of neutropenia >14 days was a risk factor for developing MDR-GNB infection. The 30-day all-cause mortality was 10.84%. Multivariate logistic regression analysis showed that the significant independent risk factors for mortality were age≥60 years (P <0.01, OR =5.85, 95% CI: 1.80-19.07) and use of vasopressor drugs (P <0.01, OR =5.89, 95% CI: 1.83-18.94).

CONCLUSION

The pathogenic bacteria of bloodstream infection in patients with hematological diseases are widely distributed, and the detection rate of multidrug-resistant bacteria is high. The clinicians should choose suitable antibiotics according to the results of bacterial culture and antibiotic susceptibility test.

The impact of central line bundles on the timing of catheter-associated bloodstream infections and their microbiological distribution in critically ill children

Catheter-associated bloodstream infection, also known as CLABSI, is the most serious consequence of central venous access devices. These infections increase the risk of mortality and morbidity. The use of central line bundles in clinical settings is increasing worldwide with the purpose of lowering the risk of catheter-associated bloodstream infections. In this study, we investigated the effect of implementing a central line bundle for the prevention of CLABSIs, the distribution of pathogens, and the duration of time it took for CLABSIs to develop in patients who had subclavian-inserted central venous catheters. This research project was a cross-sectional study investigation carried out in a pediatric tertiary teaching hospital. Participants consisted of children who had been admitted to the pediatric critical care unit with subclavian catheters during a period of 13 years. We compared the prebundle period with the bundle period for CLABSI specifically focusing on the time to infection, the number of polymicrobial infections, the proportion of Candida parapsilosis, and the percentage of Coagulase-negative staphylococci (CoNS). The "prebundle period" included the period from May 2007 to May 2013, and the "bundle period" included the period from June 2013 to June 2020. Throughout the course of the study, a total of 286 cases of CLABSI were documented. Among these patients, 141 (49.3%) had CLABSIs associated with subclavian catheters. During the prebundle period, 55 CLABSIs were diagnosed in 5235 central line days, with an overall rate of 10.5 CLABSIs per 1000 central line days; after the implementation of central line bundle, 86 CLABSIs were diagnosed in 12,450 CL days, with an overall rate of 3.6 CLABSIs per 1000 CL days. This showed a statistically significantly lower rate in the bundle period (p = 0.0126). In the prebundle period, the mean time to develop CLABSI was 15 days, whereas during the bundle period, the mean time to develop CLABSI was 27.9 days, a significantly longer time to onset (p = 0.001). While the percentage of other microorganisms was not statistically different between the prebundle and bundle periods (p > 0.05), the percentage of C. parapsilosis was significantly higher in the prebundle period (p = 0.001).   Conclusion: The results of this study imply that the use of central line bundles not only reduces the incidence of CLABSI but also delays the time to which CLABSI patients acquire an infection. In addition, as a direct consequence of the CLB, the number of CLABSIs caused by gram-positive cocci did not increase, while the proportion of CLABSIs caused by C. parapsilosis decreased. What is Known: • The most significant negative consequence of central venous access devices is catheter-associated bloodstream infections. • "Care bundles" for CLABSI prevention have been reported to reduce the CLABSI rate. What is New: • Consider what would happen if the "Care bundle" failed to prevent CLABSI. • The findings of this study imply that using central line bundles not only reduces the risk of CLABSI but also extends the time it takes for patients to develop CLABSI. While the number of CLABSIs caused by gram-positive cocci did not increase as a direct result of CLB, the rate of CLABSIs caused by C. parapsilosis, which has recently become a major problem, has decreased.

Clinical outcomes and epidemiological characteristics of bacteremia in the older Japanese population

BACKGROUND

The characteristics and clinical consequences of bacteremia in older people, who are highly susceptible to infections, need to be clarified. This study aimed to determine the epidemiological characteristics, prognosis, and predictors of 7-day mortality in patients with community-acquired (CA), healthcare-associated (HCA), and hospital-onset (HO) bacteremia in older adults aged ≥65 years.

METHODS

Patients aged ≥65 years with positive blood cultures between April 1, 2015, and March 31, 2018, were divided into three groups: pre-old (65-74 years), old (75-89 years), and super-old (≥90 years). Characteristics based on medical exposure, including CA, HCA, and HO, were also compared and factors related to mortality were identified.

RESULTS

Overall, 1716 episodes of bacteremia were identified in 1415 patients. Of the 1211 episodes without contamination, 32.8%, 54.3%, and 12.9% occurred in pre-old, old, and super-old patients. Central line-associated bloodstream infections were more common in pre-old patients and urinary tract infections in the old and super-old. The 7-day mortality rates in the pre-old, old, and super-old groups were 7.4%, 5.8%, and 14.2% (P = 0.002), respectively. Multivariable logistic regression showed that super-old age (adjusted odds ratio, aOR: 2.09 [1.13-3.88], P = 0.019) and HO bacteremia (aOR: 1.97 [1.18-3.28], P = 0.010) were independent risk factors for 7-day mortality. Infectious disease consultation had a protective effect on 7-day mortality (aOR: 0.59 [0.35-0.99], P = 0.047).

CONCLUSIONS

The epidemiology of bacteremia differs among older people; thus, they should not be treated as a single entity. A careful approach is needed for the optimal management of bacteremia in these vulnerable patients.

Strategies to Prevent Infections in Dialysis Patients

Infections are the second leading cause of death among patients with end-stage kidney disease, behind only cardiovascular disease. In addition, patients on chronic dialysis are at a higher risk for acquiring infection caused by multidrug-resistant organisms and for death resulting from infection owing to their likelihood of requiring treatment that involves invasive devices, their frequent exposure to antibiotics, and their impaired immunity. Vascular access is a major risk factor for bacteremia, hospitalization, and mortality among hemodialysis (HD) patients. Catheter-related bacteremia is the most severe central venous catheter (CVC)-related infection and increases linearly with the duration of catheter use. Given the high prevalence of CVC use and its direct association with catheter-related bacteremia, which adversely impacts morbidity and mortality rates among HD patients, several prevention measures aimed at reducing the rates of CVC-related infection have been proposed and implemented. As a result, a large number of clinical trials, systematic reviews, and meta-analyses have been conducted to assess the effectiveness, clinical applicability, and long-term adverse effects of such measures. Peritoneal dialysis chronic treatment without the occurence of peritonitis is rare. Although most cases of peritonitis can be treated adequately with antibiotics, some cases are complicated by hospitalization or a temporary or permanent need to abstain from using the peritoneal dialysis catheter. Severe and long-lasting peritonitis can lead to peritoneal membrane failure, requiring the treatment method to be switched to HD. Some measures as patients training, early diagnosis, and choice of antibiotics can contribute to the successful treatment of peritonitis. Finally, medical directors are key leaders in infection prevention and are an important resource to implement programs to monitor and improve infection prevention practices at all levels within the dialysis clinic.

Epidemiology, risk factors, and applicability of CDC definitions for healthcare-associated bloodstream infections at a level IV neonatal ICU

OBJECTIVES

We studied the epidemiology of primary bloodstream infections (BSIs), secondary BSIs, and central line-associated BSIs (CLABSIs) and applicability of CDC definitions for primary sources of infection causing secondary BSIs in patients in the neonatal ICU.

STUDY DESIGN

We classified healthcare-associated BSIs (HABSIs) as primary BSIs, secondary BSIs, and CLABSIs using CDC surveillance definitions and determined their overall incidence and incidence among different gestational age strata. We assessed the applicability of CDC definitions for infection sources causing secondary BSIs.

RESULTS

From 2010 to 2019, 141 (32.7%), 202 (46.9%), and 88 (20.4%) HABSIs were classified as primary BSIs, secondary BSIs, and CLABSIs, respectively; all declined during the study period (all p < 0.001). Gestational age <28 weeks was associated with increased incidence of all HABSI types. CDC criteria for site-specific primary sources were met in 137/202 (68%) secondary BSIs.

CONCLUSIONS

Primary and secondary BSIs were more common than CLABSIs and should be prioritized for prevention.

Risk factors for infective endocarditis in patients receiving hemodialysis: A propensity score matched cohort study

In patients receiving hemodialysis, infective endocarditis (IE) may present in a similar way to other causes of bacteremia, which may delay early diagnosis and can lead to worse outcomes. In this study, we aimed to identify the risk factors for IE in hemodialysis patients with bacteremia. This study was conducted on all patients diagnosed with IE and receiving hemodialysis between 2005 and 2018 in Salford Royal Hospital. Patients with IE were propensity score matched with similar hemodialysis patients with episodes of bacteremia between 2011 and 2015 (non-IE bacteremic (NIEB)). Logistic regression analysis was used to predict the risk factors associated with infective endocarditis. There were 35 cases of IE, and these were propensity matched with 70 NIEB cases. The median age of the patients was 65 years with a predominance of males (60%). The IE group had higher peak C-reactive protein compared to the NIEB group (median, 253 mg/L vs. 152, p = 0.001). Patients with IE had a longer duration of prior dialysis catheter use than NIEB patients (150 vs. 28.5 days: p = 0.004). IE patients had a much higher 30-day mortality rate (37.1% vs. 17.1%, p = 0.023). Logistic regression analysis showed previous valvular heart disease (OR: 29.7; p < 0.001), and a higher baseline C-reactive protein (OR: 1.01; p = 0.001) as significant predictors for infective endocarditis. Bacteremia in patients receiving hemodialysis through a catheter access should be actively investigated with a high index of suspicion for infective endocarditis, particularly in those with known valvular heart disease and a higher baseline C-reactive protein.

Clinical Outcomes in Patients With Bacteremia and Concomitant Left Ventricular Assist Devices and Cardiac Implantable Electronic Devices

Infection remains a common cause of morbidity and mortality in patients with both left ventricular assist devices (LVADs) and cardiac implanted electronic devices (CIEDs) with limited data describing outcomes in patients who have both devices implanted. We performed a single-center, retrospective, observational cohort study of patients with both a transvenous CIED and LVAD who developed bacteremia. Ninety-one patients were evaluated. Eighty-one patients (89.0%) were treated medically and nine patients (9.9%) underwent surgical management. A multivariable logistic regression showed that blood culture positivity for >72 hours was associated with inpatient death, when controlled for age and management strategy (odds ratio [OR] = 3.73 [95% confidence interval {CI} = 1.34-10.4], p = 0.012). In patients who survived the initial hospitalization, the use of long-term suppressive antibiotics was not associated with the composite outcome of death or infection recurrence within 1 year, when controlled for age and management strategy (OR = 2.31 [95% CI = 0.88-2.62], p = 0.09). A Cox proportional hazards model showed that blood culture positivity for >72 hours was associated with a trend toward increased mortality in the first year, when controlled for age, management strategy, and staphylococcal infection (hazard ratio = 1.72 [95% CI = 0.88-3.37], p = 0.11). Surgical management was associated with a trend toward decreased mortality (hazard ratio = 0.23 [95% CI = 0.05-1.00], p = 0.05).

Risk Factors and Outcome of Gram-Negative Bloodstream Infection in Living-Donor Renal Transplant Recipients: A Case-Control Study From Pakistan

OBJECTIVES

Gram-negative rods are the most common cause of bloodstream infection in renal transplant recipients. Acute rejection, urologic abnormalities, and ureteral stents are risk factors. Graft dysfunction is independently associated with gram-negative rod bloodstream infection. Our aim is to investigate the incidence, risk factors, and outcome among living donor renal transplant recipients from Pakistan.

MATERIALS AND METHODS

In this case-control study, we reviewed the medical records until June 2021 of renal transplant recipients seen from 2015 to 2019 for gram negative bacteremia. For every case, controls were matched by age, date of transplant, and sex. Demographics, risk factors, graft function, and mortality were compared. Clinical features, immunosuppression, source of blood stream infection, and microbiology were noted in cases.

RESULTS

Of 1677 renal transplant recipients, 44 developed gram negative bacteremia. The incidence was 5.9 per 1000 person-years. Median time since transplant was 5 months. The most common source was urinary tract infection. On univariate analysis, antithymocyte globulin, urinary tract infection, and recurrent urinary tract infections were associated with gram negative bacteremia. On multivariate analysis, urinary tract infection (adjusted odds ratio = 3.46; 95% CI, 1.27-9.37) and recurrent urinary tract infections (adjusted odds ratio = 4.03; 95% CI, 1.15-14.15) were significant risk factors. We found no difference in 30-day mortality and estimated glomerular filtration rate on last follow-up between cases and controls. Kaplan-Meier survival curves showed significant differences in graft survival in patients with gram negative bacteremia. Escherichia coli was the most common organism, with 75% ceftriaxone and 13% imipenem resistance.

CONCLUSIONS

The most significant risk factor for gram negative rod bloodstream infection was recurrent urinary tract infections. Timely treatment and prevention of recurrent urinary tract infections areimperative for prevention of gram negative bacteremia.

Influence of Care on the Prevention of Bacteremia in Hemodialysis: Systematic Review

Central venous catheter-related infection is the most common complication in patients on hemodialysis. Nursing care is essential for its maintenance, minimizing risk factors, and avoiding complications, such as bacteremia. A systematic review was conducted to identify the influence of nursing care on the prevention of bacteremia due to hemodialysis catheter. The primary endpoint was the bacteremia rate measured as number of events per 1000 catheter days. The rate of bacteremia in the studies ranged from 0.2 to 5.47 events per 1000 catheter days after the application of nursing care. Several studies have shown a significant reduction in central venous catheter bacteremia with the application of management protocols, appropriate vigilance, and monitoring, as well as the inclusion of the Plan Do Check Act cycle and education.

The Association Between Central Line-Associated Bloodstream Infection and Central Line Access

OBJECTIVES

Identifying modifiable risk factors associated with central line-associated bloodstream infections (CLABSIs) may lead to modifications to central line (CL) management. We hypothesize that the number of CL accesses per day is associated with an increased risk for CLABSI and that a significant fraction of CL access may be substituted with non-CL routes.

DESIGN

We conducted a retrospective cohort study of patients with at least one CL device day from January 1, 2015, to December 31, 2019. A multivariate mixed-effects logistic regression model was used to estimate the association between the number of CL accesses in a given CL device day and prevalence of CLABSI within the following 3 days.

SETTING

A 395-bed pediatric academic medical center.

PATIENTS

Patients with at least one CL device day from January 1, 2015, to December 31, 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 138,411 eligible CL device days across 6,543 patients, with 639 device days within 3 days of a CLABSI (a total of 217 CLABSIs). The number of per-day CL accesses was independently associated with risk of CLABSI in the next 3 days (adjusted odds ratio, 1.007; 95% CI, 1.003-1.012; p = 0.002). Of medications administered through CLs, 88% were candidates for delivery through a peripheral line. On average, these accesses contributed a 6.3% increase in daily risk for CLABSI.

CONCLUSIONS

The number of daily CL accesses is independently associated with risk of CLABSI in the next 3 days. In the pediatric population examined, most medications delivered through CLs could be safely administered peripherally. Efforts to reduce CL access may be an important strategy to include in contemporary CLABSI-prevention bundles.

Pseudomonas putida bacteremia secondary to a soft tissue wound: A case report

Pseudomonas putida is an uncommon cause of bacteremia, that usually seeds from multiple sources including soft tissues. Immunocompromised states predispose patients to fulminant infections, and sometimes death. Broad-spectrum antibiotics, such as fourth-generation cephalosporins, are usually indicated for treatment. Herein, we present a 71-year-old gentleman with fever and left leg swelling, found to have P. putida bacteremia. Intravenous (IV) ceftazidime was initiated, yielding clearance of blood cultures and clinical improvement.

Mitigation strategies among cutaneous T-cell lymphoma patients with positive Staphylococcus aureus skin and soft tissue cultures have unclear impacts on the risk of subsequent bacteremia

Infections originating in the skin/soft tissue are a major cause of mortality in cutaneous T-cell lymphoma (CTCL). We performed a retrospective analysis to characterize cutaneous cultures and assess risk factors for bacteremia among 69 patients with CTCL. Cutaneous infections and antimicrobial resistance were common. Black race and lymph node involvement were associated with bacteremia. Mitigating strategies for invasive infections in CTCL remain unclear. HighlightsSkin/soft tissue infections are common in cutaneous T-cell lymphoma (CTCL).Black race, lymph node involvement, and positive cultures for S. aureus, Gram-negative bacteria, or multiple organisms were associated with an increased rate of bacteremia.The role of antimicrobial prophylaxis and staphylococcus decolonization is unclear.

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.

Antirheumatic treatment, disease activity and risk of Staphylococcus aureus bacteraemia in rheumatoid arthritis: a nationwide nested case-control study

OBJECTIVES

To assess how biological disease-modifying antirheumatic drugs (bDMARDs), glucocorticoids and disease activity affect risk of Staphylococcus aureus bacteraemia (SAB) in patients with rheumatoid arthritis (RA).

METHODS

In a nationwide cohort of patients with RA from the DANBIO registry, we conducted a nested case-control study including first-time microbiologically verified SAB cases from 2010 to 2018 and incidence density matched controls (1:4 by sex, age). We interlinked Danish registries and identified antirheumatic treatments, RA-specific clinical characteristics, comorbidities and socioeconomic status. The relative risk of SAB was assessed by adjusted ORs with 95% CIs and number needed to harm (NNH) reflected the absolute risk.

RESULTS

Among 30 479 patients, we identified 180 SAB cases (incidence rate: 106.7/100 000 person-years) and matched 720 controls (57% women, median age 73 years, IQR: 65-80). Risk of SAB was increased in current (OR 1.8 (95% CI 1.1 to 3.2)) and former bDMARD users (OR 2.5 (95% CI 0.9 to 7.0)), and in current users of oral glucocorticoids ≤7.5 prednisolone-equivalent mg/day (OR 2.2 (95% CI 1.3 to 4.0) and >7.5 mg/day (OR 9.5 (95% CI 3.9 to 22.7)) (non-use as reference). ORs for moderate/high disease activity compared with remission were 1.6 (95% CI 0.8 to 3.3)/1.5 (95% CI 0.6 to 4.3). Risk was increased in patients with longstanding RA (>10 years vs ≤3 years, OR=2.4 (95% CI 1.1 to 5.3)). The NNH was 1172(95% CI 426 to 9374) for current use of bDMARDs and 110(95% CI 43 to 323) for glucocorticoids >7.5 mg/day.

CONCLUSION

We identified a dose-dependent increased risk of SAB in patients with RA currently using oral glucocorticoids. Daily use of >7.5 mg appeared to be a clinically relevant risk factor, whereas the absolute risk was low for bDMARDs. No clear impact of disease activity was found.

Gram-negative bacteremia in solid organ transplant recipients: Clinical characteristics and outcomes as compared to immunocompetent non-transplant recipients

BACKGROUND

Outcomes from Gram-negative bacteremia (GNB) in solid organ transplant (SOT) recipients are poorly understood.

METHODS

This is a single center prospective cohort study comparing the clinical characteristics and outcomes of SOT recipients with GNB to immunocompetent non-SOT patients with GNB between 1/1/2002 through 12/31/2018. Outcomes of interest included incidence of septic shock, respiratory failure, and time to death. A multivariable logistic regression model was used to determine factors associated with incidence of septic shock and respiratory failure. Time to death was evaluated using Cox proportional hazard models.

RESULTS

A total of 297 SOT and 1245 immunocompetent non-SOT patients were included. Incidence of septic shock did not significantly differ between the groups (SOT 25.3% vs. non-SOT 24.6%, p = .8225). Overall survival did not significantly differ by transplant status (30-day survival: SOT 76%, 95% confidence interval [CI] 70, 92, non-SOT 74%, 95% CI 71, 77: log rank: p = .76). SOT recipients taking three immunosuppressive medications had significantly lower odds of developing septic shock or respiratory failure requiring intubation and mechanical ventilation than those taking ≤1 agent (shock: adjusted odds ratio [aOR] 0.29, 95% CI 0.09, 0.90, p = .0316; respiratory failure: aOR 0.14, 95% CI: 0.04, 0.49, p = .0020).

CONCLUSIONS

SOT recipients with GNB do not experience higher rates of septic shock, respiratory failure, or mortality than immnon-SOT recipients with GNB. Among SOT recipients, a greater number of immunosuppressive medications may be associated with improved outcomes during GNB. Future studies are needed to understand the potential relationship between levels of immunosuppression and clinical outcome in SOT recipients with GNB.

Effect of Selective Decontamination of the Digestive Tract on Hospital Mortality in Critically Ill Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial

IMPORTANCE

Whether selective decontamination of the digestive tract (SDD) reduces mortality in critically ill patients remains uncertain.

OBJECTIVE

To determine whether SDD reduces in-hospital mortality in critically ill adults.

DESIGN, SETTING, AND PARTICIPANTS

A cluster, crossover, randomized clinical trial that recruited 5982 mechanically ventilated adults from 19 intensive care units (ICUs) in Australia between April 2018 and May 2021 (final follow-up, August 2021). A contemporaneous ecological assessment recruited 8599 patients from participating ICUs between May 2017 and August 2021.

INTERVENTIONS

ICUs were randomly assigned to adopt or not adopt a SDD strategy for 2 alternating 12-month periods, separated by a 3-month interperiod gap. Patients in the SDD group (n = 2791) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191) received standard care.

MAIN OUTCOMES AND MEASURES

The primary outcome was in-hospital mortality within 90 days. There were 8 secondary outcomes, including the proportion of patients with new positive blood cultures, antibiotic-resistant organisms (AROs), and Clostridioides difficile infections. For the ecological assessment, a noninferiority margin of 2% was prespecified for 3 outcomes including new cultures of AROs.

RESULTS

Of 5982 patients (mean age, 58.3 years; 36.8% women) enrolled from 19 ICUs, all patients completed the trial. There were 753/2791 (27.0%) and 928/3191 (29.1%) in-hospital deaths in the SDD and standard care groups, respectively (mean difference, -1.7% [95% CI, -4.8% to 1.3%]; odds ratio, 0.91 [95% CI, 0.82-1.02]; P = .12). Of 8 prespecified secondary outcomes, 6 showed no significant differences. In the SDD vs standard care groups, 23.1% vs 34.6% had new ARO cultures (absolute difference, -11.0%; 95% CI, -14.7% to -7.3%), 5.6% vs 8.1% had new positive blood cultures (absolute difference, -1.95%; 95% CI, -3.5% to -0.4%), and 0.5% vs 0.9% had new C difficile infections (absolute difference, -0.24%; 95% CI, -0.6% to 0.1%). In 8599 patients enrolled in the ecological assessment, use of SDD was not shown to be noninferior with regard to the change in the proportion of patients who developed new AROs (-3.3% vs -1.59%; mean difference, -1.71% [1-sided 97.5% CI, -∞ to 4.31%] and 0.88% vs 0.55%; mean difference, -0.32% [1-sided 97.5% CI, -∞ to 5.47%]) in the first and second periods, respectively.

CONCLUSIONS AND RELEVANCE

Among critically ill patients receiving mechanical ventilation, SDD, compared with standard care without SDD, did not significantly reduce in-hospital mortality. However, the confidence interval around the effect estimate includes a clinically important benefit.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02389036.

Effects of the COVID-19 Pandemic on Incidence and Epidemiology of Catheter-Related Bacteremia, Spain

We compared hospital-acquired catheter-related bacteremia (CRB) episodes diagnosed at acute care hospitals in Catalonia, Spain, during the COVID-19 pandemic in 2020 with those detected during 2007–2019. We compared the annual observed and predicted CRB rates by using the negative binomial regression model and calculated stratified annual root mean squared errors. A total of 10,030 episodes were diagnosed during 2007–2020. During 2020, the observed CRB incidence rate was 0.29/10³ patient-days, whereas the predicted CRB rate was 0.14/10³ patient-days. The root mean squared error was 0.153. Thus, a substantial increase in hospital-acquired CRB cases was observed during the COVID-19 pandemic in 2020 compared with the rate predicted from 2007–2019. The incidence rate was expected to increase by 1.07 (95% CI 1–1.15) for every 1,000 COVID-19–related hospital admissions. We recommend maintaining all CRB prevention efforts regardless of the coexistence of other challenges, such as the COVID-19 pandemic.

Risk factors associated with increased incidences of catheter-related bloodstream infection

We have implemented several preventive measures to reduce central line-associated bloodstream infection (CLABSI) in the general intensive care unit (ICU) of a university hospital in Japan. Here, we analyzed the factors associated with CLABSI in patients with central venous catheter (CVC) insertions and evaluated the effects of our implemented preventive measures. From July 2013 to June 2018, data was collected from the medical records of 1472 patients with 1635 CVC insertions, including age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, duration of ICU stay, duration of catheter insertion, insertion site, and mechanical ventilation status. During weekly conferences, a surveillance team comprising intensive care and infection control doctors and nurses determined the patients' CLABSI status. The analyzed factors were compared between CLABSI and central line patients without bloodstream infection. Multivariate analysis revealed three factors associated with CLABSI. Adjusted odds ratios with 95% confidence intervals were as follows: duration of ICU stay, 1.032 (1.019-1.044); duration of catheter insertion, 1.041 (1.015-1.066); and APACHE II score, 1.051 (1.000-1.105). The prominent risk factors were associated with the severity of the initial condition and exacerbation of the clinical condition of the patients during their stays in the ICU. Further strategies to reduce CLABSI must be developed.

Cost-effectiveness Analysis of Peripherally Inserted Central Catheters Versus Central Venous Catheters for in-Hospital Parenteral Nutrition

OBJECTIVE

Our objective was to evaluate the cost-effectiveness of the use of peripherally inserted central venous catheters (PICCs) by a vascular access team (VAT) versus central venous catheters (CVCs) for in-hospital total parenteral nutrition (TPN).

METHODS

The study used a cost-effectiveness analysis based on observational data retrospectively obtained from electronic medical records from 2018 to 2019 in a teaching hospital. We included all interventional procedures requiring PICCs or CVCs with the indication of TPN. We recorded the costs of insertion, maintenance, removal, and complications. The main outcome measure was the incidence rate of catheter-associated bacteremia per 1000 catheter days. Cost-effectiveness analysis was performed from the hospital perspective within the context of the publicly funded Spanish health system. Confidence intervals for costs and effectiveness differences were calculated using bootstrap methods.

RESULTS

We analyzed 233 CVCs and 292 PICCs from patients receiving TPN. Average duration was longer for PICC (13 versus 9.4 days, P < 0.001). The main reason for complications in both groups was suspected infection (9.77% CVC versus 5.18% PICC). Complication rates due to bacteremia were 2.44% for CVC and 1.15% for PICC. The difference in the incidence of bacteremia per 1000 catheter days was 1.29 (95% confidence interval, -0.89 to 3.90). Overall, costs were lower for PICCs than for CVCs: the difference in mean overall costs was -€559.9 (95% confidence interval, -€919.9 to -€225.4). Uncertainty analysis showed 86.37% of results with lower costs and higher effectiveness for PICC versus CVC.

CONCLUSIONS

Placement of PICC by VAT compared with CVC for TPN reduces costs and may decrease the rate of bacteremia.

Institutional factors associated with the incidence rates of central line-associated bloodstream infection in California community hospitals

Central line-associated bloodstream infections are frequent, deadly, costly, and preventable. The study aimed to explore how some hospital-related characteristics were associated with incidence rates of central line-associated bloodstream infections reported by community hospitals in California from January to December 2019. This retrospective, cross-sectional study used combined data from records submitted to the California Department of Public Health, California Open Data Portal, the California Health and Human Services Open Data Portal, and the American Hospital Directory by community hospitals in California with central line-associated bloodstream infections in 2019. Results showed that CLABSIs are significantly associated with bed capacity, health care system affiliation, ownership, and hospital accreditation status (p < 0.0001). CLABSI remains a relevant threat to patient safety and quality of care, even more so in the community hospital setting. Understanding if a relationship exists between institutional factors and CLABSI rates might better prepare leaders in healthcare organizations to reduce HAIs.

Analysis of related complications of totally implantable venous access ports in children's chemotherapy: Single center experience

Totally implantable venous access port (TIVAP) has become an important infusion channel for children who need chemotherapy. With the popularization of TIVAP, its related complications have gradually received clinical attention. However, there are few studies on the complications of TIVAP in children. Therefore, this study intends to analyze the risk factors of complications in children's infusion port, so as to provide basis for guiding clinical prevention and intervention. This paper retrospectively analyzed 182 children who received TIVAP implantation in our hospital from January 2018 to January 2021. According to the demographic data, basic disease status and operation related data obtained through Hospital Information System and manual follow-up, the complications and related influencing factors after implantation and implantation were summarized and analyzed. SPSS software was used to analyze the influencing factors between the complication group and the control group. There were 182 cases of children implanted in intravenous infusion port, of which 71 cases had complications, infection was the most common complication in 50 cases, followed by catheter blockage in 23 cases. Among the infection factors, catheter-related blood stream infection accounted for the highest proportion in 31 cases (17.0%), and Staphylococcus epidermidis was the most common pathogen. A total of 19 cases were pulled out early, and the unplanned pullout rate of catheter-related blood stream infection was the highest. In the analysis of influencing factors, age had significant differences in catheter-related infection, all complications and no complications (P < .05). The overall incidence of complications in the use of TIVAP in children with chemotherapy is high, and infection is the most common complication, among which catheter-related blood stream infection is the most common cause of unplanned pullout. Lower age may be associated with a higher incidence of complications.

Extracorporeal Membrane Oxygenation Cannula-Related Infections: Epidemiology and Risk Factors

Although being a potential major source of infection in extracorporeal membrane oxygenation (ECMO) patients, data regarding cannula-related infections (CRI) remain scarce. We therefore aimed at describing the epidemiology of CRI among critically ill patients supported by ECMO. Between October 2017 and November 2019, adult patients supported by either venoarterial (VA), venopulmonary arterial, or venovenous (VV) ECMO for more than 24 hours were prospectively enrolled. When CRI was suspected, cannula swab and subcutaneous needle aspirate samples were obtained for microbiological culture. Cannula tips were systematically sent for culture at the time of ECMO removal. Primary end-point was CRI, which was defined by sepsis or local sign of cannula infection and at least one positive culture among swab, subcutaneous needle aspirate or tip. Multivariate analysis was performed to identify risk factors of CRI. Hundred patients were included, including 77 VA, 12 venopulmonary arterial, and 11 VV ECMO. Cannula-related infections were diagnosed after a median duration of ECMO of 10 [7-13] days. Rate of CRI was 24%, including 10% with bacteremia. Most frequent involved pathogens were Enterobacteriaceae (n = 14), Enterococci (n = 8), and coagulase-negative Staphylococci (n = 7). By multivariate analysis, diabetes and ECMO duration were independently associated with CRI.