Acutely ill hematology/oncology patients with central-line associated bloodstream infections and the impact of timing of catheter removal on outcomes

Abstract Objective: To evaluate the effect of 70% isopropyl alcohol–impregnated central venous catheter caps on ambulatory central-line–associated bloodstream infections (CLABSIs) in pediatric hematology-oncology patients. Design: This study was a 24-month, cluster-randomized, 2 period, crossover clinical trial. Setting: The study was conducted in 15 pediatric healthcare institutions, including 16 pediatric hematology-oncology clinics. Participants: All patients with an external central line followed at 1 of the 16 hematology-oncology clinics. Intervention: Usual ambulatory central-line care per each institution using 70% isopropyl alcohol–impregnated caps at home compared to usual ambulatory central-line care in each institution without using 70% isopropyl alcohol–impregnated caps. Results: Of the 16 participating clinics, 15 clinics completed both assignment periods. As assigned, there was no reduction in CLABSI incidence in clinics using 70% isopropyl alcohol–impregnated caps (1.23 per 1,000 days) compared with standard practices (1.38 per 1,000 days; adjusted incidence rate ratio [aIRR], 0.83; 95% CI, 0.63–1.11). In the per-protocol population, there was a reduction in positive blood culture incidence in clinics using 70% isopropyl alcohol-impregnated caps (1.51 per 1,000 days) compared with standard practices (1.88 per 1,000 days; aIRR, 0.72; 95% CI, 0.52–0.99). No adverse events were reported. Conclusions: Isopropyl alcohol–impregnated central-line caps did not lead to a statistically significant reduction in CLABSI rates in ambulatory hematology-oncology patients. In the per-protocol analysis, there was a statistically significant decrease in positive blood cultures. Larger trials are needed to elucidate the impact of 70% isopropyl alcohol–impregnated caps in the ambulatory setting. Registration: ClinicalTrials.gov; NCT02351258

Download Full-text

Management of enterococcal central line-associated bloodstream infections in patients with cancer

BMC Infectious Diseases ◽

10.1186/s12879-021-06328-9 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Hesham Awadh ◽

Anne-Marie Chaftari ◽

Melissa Khalil ◽

Johny Fares ◽

Ying Jiang ◽

...

Keyword(s):

Bloodstream Infections ◽

Venous Catheter ◽

Central Line ◽

Catheter Removal ◽

Mucosal Barrier ◽

Successful Outcome ◽

Success Rates ◽

Group 2 ◽

Polymicrobial Bacteremia ◽

The Impact

Abstract Objective Enterococcus species are the third most common organisms causing central line-associated bloodstream infections (CLABSIs). The management of enterococcal CLABSI, including the need for and timing of catheter removal, is not well defined. We therefore conducted this study to determine the optimal management of enterococcal CLABSI in cancer patients. Methods We reviewed data for 542 patients diagnosed with Enterococcus bacteremia between September 2011 to December 2018. After excluding patients without an indwelling central venous catheter (CVC), polymicrobial bacteremia or with CVC placement less than 48 h from bacteremia onset we classified the remaining 397 patients into 3 groups: Group 1 (G1) consisted of patients with CLABSI with mucosal barrier injury (MBI), Group 2 (G2) included patients with either catheter-related bloodstream infection (CRBSI) as defined in 2009 Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection by the Infectious Diseases Society of America (IDSA) or CLABSI without MBI, and Group 3 (G3) consisted of patients who did not meet the CDC criteria for CLABSI. The impact of early (< 3 days after bacteremia onset) and late (3–7 days) CVC removal was compared. The composite primary outcome included absence of microbiologic recurrence, 90-day infection-related mortality, and 90-day infection-related complications. Results Among patients in G2, CVC removal within 3 days of bacteremia onset was associated with a trend towards a better overall outcome than those whose CVCs were removed later between days 3 to 7 (success rate 88% vs 63%). However, those who had CVCs retained beyond 7 days had a similar successful outcome than those who had CVC removal < 3 days (92% vs. 88%). In G1, catheter retention (removal > 7 days) was associated with a better success rates than catheter removal between 3 and 7 days (93% vs. 67%, p = 0.003). In non-CLABSI cases (G3), CVC retention (withdrawal > 7 days) was significantly associated with a higher success rates compared to early CVC removal (< 3 days) (90% vs. 64%, p = 0.006). Conclusion Catheter management in patients with enterococcal bacteremia is challenging. When CVC removal is clinically indicated in patients with enterococcal CLABSI, earlier removal in less than 3 days may be associated with better outcomes. Based on our data, we cannot make firm conclusions about whether earlier removal (< 3 days) could be associated with better outcomes in patients with Enterococcal CLABSI whose CVC withdrawal is clinically indicated. In contrast, it seemed that catheter retention was associated to higher success outcome rates. Therefore, future studies are needed to clearly assess this aspect.

Download Full-text

Effect of Removing Contact Precautions for Multidrug-Resistant Organisms on Hospital Infections in a Pediatric Health System

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.742 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s199-s200

Author(s):

Matthew Linam ◽

Dorian Hoskins ◽

Preeti Jaggi ◽

Mark Gonzalez ◽

Renee Watson ◽

...

Keyword(s):

Hand Hygiene ◽

Antibiotic Stewardship ◽

Infection Prevention ◽

Tertiary Care ◽

Bloodstream Infections ◽

Central Line ◽

Contact Precautions ◽

Stewardship Program ◽

Tract Infections ◽

The Impact

Background: Discontinuation of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) have failed to show an increase in associated transmission or infections in adult healthcare settings. Pediatric experience is limited. Objective: We evaluated the impact of discontinuing contact precautions for MRSA, VRE, and extended-spectrum β-lactamase–producing gram-negative bacilli (ESBLs) on device-associated healthcare-associated infections (HAIs). Methods: In October 2018, contact precautions were discontinued for children with MRSA, VRE, and ESBLs in a large, tertiary-care pediatric healthcare system comprising 2 hospitals and 620 beds. Coincident interventions that potentially reduced HAIs included blood culture diagnostic stewardship (June 2018), a hand hygiene education initiative (July 2018), a handshake antibiotic stewardship program (December 2018) and multidisciplinary infection prevention rounding in the intensive care units (November 2018). Compliance with hand hygiene and HAI prevention bundles were monitored. Device-associated HAIs were identified using standard definitions. Annotated run charts were used to track the impact of interventions on changes in device-associated HAIs over time. Results: Average hand hygiene compliance was 91%. Compliance with HAI prevention bundles was 81% for ventilator-associated pneumonias, 90% for catheter-associated urinary tract infections, and 97% for central-line–associated bloodstream infections. Overall, device-associated HAIs decreased from 6.04 per 10,000 patient days to 3.25 per 10,000 patient days after October 2018 (Fig. 1). Prior to October 2018, MRSA, VRE and ESBLs accounted for 10% of device-associated HAIs. This rate decreased to 5% after October 2018. The decrease in HAIs was likely related to interventions such as infection prevention rounds and handshake stewardship. Conclusions: Discontinuation of contact precautions for children with MRSA, VRE, and ESBLs were not associated with increased device-associated HAIs, and such discontinuation is likely safe in the setting of robust infection prevention and antibiotic stewardship programs.Funding: NoneDisclosures: None

Download Full-text

COVID-19 Pandemic, CLABSI, and CAUTI: The Urgent Need to Refocus on Hardwiring Prevention Efforts

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2021.70 ◽

2021 ◽

pp. 1-22

Author(s):

Mohamad G. Fakih ◽

Angelo Bufalino ◽

Lisa Sturm ◽

Ren-Huai Huang ◽

Allison Ottenbacher ◽

...

Keyword(s):

Urinary Catheter ◽

Bloodstream Infections ◽

Central Line ◽

Coagulase Negative Staphylococcus ◽

Safe Environment ◽

Candida Sp ◽

Optimal Line ◽

Considerable Impact ◽

Tract Infections ◽

The Impact

Abstract Background: The coronavirus disease 2019 (COVID-19) pandemic has had a considerable impact on US hospitalizations, affecting processes and patient population. Methods: We evaluated the impact of COVID-19 pandemic in 78 US hospitals on central line associated bloodstream infections (CLABSI) and catheter associated urinary tract infections (CAUTI) events 12 months pre-COVID-19 and 6 months during COVID-19 pandemic. Results: There were 795,022 central line-days and 817,267 urinary catheter-days over the two study periods. Compared to pre-COVID-19 period, CLABSI rates increased during the pandemic period from 0.56 to 0.85 (51.0%) per 1,000 line-days (p<0.001) and from 1.00 to 1.64 (62.9%) per 10,000 patient-days (p<0.001). Hospitals with monthly COVID-19 patients representing >10% of admissions had a NHSN device standardized infection ratio for CLABSI that was 2.38 times higher compared to those with <5% prevalence during the pandemic period (p=0.004). Coagulase-negative staphylococcus CLABSI increased by 130% from 0.07 to 0.17 events per 1,000 line-days (p<0.001), and Candida sp. by 56.9% from 0.14 to 0.21 per 1,000 line-days (p=0.01). In contrast, no significant changes were identified for CAUTI (0.86 vs. 0.77 per 1,000 catheter-days; p=0.19). Conclusions: The COVID-19 pandemic was associated with substantial increases in CLABSI but not CAUTI events. Our findings underscore the importance of hardwiring processes for optimal line care, and regular feedback on performance to maintain a safe environment.

Download Full-text

Review of Best Practices for CLABSI Prevention and the Impact of Recent Legislation on CLABSI Reporting

SAGE Open ◽

10.1177/2158244016677747 ◽

2016 ◽

Vol 6 (4) ◽

pp. 215824401667774 ◽

Cited By ~ 1

Author(s):

Benjamin Woodward ◽

Reba Umberger

Keyword(s):

Best Practices ◽

Healthcare Providers ◽

Bloodstream Infections ◽

Central Line ◽

Mandatory Reporting ◽

Future Research ◽

Common Source ◽

Healthcare Associated Infection ◽

Extrinsic Factors ◽

The Impact

Central line-associated bloodstream infections (CLABSI) are a very common source of healthcare-associated infection (HAI). Incidence of CLABSI has been significantly reduced through the efforts of nurses, healthcare providers, and infection preventionists. Extrinsic factors such as recently enacted legislation and mandatory reporting have not been closely examined in relation to changes in rates of HAI. The following review will examine evidence-based practices related to CLABSI and how they are reported, as well as how the Affordable Care Act, mandatory reporting, and pay-for-performance programs have affected these best practices related to CLABSI prevention. There is a disconnect in the methods and guidelines for reporting CLABSI between these programs, specifically among local monitoring agencies and the various federal oversight organizations. Future research will focus on addressing the gap in what defines a CLABSI and whether or not these programs to incentivize hospital to reduce CLABSI rates are effective.

Download Full-text

#31: Risk Factors Associated with Mortality due to Multidrug-Resistant Organisms in Pediatric Oncology Patients with Febrile Neutropenia

Journal of the Pediatric Infectious Diseases Society ◽

10.1093/jpids/piaa170.048 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

pp. S15-S16

Author(s):

Miguel A Minero ◽

Asia Castro ◽

Martha Avilés-Robles

Keyword(s):

Risk Factors ◽

Septic Shock ◽

Febrile Neutropenia ◽

Pediatric Oncology ◽

Pediatric Patients ◽

Bloodstream Infections ◽

Oncology Patients ◽

Factors Associated ◽

Patients With Cancer ◽

The Impact

Abstract Background Infectious processes are frequent complications presented in pediatric patients with cancer. Currently, the indiscriminate use of antibiotics induces resistance to available treatments, creating the emergence of multi-drug-resistant organisms (MDROs). Due to the impact in morbidity and mortality secondary to MDRO infection, we aimed to identify risk factors associated with mortality in infections due to MDROs in pediatric patients with cancer. Methods Case–control study nested in a prospective cohort of pediatric oncology patients with febrile neutropenia (FN) at Hospital Infantil de México Federico Gómez (HIMFG) in Mexico City from March 2015 to September 2017. MDRO was defined as acquired non-susceptibility to at least one agent in three or more antimicrobial categories. Patients with FN episodes who died from an infection due to MDROs were defined as cases and patients with FN episodes of an infection due to MDROs who did not die were defined as controls. Mucositis, septic shock, PICU stay, and bacterial prophylaxis (Trimethoprim/Sulfamethoxazole) were compared between groups. Descriptive statistics was performed and Pearson χ 2 or Student’s t-test were used to compare risk factors between groups. Results A total of 929 FN episodes were documented, 44.4% episodes occurred in male patients, mean age was 7.9 years, with the population under 5 years being the most represented (68.2%). The most frequent diagnosis was acute lymphoblastic leukemia in 75% followed by rhabdomyosarcoma in 10.5% and acute myeloid leukemia in 9.6%. Prophylaxis (trimethoprim/sulfamethoxazole) was used in 86%, mucositis was present in 9.2% of episodes. 12.1% had septic shock and 4.7% were admitted to PICU. In 148 FN episodes (15.9%) a microorganism was identified, of these 50 (33.7%) were due to an MDROs. Urinary tract infection was the most frequent site (49%), followed by bloodstream infections (47%). K. pneumoniae was the most frequent MDRO in 22.8%, followed by E. coli in 19.2% and P. aeruginosa in 14%. Septic shock was presented in 26% of MDROs infections. Overall mortality was 1.94% and only 0.86% (8) were secondary to MDROs. Of patients with MDRO isolated mortality was 30% (15/50). Mortality associated with bloodstream infection due to MDROs was 25% compared with other source of MDROs infections (3%) (P = 0.01). Septic shock was present in 40% of patients with death due to MDROs infection (P = 0.001). Conclusions In our population of children with FN episodes who had an isolated microorganism, infection due to MDROs are high (33.7%) and MDROs infection-directed mortality was as high as 30%. Bloodstream infections and septic shock were risk factors associated with mortality due to MDROs.

Download Full-text

2091. The Impact of Infection Control Cost Reimbursement Policy on Trends in Central Line-Associated Bloodstream Infections

Open Forum Infectious Diseases ◽

10.1093/ofid/ofy210.1747 ◽

2018 ◽

Vol 5 (suppl_1) ◽

pp. S613-S613 ◽

Cited By ~ 2

Author(s):

Ki Tae Kwon ◽

Won Kee Lee ◽

Mi Hyae Yu ◽

Hyun Ju Park ◽

Kyeong Hee Lee ◽

...

Keyword(s):

Infection Control ◽

Bloodstream Infections ◽

Central Line ◽

Reimbursement Policy ◽

Control Cost ◽

The Impact

Download Full-text

Chlorhexidine Bathing in a Tertiary Care Neonatal Intensive Care Unit: Impact on Central Line–Associated Bloodstream Infections

Infection Control and Hospital Epidemiology ◽

10.1086/674862 ◽

2014 ◽

Vol 35 (2) ◽

pp. 158-163 ◽

Cited By ~ 32

Author(s):

Caroline Quach ◽

Aaron M. Milstone ◽

Chantal Perpête ◽

Mario Bonenfant ◽

Dorothy L. Moore ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Birth Weight ◽

Adverse Events ◽

Neonatal Intensive Care Unit ◽

Neonatal Intensive Care ◽

Tertiary Care ◽

Bloodstream Infections ◽

Central Line ◽

The Impact

Background.Despite implementation of recommended best practices, our central line-associated bloodstream infection (CLABSI) rates remained high. Our objective was to describe the impact of chlorhexidine gluconate (CHG) bathing on CLABSI rates in neonates.Methods.Infants with a central venous catheter (CVC) admitted to the neonatal intensive care unit from April 2009 to March 2013 were included. Neonates with a birth weight of 1,000 g or less, aged less than 28 days, and those with a birth weight greater than 1,000 g were bathed with mild soap until March 31, 2012 (baseline), and with a 2% CHG-impregnated cloth starting on April 1, 2012 (intervention). Infants with a birth weight of 1,000 g or less, aged 28 days or more, were bathed with mild soap during the entire period. Neonatal intensive care unit nurses reported adverse events. Adjusted incidence rate ratios (aIRRs), using Poisson regression, were calculated to compare CLABSIs/1,000 CVC-days during the baseline and intervention periods.Results.Overall, 790 neonates with CVCs were included in the study. CLABSI rates decreased during the intervention period for CHG-bathed neonates (6.00 vs 1.92/1,000 CVC-days; aIRR, 0.33 [95% confidence interval (CI), 0.15-0.73]) but remained unchanged for neonates with a birth rate of 1,000 g or less and aged less than 28 days who were not eligible for CHG bathing (8.57 vs 8.62/1,000 CVC-days; aIRR, 0.86 [95% CI, 0.17-4.44]). Overall, 195 infants with a birth weight greater than 1,000 g and 24 infants with a birth weight of 1,000 g or less, aged 28 days or more, were bathed with CHG. There was no reported adverse event.Conclusions.We observed a decrease in CLABSI rates in CHG-bathed neonates in the absence of observed adverse events. CHG bathing should be considered if CLABSI rates remain high, despite the implementation of other recommended measures.

Download Full-text

Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infections (MBI-LCBI): Descriptive Analysis of Data Reported to National Healthcare Safety Network (NHSN), 2013

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2015.245 ◽

2015 ◽

Vol 37 (1) ◽

pp. 2-7 ◽

Cited By ~ 18

Author(s):

Lauren Epstein ◽

Isaac See ◽

Jonathan R. Edwards ◽

Shelley S. Magill ◽

Nicola D. Thompson

Keyword(s):

Acute Care ◽

Descriptive Analysis ◽

Bloodstream Infections ◽

Central Line ◽

Mucosal Barrier ◽

National Healthcare ◽

National Healthcare Safety Network ◽

Mucosal Barrier Injury ◽

The Impact ◽

Clabsi Rate

OBJECTIVESTo determine the impact of mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBIs) on central-line–associated bloodstream infection (CLABSI) rates during the first year of MBI-LCBI reporting to the National Healthcare Safety Network (NHSN)DESIGNDescriptive analysis of 2013 NHSN dataSETTINGSelected inpatient locations in acute care hospitalsMETHODSA descriptive analysis of MBI-LCBI cases was performed. CLABSI rates per 1,000 central-line days were calculated with and without the inclusion of MBI-LCBIs in the subset of locations reporting ≥1 MBI-LCBI, and in all locations (regardless of MBI-LCBI reporting) to determine rate differences overall and by location type.RESULTSFrom 418 locations in 252 acute care hospitals reporting ≥1 MBI-LCBIs, 3,162 CLABSIs were reported; 1,415 (44.7%) met the MBI-LCBI definition. Among these locations, removing MBI-LCBI from the CLABSI rate determination produced the greatest CLABSI rate decreases in oncology (49%) and ward locations (45%). Among all locations reporting CLABSI data, including those reporting no MBI-LCBIs, removing MBI-LCBI reduced rates by 8%. Here, the greatest decrease was in oncology locations (38% decrease); decreases in other locations ranged from 1.2% to 4.2%.CONCLUSIONSAn understanding of the potential impact of removing MBI-LCBIs from CLABSI data is needed to accurately interpret CLABSI trends over time and to inform changes to state and federal reporting programs. Whereas the MBI-LCBI definition may have a large impact on CLABSI rates in locations where patients with certain clinical conditions are cared for, the impact of MBI-LCBIs on overall CLABSI rates across inpatient locations appears to be more modest.Infect. Control Hosp. Epidemiol. 2015;37(1):2–7

Download Full-text

COMMUNITY ONSET CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTIONS (CLABSIS) IN PEDIATRIC ONCOLOGY PATIENTS: AN UNDERESTIMATED PROBLEM?

10.26226/morressier.5ad774ddd462b80296ca6904 ◽

2018 ◽

Author(s):

John Kopsidas

Keyword(s):

Pediatric Oncology ◽

Bloodstream Infections ◽

Central Line ◽

Oncology Patients ◽

Community Onset

Download Full-text