Malassezia furfur fungaemia in infants receiving intravenous lipid emulsions. A rarity or just underestimated?

Malassezia furfur fungaemia is reported in six preterm infants receiving a parenteral fat emulsion through a deep central venous catheter. The fungus was detected in blood cultures drawn through the catheter. The features of these cases are compared to those reported since 1981, whenM. furfur was described for the first time as a cause of deep tissue infection. Clinical signs such as fever, in spite of broadspectrum antibiotics, and the presence of pulmonary infiltrates, associated with leucocytosis and thrombocytopenia in neonatcs with cardiac or pulmonary disease should raise the suspicion ofM. furfur fungaemia. The laboratory should be informed of this possibility since routine blood culture techniques are not appropriate for the isolation of this lipid-dependent organism. Treatment of the condition consists in removal of the catheter and discontinuation of the lipid administration. Effects and choice of antifungal therapy should be further investigated.Abbreviations BPD bronchopulmonary dysplasia - CVC central venous catheter     

Central venous catheter infections

When used wisely, central venous catheters are capable of providing vital circulatory access in any patient with a remarkably low risk of infection or major complication. Tunneled silicone catheters are the route of choice for long-term or outpatient use, particularly for oncology or TPN patients; insertion of such a catheter should occur early in the hospitalization of a newly diagnosed patient on chemotherapy. The greatest experience has accrued with the cuffed silicone catheters (for example, Broviac), but the totally implantable devices (for instance, Port-a-cath) may become the device of choice in pediatric outpatients. For infants, small, percutaneously inserted noncuffed silicone catheters appear to offer the greatest safety. Among acute care patients, percutaneous plastic central venous catheters fulfill a vital role but represent an important source of infection. Scrupulous technique, the minimizing of manipulation, and a readiness to replace the catheter at any suggestion of trouble are important to achieving the best results. Within a given design, it is generally best to use the smallest diameter catheter capable of performing the desired tasks. However, on the basis of currently available data, there need be no hesitation to use a multilumen catheter if the care of the patient demands multiple access ports. The various silicone catheters can usually be left in place while infection is treated, although fungal and certain other infections are more likely to require catheter removal. Percutaneous plastic catheters should be removed or changed over a wire if infection is suspected; if tip culture of the removed catheter is positive, and the catheter was replaced over a wire, then the replacement catheter should be promptly removed.     

Diagnostics and management of central venous line infections in pediatric cancer patients

Otherwise unexplained clinical signs of infection in patients with tunneled or totally implanted central venous access devices (CVAD) are highly suspicious of an underlying CVAD-associated infection. Diagnostic methods include catheter swabs, blood cultures and cultures of the catheter tip or port reservoir. In case of a suspected CVAD-related blood stream infection in pediatric cancer patients in situ treatment without prompt removal of the device can be tried. The removal of the CVAD should be considered, if bacteremia persists or relapses 72 hours or longer after the initiation of an (in vitro effective) antibacterial therapy administered through the line. The CVAD should be removed even earlier, if the patient suffers from hypotension or other signs of severe organ dysfunction related to the infection. If S. aureus, Pseudomonas aeruginosa, multiresistant Acinetobacter baumannii or Candida spp.are isolated from blood cultures taken through a CVAD, patients are at a high risk for severe complications and immediate device removal is also recommended. Duration of therapy depends on the immunological recovery of the patient (neutrophils counts), the pathogen isolated and on the presence of related complications like thrombosis, pneumonia, endocarditis, osteomyelitis. Antibiotic-lock techniques in addition to systemic treatment are beneficial in Gram-positive infections. Although prospectively controlled studies are missing, the concomitant use of urokinase- or taurolidine seems to favour catheter salvage.     

Transmission of mycobacterium tuberculosis to and from children and adolescents

Although adult-type pulmonary tuberculosis frequently arises from a long-dormant infection with Mycobacterium tuberculosis, children usually develop tuberculosis as a direct complication of the initial infection. Adults with pulmonary tuberculosis frequently are infectious, but children with typical primary tuberculosis—enlarged hilar or mediastinal lymph nodes with or without bronchial obstruction and subsequent atelectasis—rarely, if ever, transmit the organism to others. This article reviews the pathophysiology of pediatric tuberculosis and the published evidence concerning transmission of M tuberculosis to and from children and adolescents. Children with congenital tuberculosis or older children with the characteristics of adult-type tuberculosis should be considered potentially infectious. However, there is no evidence that children with primary-type tuberculosis infect other individuals. Recommendations are made concerning the handling of children with suspected tuberculosis and their family members in pediatric healthcare settings. Copyright © 2001 by W.B. Saunders Company     

Healthcare-associated infections in the hospitalized neonate: a review

Healthcare-associated infections in the neonatal intensive care unit add considerably to hospital stays and costs, and contribute to numerous adverse outcomes, including death. The relatively high prevalence of healthcare-associated infections among neonates is secondary to the newborn's underdeveloped immune system, the need for frequent invasive procedures, and generally prolonged hospitalization. Central line associated bloodstream infections (CLABSI) are the most common form of healthcare-associated infection, with coagulase-negative Staphylococcus species (CONS) being the most commonly cultured microorganism. Interpretation of culture results in the setting of any suspected healthcare-associated infection can be made difficult by the possibility that a recovered organism represents a commensal contaminant, rather than an actual cause of infection. This is especially true in the case of a blood culture that grows CONS during evaluation for suspected CLABSI. This article provides an overview of the epidemiology, diagnosis, prevention, and treatment of healthcare-associated infections in the NICU.     

The effects of intravenous epidermal growth factor on bacterial translocation and central venous catheter infection in the rat total parenteral nutrition model

 Sepsis is a major complication of total parenteral nutrition (TPN) in children. Gut mucosal atrophy (GMA) and bacterial translocation (BT) occur in patients receiving TPN, and the translocated enteric organisms may cause central venous catheter (CVC) infection. Epidermal growth factor (EGF) has a trophic effect on the gut mucosa and may reduce BT, thereby reducing catheter infection. Using a rat TPN model, the relationship between GMA, BT, and catheter sepsis was examined and the effect on these of intravenous EGF was studied. There were four experimental groups. Group 1 had no CVC, Groups 2, 3, and 4 had a continuous central venous infusion as follows: group 2, saline; group 3, TPN; group 4, TPN with EGF. Groups 1 and 2 had free access to chow, groups 3 and 4 had no enteral feeds. After killing at 1 week, blood, tissue, and catheter specimens were cultured and mucosal morphology analysed. BT was defined as the presence of the same organism in cultures from the gut lumen and mesenteric lymph nodes (MLN). TPN only (group 3) resulted in GMA and BT, and 5 of 12 animals with BT had the same gut bacteria in blood and/or catheter cultures. The addition of EGF to the TPN significantly reduced GMA, BT to the MLN, and blood and/or catheter infections (P =< 0.05). In animals carrying enterococci, there was a significant reduction in translocation of enterococci (group 3: 8/14; group 4: 0/11; P < 0.05) and catheter infection by enterococci was prevented (group 3: 3/14; group 4: 0/11). EGF thus reduced GMA, BT, and blood and/or catheter infection when given IV to rats receiving TPN. Enterococcal translocation and subsequent blood and/or catheter infection was completely prevented, suggesting a selective effect of EGF. Accepted: 13 December 1999     

Catheter-related infection in infants due to an unusual lipophilic yeast--Malassezia furfur

Malassezia furfur (Pityrosporum orbiculare, P ovale), a lipophilic yeast that is part of the normal skin flora, causes tinea versicolor but has only rarely been associated with more serious infections. We report five episodes in four infants of catheter-related infection caused by this organism. All episodes occurred in infants who had survived serious neonatal disorders and were receiving prolonged therapy with intravenous fat emulsion. Sudden onset of fever without focal findings was the usual presentation; however, one afebrile patient had recurrent episodes of apnea, bradycardia, and cyanosis. Thrombocytopenia was a prominent finding. Patients were generally treated with amphotericin B. All patients recovered when the colonized catheter was removed or fat emulsion therapy was stopped. The yeast usually grew slowly in blood culture media but grew readily when subcultured onto Sabouraud's medium coated with sterile olive oil. Yeasts were readily identified in all four patients in whom a buffy coat Gram stain was obtained of blood from the central intravenous catheter. M furfur may be a fairly common but unrecognized cause of catheter-related sepsis in infants receiving long-term fat emulsion therapy. This organism should be sought whenever routine blood cultures are negative for bacteria and yeasts are observed in a buffy coat Gram stain.     

Salvaging the infected central line: limited success of antibiotic therapy without line removal

When an indwelling central venous catheter (CVC) is the source of bacteremia in infants with long-term nutritional problems, CVC removal controls sepsis but a central venous access site is sacrificed. If transcatheter antibiotics could resterilize infected lines, then some of the precious CVCs could be salvaged. We reviewed the management and outcome of CVC line infections at the Children's Hospital of Philadelphia from July 1980 to September 1984. Bacteremia or fungemia occurred 55 times in 47 patients, aged 1 week to 16 years (median 3 mos), an overall rate of 8% for the study period. CVCs were in place 4 to 310 days (median 27 days) at the time of infection. Staphylococcus epidermidis was the most common organism isolated, followed by Candila albicans. CVC removal was the primary mode of controlling bacteremia in 32 patients. Generally, antibiotic coverage was added (21 patients), but removal alone without antibiotics appeared to be adequate therapy in 11 patients, including 5 with Candila fungemia. In 15 patients antibiotics were given, attempting to clear the line of infection. Persistent sepsis or positive repeat cultures led to removal of the CVCs in 9 of the 15 (60%). Line infection cleared on initial antibiotic therapy alone in 6 patients, allowing line salvage. However, bacteremia recurred in 3 and in each an organism different from the one causing the original infection was isolated. Sepsis cleared after the removal in 2, and one died of Candila superinfection during a second attempt at line sterilization. Two patients remained free from sepsis with CVC salvage with antibiotic therapy alone (13%). One patient died of peritonitis not related to catheter infection with the original CVC. Of the 47 patients, 8 received replacement CVCs and 1 received a third CVC. Five (55%) suffered another bout of line sepsis, often with organisms different from the one causing the original infection. CVC removal remains the most reliable means of managing line sepsis. Those receiving another CVC are at risk of infecting their new line, often with an organism different from the original one causing the first septic bout. Although theoretically desirable, sterilizing CVCs with transcatheter antibiotics alone has limited success.     

Early Eradication of Pseudomonas aeruginosa in Patients with Cystic Fibrosis

Pseudomonas aeruginosa (Pa) is the predominant organism infecting the airways of patients with cystic fibrosis (CF). This organism has an armamentarium of survival mechanisms that allows it to survive in the CF airway. Since colonization and chronic infection with Pa is associated with poorer lung function and increased morbidity and mortality, therapies that can prevent infection could significantly improve the lives of patients with CF. Numerous studies have examined the effects of treatment on the eradication of Pa as a means to ameliorate disease. This article outlines the pathophysiology and clinical implication of Pa acquisition, and reviews the existing treatment regimens aimed at early eradication of Pa in patients with CF.     

Central venous catheter tip position and malfunction in a paediatric oncology unit

An audit of 151 central venous catheters (CVCs) in 118 children with malignant disease was carried out over 20 months. The types included 31 valved silastic (Groshong), 58 non-valved silastic (Hickman), and 62 non-valved polyurethane (Cuff Cath) CVCs. There was no difference between the three groups with regard to the clinical diagnosis. The mean patient age at catheter insertion was 5.5 years and the mean weight 21.6 kg. None of the catheter types were associated with an increased risk of problems at insertion, migration, mechanical damage, blockage, sampling, or catheter infection. The incidence of catheter infection was 1.4/1,000 catheter days. Exit-site infection was less frequent with Groshong CVCs (P <0.05), which were in situ for the shortest period. The risk of problems with blood sampling was significantly increased in those catheters whose tip was sited outside the right atrium (P <0.005). For the 60 CVCs removed electively, the mean duration in situ was similar for all catheter types; 43 were removed following a problem. Of these, Groshong catheters were in situ for the shortest period (P = 0.05), probably as a result of delayed anchoring of the cuff. The tip position was the single most important determinant in the correct functioning of CVCs, irrespective of the type of catheter. Intraoperative screening of the tip position at catheter insertion is therefore mandatory for optimal catheter functioning.     

Complications of central venous access in children

Central venous access has become a frequent requirement in the management of seriously ill or injured infants and children with a wide variety of conditions. This report evaluates the complications observed with the use of central venous catheters in 1,378 cases. Central venous catheters (n = 2,281) were placed in 1,378 children (728 boys:650 girls). There were 1,012 temporary catheters (noncuffed/percutaneously placed) while 1,268 were inserted operatively, including 37 portacaths and 1,231 with dacron cuffs (Hickman, Broviac) for long-term use. A single catheter was inserted in 542 cases and multiple catheters in 836. Indications for catheter insertion included emergency resuscitation or access (501), malignancy (462), and intestinal dysfunction (415). Catheter infection occurred in 430 cases (18.8%). Of 219 infected temporary access catheters, 123 were removed while 96 were changed over a guide wire. Of 211 infected permanent catheters, 18 were immediately removed while 193 were treated with i.v. (vancomycin, gentamicin) antibiotics. Forty-seven of 193 (24%) catheters were eventually removed because of persistent or recurrent infection (16 cases) or subsequent fungal sepsis due to Candida albicans (31 cases). Only 3 of 37 portacaths were removed because of infection. Bacterial isolates were single in 125 cases and multiple in 86. Organisms included Staphylococcus epidermidis in 104 cases, Staph. aureus in 65, Klebsiella pneumoniae in 51, Escherichia coli in 51, and others in 18. Catheter complications occurred in 107 (5%) cases, including symptomatic vessel thrombosis in 49, pneumothorax in 26, catheter migration in 25, vessel injury in 5, and catheter embolus in 2. Despite the relatively high complication rate there were no catheter-related deaths. Multiple-lumen catheters had twice the complication rate and infection rate of single lumen catheters (P < 0.05). Temporary percutaneous catheters had a complication/infection rate 1.5 times greater than permanent catheters (P < 0.05) that were operatively placed. Bacterial infection cleared with antibiotics in 76% of cases with catheter sepsis, however secondary fungal infection necessitated prompt catheter removal. These data indicate that percutaneously placed catheters and multilumen catheters are associated with significantly higher complication and infection rates. Surgeons should balance the risks of convenience vs. complications in their choice of catheters and methods of insertion.     

Two cases of coxsackie B2 infection in neonates: Clinical,virological, and epidemiological aspects

Two cases of neonatal coxsackie virus B2 infection are described. One infant presented with meningitis and enteritis, the other with rhinitis, meningoencephalitis, and enteritis. Both infants made good recoveries. The virus infection could also be demonstrated in all nonimmune family members, most of whom gave a history of recent mild febrile disease (pharyngitis, diarrhea). Enterovirus infections may be suspected in cases of neonatal meningitis or myocarditis associated with gastrointestinal signs, especially 1. when it is during the hot season July-October, 2. when there has been febrile illness in other family members recently. For an effective and rapid isolation of the agent, rectal swabs or stool specimens not only from the patient, but also from household contactss should be sent to the virus laboratory on several consecutive days. Meningitic infection may be proved by anearly c.s.f. sample. For serodiagnosis a first blood specimen should be drawn as soon as possible, a second one some days later. The importance of rapid virological diagnosis and of stringent hygienic measures to prevent spread of the infection is stressed.     

Qualitative versus quantitative blood cultures in the diagnosis of catheter-related bloodstream infections in children with malignancy

BACKGROUND: Paired quantitative and qualitative blood cultures have been introduced for the diagnosis of catheter-related bloodstream infections (CRBI) with the catheter in situ. The aim of the study was to compare the diagnostic performance and the prognostic value of the two methods in the evaluation of febrile episodes without an apparent source in children with cancer. PROCEDURE: During a 4-year period, in every febrile episode without an apparent focus, blood was drawn simultaneously from the catheter lumen and a peripheral vein in order to perform paired quantitative (Isolator) as well as qualitative (BacT/Alert) blood cultures. The diagnosis of a CRBI was defined as either a case of greater (at least 10 fold) or earlier (differential time to positivity >2 h) bacterial growth from the catheter compared to the peripheral blood sample, respectively. RESULTS: Nineteen febrile episodes manifested in 16 children (total period of observation 11,150 catheter-days) were evaluated with both methods. A concordant diagnosis of CRBI was stated with both methods in six episodes; one episode was diagnosed as CRBI only with qualitative culture criteria. Treatment failure resulted in catheter removal in five out of the seven episodes defined as CRBI with either method. Episodes where a CRBI was ruled out with both methods had a favorable outcome. CONCLUSIONS: In this study the two methods showed comparable results in the diagnosis of CRBI and both were of prognostic significance, regarding the outcome of the treatment. However, large scale studies are required in order to evaluate the clinical relevance and the cost effectiveness of performing routinely paired blood cultures with either method.     

Study of Feasibility and Acceptability of Subcutaneous Implantable Ports (SIPs) in Cancer Patients

Objective

To assess the feasibility and complication rate associated with Subcutaneous Implantable Ports (SIPs) in pediatric cancer patients.

Methods

Ninety nine patients underwent chemo port insertion between January2003 to May 2011 with variety of neoplastic diseases. Data was collected with regards to underlying condition, duration the catheter was in situ and complications during insertion, accessing and removal. Chemoport was inserted either at diagnosis or once optimal conditions were achieved. Ports were placed in internal jugular vein (IJV) or subclavian vein (SCV) under general or local anesthesia under strict aseptic conditions in theatre.

Results

A total of 100 ports were placed in 99 patients. The mean duration of the implantable ports was 393?days (range 30?C1300). In 49 cases (49%), ports were removed electively, 15 cases (15%) died with port in situ and 36 cases (36%) still have port in situ and receiving chemotherapy without any complications. Complications observed were suspected infection (4%), port fracture (4%), thrombosis of catheter (1%) and blockage (1%).

Conclusions

The use of ports is safe and feasible in Pediatric Oncology patients if strict asepsis guidelines are followed.     

Central venous catheter infection by Aspergillus fumigatus in a patient with B-type non-Hodgkin lymphoma

Invasive Aspergillus infection is still a major problem in immunocompromised patients. A central venous catheter infection by Aspergillus fumigatus, however, has not yet been reported. We describe the case of a 10-year-old female patient with B-type non-Hodgkin lymphoma treated according to the German chemotherapy protocol NHI-BFM 90. Isolation of Aspergillus fumigatus from the blood was the first hint of invasive aspergillosis. A central venous catheter associated infection was suggested, since Aspergillus was also isolated from the thrombotic tip of the removed catheter. Secondary pulmonary aspergillosis was documented radiologically. The patient was treated successfully by Amphothericin B and Itraconazol and explantation of the central venous catheter under conditions of complete hematopoietic regeneration of the bone marrow with omission of the final chemotherapeutic cycle. © 1996 Wiley-Liss, Inc.     

A 1-year survey of catheter-related infections in a pediatric university hospital: A prospective study

BackgroundCentral venous catheters (CVCs) provide a great comfort for hospitalized children. However, CVCs increase the risk of severe infection. As there are few data regarding pediatric epidemiology of catheter-related infections (CRIs), the main objective of this study was to measure the incidence rate of CRIs in our pediatric university hospital. We also sought to characterize the CRIs and to identify risk factors.Materials and methodsWe conducted an epidemiological prospective monocentric study including all CVCs, except Port-a-Caths and arterial catheters, inserted in children from birth to 18 years of age between April 2015 and March 2016 in the pediatric University Hospital of Nantes. Our main focus was the incidence rate of CRIs, defined according to French guidelines, while distinguishing between bloodstream infections (CRBIs) and non-bloodstream infections (CRIWBs). The incidence rate was also described for each pediatric ward. We analyzed the association between infection and potential risk factors using univariate and multivariate analysis by Cox regression.ResultsWe included 793 CVCs with 60 CRBIs and four CRIWBs. The incidence rate was 4.6/1000 catheter-days, with the highest incidence rate occurring in the neonatal intensive care unit (13.7/1000 catheter-days). Coagulase-negative staphylococci were responsible for 77.5% of the CRIs. Factors independently associated with a higher risk of infection in neonates were invasive ventilation and low gestational age.ConclusionsThe incidence of CRIs in children hospitalized in our institution appears to be higher than the typical rate of CRIs reported in the literature. This was particularly true for neonates. These results should lead us to reinforce preventive measures and antibiotic stewardship but they also raise the difficulty of diagnosing with certainty CRIs in neonates.     

Duration of fever and markers of serious bacterial infection inyoung febrile children

BACKGROUND: Despite the drastic change in the evaluation of the febrile young child due to the decreased incidence of serious bacterial infections (SBI) effected by Haemophilus influenza type B and pneumococcal vaccine, there remains a small role for blood work in the evaluation of these patients. Bacterial markers including white blood cell (WBC) count, absolute neutrophil count (ANC) and C-reactive protein (CRP) have been studied and are widely used as predictors of SBI in febrile children. It has been suggested that CRP values should be interpreted cautiously when fever has been present <12 h based on the kinetics of this biological marker. This limitation has not been previously addressed with CRP, nor was it described with other markers, specifically WBC and ANC, therefore the purpose of the present paper was to assess WBC, ANC and CRP values as predictors of SBI in relation to duration of fever. METHODS: Patients who presented to a pediatric emergency department between the ages of 1 and 36 months, with fever > or =39 degrees C and no source of infection had a complete blood count (CBC) blood culture, and CRP level drawn. A urinalysis and/or urine culture was obtained when age and gender appropriate. A chest X-ray was performed at the discretion of the treating physician. The study subjects were enrolled prospectively and then divided into two groups based on duration of fever of < or = or >12 h, and compared. RESULTS: One hundred and twenty-eight patients were originally enrolled. Nine patients were excluded. Seventeen patients (14%) had SBI. One patient (<1%) had bacteremia, three (3%) had pneumonia, and 13 (10%) had urinary tract infections. Forty-five patients presented with fever < or =12 h and 74 patients presented with fever >12 h. Area under the curve (AUC) for WBC, ANC and CRP was significantly larger in patients with SBI presenting with fever >12 h (0.85, 0.83, 0.92 respectively) compared to patients with SBI who presented with fever for <12 h (0.37, 0.42, 0.68 respectively). CONCLUSIONS: Bacterial markers studied were more predictive of SBI if the duration of fever was >12 h as shown by the AUC. CRP performed better than WBC and ANC in both scenarios.     

More serious infectious morbidity and mortality associated with simultaneous candidemia and coagulase-negative staphylococcal bacteremia in neonates and in vitro adherence studies between Candida albicans and Staphylococcus epidermidis

BackgroundCandida species and coagulase-negative staphylococci (CoNS) are common etiologies of hospital acquired bloodstream infection in the neonatal intensive care unit (NICU). Sepsis with either organism may result in serious infectious sequelae and along with other staphylococci are the most common causes of abscess formation in preterm infants. This increased incidence of abscess formation may be in part due to adherence factors of both pathogens.MethodsAll cases of concurrent positive blood cultures for both Candida species and CoNS were identified from the microbiology database in NICU patients from January 1998 to December 2000 and analyzed for risk factors and outcomes. In vitro co-aggregation studies between Candida albicans and Staphylococcus epidermidis were also performed.ResultsSix premature infants were identified as having concurrent Candida and CoNS bloodstream infections during this time period. Four of the six patients developed end-organ dissemination with abscess or infected thrombus formation. Three of the six patients expired during or after their infection. In vitro, co-aggregation studies did not demonstrate reproducible direct adherence between C. albicans and S. epidermidis.ConclusionsSimultaneous bloodstream infection with Candida and CoNS, compared to either one alone, is more likely to predispose to abscess formation, septic thrombophlebitis and mortality. Further studies are needed to examine the pathogenesis of these complex infections.     

Diagnosis of catheter-related bloodstream infection in neonates: a study on the value of differential time to positivity of paired blood cultures.

OBJECTIVE: Diagnosis of neonatal catheter-related bloodstream infection (CRBSI) is currently based on isolation of identical bacterial species from bloodstream and catheter tip cultures. This requires removal of the catheter followed by the insertion of a new catheter. The objective of this study was to investigate whether differential time to positivity (DTP) of blood cultures drawn from paired peripheral vein and central vascular catheter is useful for diagnosing neonatal CRBSI, avoiding removal of the catheter. DESIGN: Retrospective observational study. SETTING: Neonatal intensive care unit, University Hospital of Antwerp, Belgium. PATIENTS: Neonates with probable and definite nosocomial bloodstream infection. INTERVENTIONS: All episodes of nosocomial bloodstream infection (NBSI) in an approximately 7.5-yr period were identified retrospectively. Definite NBSI episodes in which paired blood cultures were obtained were retained to calculate DTP, to determine the optimal DTP cutoff for the diagnosis of CRBSI, and to assess the validity of DTP for the diagnosis of CRBSI. MEASUREMENTS AND MAIN RESULTS: Of 32 NBSI episodes included in the study, 16 were CRBSI, seven were non-CRBSI, and nine were classified as "diagnosis uncertain." In CRBSI, blood cultures drawn from a central vascular catheter were positive earlier than those drawn from a peripheral vein (median 9.67 hrs vs. 21.58 hrs, p < .01). Median DTP was 10.42 hrs in CRBSI and -0.33 hrs in non-CRBSI (p = .01). The optimal DTP cutoff for the diagnosis of CRBSI was > or =1 hr (area under the receiver operating characteristic curve = 0.84 +/- 0.11), with a sensitivity of 94%, a specificity of 71%, a positive predictive value of 88%, and a negative predictive value of 83%. CONCLUSIONS: Differential time to positivity of paired blood cultures may have some potential in the diagnosis of catheter-related infections in neonatal intensive care unit patients and should be subjected to a prospective study.     

How Many Sources Should Be Cultured for the Diagnosis of a Blood Stream Infection in Children with Cancer?

Blood stream infection (BSI) in a child with cancer is a life-threatening condition while blood cultures (BCs) play a crucial role for the diagnosis. The current practice of obtaining a BC from all sources—peripheral vein, central venous catheter (CVC), all lumens—is controversial and therefore in this study, our aim was to evaluate the utility of obtaining BCs from all these available sources. A retrospective study of BC sets obtained from all newly diagnosed patients with malignancy was conducted. A total number of 633 BC sets from 123 boys and 88 girls (median age: 5 5/12 years) were evaluated during infection episodes from January 1, 2005, to August 31, 2010. Among these cases, 134 were classified as true BSI (21%), 468 as non-BSI, and 31 as false-positive. In 64 cases, the results from peripheral and CVC sources were discordant: 57 catheter positive–peripheral negative and seven catheter negative–peripheral positive. Consequently, seven out of 134 true BSIs (5.2%) would not have been identified if only a BC from a CVC had been obtained. Moreover, if no BCs from all lumens had been obtained we would have missed up to 25% of true-positive BSIs. In the same way, if BCs from all sources had not been drawn we would not have detected up to 52% of true-positive BSIs. Conclusion: Obtaining BCs during an infection episode from all sources in a child with cancer is still mandatory.