Total parenteral nutrition catheter sepsis: impact of the team approach

For a period of 32 months from the inception of the Parenteral and Enteral Nutrition (PEN) Team at the University of Michigan, the infection rate (IR) related to central venous catheters (CVCs) for total parenteral nutrition (TPN) was prospectively evaluated. Six hundred twenty-two catheters were placed in 377 patients for a total of 9,200 patient days. The length of CVC stay ranged from 2 to 108 days with a mean of 14.5. CVC longevity was longer on units where certification of nurses by the PEN team was mandatory (mean 20.4 days, IR 3.5%) vs comparable units which utilized informal instruction (mean 14.4 days, IR 3.5%). Twenty-two catheters led to patient sepsis for a rate of 3.5%, or 2.39 CVC-related infections per 1000 patient days. The preteam infection rate was 24.0%, as determined by a 6-month prospective study. Infection rates for CVCs used for TPN only and those used for parenteral nutrition (PN) plus blood products, antibiotics, and CVP measurements were identical, 3.5%. The team approach can effectively increase PN catheter longevity and reduce infection rates. Conservative cost accounting of best and worst case scenarios determined a range of $3,700 to $8,900 per episode of catheter sepsis.     

Catheter‐Related Complications in Children With Cancer Receiving Parenteral Nutrition: Change in Risk Is Moderated by Catheter Type

Background: Although central venous catheters (CVCs) are essential to pediatric cancer care, complications are common (eg, occlusion, central line–associated bloodstream infection [CLABSI]). Parenteral nutrition (PN) and external CVCs are associated with an increased complication risk, but their interaction is unknown. Methods: A retrospective matched cohort study of pediatric oncology patients who received PN through subcutaneous ports or external CVCs. Complication rates were compared between CVC types during PN and non‐PN periods (log‐negative binomial model). Results: Risk of CLABSI was higher during PN for children with ports (relative risk [RR] = 39.6; 95% confidence interval, 5.0–309) or external CVCs (RR = 2.9; 95% confidence interval, 1.1–7.4). This increased risk during PN was greater for ports than for external CVCs (ratio of relative risks = 13.6). Occlusion risk was higher during PN in both groups (RR = 10.0 for ports; RR = 2.0 for external CVCs), and the increase was significantly greater in ports (ratio of relative risks, 4.9). Overall, complication rates for ports were much lower than for external CVCs during the non‐PN period but similar during the PN period. Conclusion: Children with cancer who receive PN have increased risk of CLABSI and occlusion. The risk increase is greatest in children with ports: a 40‐ and 10‐fold increase in infection risk and occlusion, respectively, resulting in similar complication rates during PN regardless of CVC type and negating the usual benefits of ports. Children with cancer who will require PN should have primary insertion of external CVCs where possible.     

Preventing catheter-associated bloodstream infections: a survey of policies for insertion and care of central venous catheters from hospitals in the prevention epicenter program.

OBJECTIVE: To determine the extent to which evidence-based practices for the prevention of central venous catheter (CVC)-associated bloodstream infections are incorporated into the policies and practices of academic intensive care units (ICUs) in the United States and to determine variations in the policies on CVC insertion, use, and care. DESIGN: A 9-page written survey of practices and policies for nontunneled CVC insertion and care. SETTING: ICUs in 10 academic tertiary-care hospitals. PARTICIPANTS: ICU medical directors and nurse managers. RESULTS: Twenty-five ICUs were surveyed (1-6 ICUs per hospital). In 80% of the units, 5 separate groups of clinicians inserted 24%-50% of all nontunneled CVCs. In 56% of the units, placement of more than two-thirds of nontunneled CVCs was performed in a single location in the hospital. Twenty units (80%) had written policies for CVC insertion. Twenty-eight percent of units had a policy requiring maximal sterile-barrier precautions when CVCs were placed, and 52% of the units had formal educational programs with regard to CVC insertion. Eighty percent of the units had a policy requiring staff to perform hand hygiene before inserting CVCs, but only 36% and 60% of the units required hand hygiene before accessing a CVC and treating the exit site, respectively. CONCLUSION: ICU policy regarding the insertion and care of CVCs varies considerably from hospital to hospital. ICUs may be able to improve patient outcome if evidence-based guidelines for CVC insertion and care are implemented.     

Prevalence of the use of central venous access devices within and outside of the intensive care unit: results of a survey among hospitals in the prevention epicenter program of the Centers for Disease Control and Prevention.

OBJECTIVE: To determine the prevalence of central venous catheter (CVC) use among patients both within and outside the ICU setting. DESIGN: A 1-day prevalence survey of CVC use among adult inpatients at six medical centers participating in the Prevention Epicenter Program of the CDC. Using a standardized form, observers at each Epicenter performed a hospital-wide survey, collecting data on CVC use. SETTING: Inpatient wards and ICUs of six large urban teaching hospitals. RESULTS: At the six medical centers, 2,459 patients were surveyed; 29% had CVCs. Among the hospitals, from 43% to 80% (mean, 59.3%) of ICU patients and from 7% to 39% (mean, 23.7%) of non-ICU patients had CVCs. Despite the lower rate of CVC use on non-ICU wards, the actual number of CVCs outside the ICUs exceeded that of the ICUs. Most catheters were inserted in the subclavian (55%) or jugular (22%) site, with femoral (6%) and peripheral (15%) sites less commonly used. The jugular (33.0% vs 16.6%; P < .001) and femoral (13.8% vs 2.7%; P < .001) sites were more frequently used in ICU patients, whereas peripherally inserted (19.9% vs 5.9%; P < .001) and subclavian (60.7% vs 47.3%; P < .001) catheters were more commonly used in non-ICU patients. CONCLUSIONS: Current surveillance and infection control efforts to reduce morbidity and mortality associated with bloodstream infections concentrate on the high-risk ICU patients with CVCs. Our survey demonstrated that two-thirds of identified CVCs were not in ICU patients and suggests that more efforts should be directed to patients with CVCs who are outside the ICU.     

Scheduled replacement of central venous catheters is not necessary.

Although half of intensivists routinely replace their central venous catheters (CVCs), this practice is not supported by data from randomized control studies or by pathophysiology of CVC infection. The daily risk of CVC infection is considered to be a constant; the risk of catheter infection is directly related to the duration of catheter insertion. Consequently, the routine change of the catheter is able to decrease the number of infections per catheter but not to modify the number of infections per day of catheter insertion. This assertion is supported by evidence-based medicine: scheduled replacement every 3 or 7 days has not been shown to alter the infectious risks of CVCs in randomized studies or a meta-analysis. Moreover, routine replacement at a new site exposes the patient to an increased risk of mechanical complications. The overall rate of mechanical complications per catheter inserted is approximately 3%. Guidewire exchange of the catheters may reduce the risk of mechanical complications, but unfortunately is associated with a higher rate of catheter colonization and catheter-related bacteremia. Routine replacement of CVCs is not necessary.     

Blood Culture as a Guide for the Diagnosis of Central Venous Catheter Sepsis

The purpose of this study was to evaluate the predictability of peripheral (PBC) and central blood cultures (CBC) in the diagnosis of central venous catheter (CVC) sepsis (growth of the same microorganism in the peripheral blood and on the catheter tip). The contamination and sepsis rate of 256 CVCs and the relationship with PBC and CBC was evaluated in a series of cancer patients included in a prospective protocol on CVC infections at the Istituto Nazionale Tumori of Milan. Overall CVC contamination was 10.5% and sepsis rate was 3.1%. The positive predictive value for CVC sepsis was 46.7% for positive PBC + CBC, 38.1% for positive PBC and 16.6% for positive CBC. The small gain in the predictive positive value obtained with the use of PBC and CBC and the slight increase in the specificity does not justify, in our opinion, the use of both these parameters for the diagnosis of CVC sepsis. (Journal of Parenteral and Enteral Nutrition 8 :396–398, 1984)     

Central Venous Catheter Salvage in Home Parenteral Nutrition Catheter‐Related Bloodstream Infections

Background: Catheter‐related bloodstream infections (CRBSIs) are a serious complication in the provision of home parenteral nutrition (HPN). Antibiotic salvage of central venous catheters (CVCs) in CRBSI is recommended; however, this is based on limited reports. We assessed the efficacy of antibiotic salvage of CRBSIs in HPN patients. Materials and Methods: All confirmed CRBSIs occurring in patients receiving HPN in a national intestinal failure unit (IFU), between 1993 and 2011, were analyzed. A standardized protocol involving antibiotic and urokinase CVC locks and systemic antibiotics was used. Results: In total, 588 patients were identified with a total of 2134 HPN years, and 297 CRBSIs occurred in 137 patients (65 single and 72 multiple CRBSIs). The overall rate of CRBSI in all patients was 0.38 per 1000 catheter days. Most (87.9%) infections were attributable to a single microorganism. In total, 72.5% (180/248) of CRBSIs were salvaged when attempted (coagulase‐negative staphylococcus, 79.8% [103/129], Staphylococcus aureus, 56.7% [17/30]; polymicrobial infections, 67.7% [21/30]; and miscellaneous, 66.1% [39/59]). CVC salvage was not attempted in 49 episodes because of life‐threatening sepsis (n = 18), fungal infection (n = 7), catheter problems (n = 20), and CVC tunnel infection (n = 4). Overall, the CVC was removed in 33.7% (100/297) of cases. There were 5 deaths in patients admitted to the IFU for management of the CRBSI (2 severe sepsis at presentation, 3 metastatic infection). Conclusions: This is the largest reported series of catheter salvage in CRBSIs and demonstrates successful catheter salvage in most cases when using a standardized protocol.     

Octenidine hydrochloride for the care of central venous catheter insertion sites in severely immunocompromised patients.

OBJECTIVE: To determine the efficacy and tolerability of octenidine hydrochloride, a non-alcoholic skin antiseptic, for the care of central venous catheter (CVC) insertion sites. DESIGN: Prospective, observational study. SETTING: Bone marrow transplantation unit of a university hospital. PATIENTS: All consecutive patients with a nontunneled CVC were enrolled prospectively after informed consent. METHODS: Octenidine hydrochloride (0.1%) was applied for disinfection at the CVC insertion site during dressing changes. The following cultures were performed weekly as well as at the occurrence of any systemic inflammatory response syndrome criteria: cultures of the skin surrounding the CVC entry site, cultures of the three-way hub connected to the CVC, blood cultures, and cultures of the CVC tip on removal. Enhanced microbiological methods (skin swabs of a 24-cm2 standardized area, roll plate, and sonication of catheter tips) were applied. RESULTS: One hundred thirty-five CVCs were inserted in 62 patients during the study period and remained for a mean period of 19.1 days, corresponding to 2,462 catheter-days. Bacterial density at the insertion site declined substantially over time, and most cultures became negative 2 weeks after insertion. Only 6 patients had a documented catheter-related bloodstream infection. The incidence density was 2.39 catheter infections per 1,000 catheter-days. No side effects were noted with application of the antiseptic. CONCLUSIONS: Disinfection with a skin antiseptic that contains octenidine hydrochloride is highly active and well tolerated. It leads to a decrease in skin colonization over time and may be a new option for CVC care.     

ω-3 Fatty-Acid Enriched Parenteral Nutrition in Hospitalized Patients: Systematic Review With Meta-Analysis and Trial Sequential Analysis

This systematic review and meta-analysis investigated ω-3 fatty-acid enriched parenteral nutrition (PN) vs standard (non-ω-3 fatty-acid enriched) PN in adult hospitalized patients (PROSPERO 2018 CRD42018110179). We included 49 randomized controlled trials (RCTs) with intervention and control groups given ω-3 fatty acids and standard lipid emulsions, respectively, as part of PN covering ≥70% energy provision. The relative risk (RR) of infection (primary outcome; 24 RCTs) was 40% lower with ω-3 fatty-acid enriched PN than standard PN (RR 0.60, 95% confidence interval [CI] 0.49-0.72; P < 0.00001). Patients given ω-3 fatty-acid enriched PN had reduced mean length of intensive care unit (ICU) stay (10 RCTs; 1.95 days, 95% CI 0.42-3.49; P = 0.01) and reduced length of hospital stay (26 RCTs; 2.14 days, 95% CI 1.36-2.93; P < 0.00001). Risk of sepsis (9 RCTs) was reduced by 56% in those given ω-3 fatty-acid enriched PN (RR 0.44, 95% CI 0.28-0.70; P = 0.0004). Mortality rate (co-primary outcome; 20 RCTs) showed a nonsignificant 16% reduction (RR 0.84, 95% CI 0.65-1.07; P = 0.15) for the ω-3 fatty-acid enriched group. In summary, ω-3 fatty-acid enriched PN is beneficial, reducing risk of infection and sepsis by 40% and 56%, respectively, and length of both ICU and hospital stay by about 2 days. Provision of ω-3-enriched lipid emulsions should be preferred over standard lipid emulsions in patients with an indication for PN.     

Impact of central venous catheter type and methods on catheter-related colonization and bacteraemia

A prospective, randomized, controlled, multi-centre clinical trial was performed to test the effectiveness of an antimicrobial central venous catheter (CVC) made of polyurethane integrated with silver, platinum and carbon black (Vantex). Adults expected to require a CVC for more than 60 h were eligible, and were randomized to receive the test or control catheter. All CVCs were inserted with new venipunctures using full aseptic technique. Following catheter removal, the distal tip and an intracutaneous segment were removed and cultured using semiquantitative and quantitative methods. Peripheral blood samples were obtained and cultured to confirm cases of catheter-related bloodstream infection (CRBSI). Bacterial and fungal organisms were identified by standard microbiological methods. Catheter placement was performed primarily in the intensive care unit (50%) or operating theatre (42%). Complete data could be evaluated for 539 patients (77%). The mean duration of CVC placement was 149.3h (six days). There were no significant differences in colonization or bacteraemia rates between the test and control catheters. The overall colonization rate was not particularly low (24.5%), and yet CVC-related bacteraemia occurred in only 1.4% of patients, and CRBSI occurred in only one patient from the control group (0.2%). Insertion site and dressing change frequency were significantly associated with the colonization rate. Although CVCs with antimicrobial features have been associated with a decrease in catheter-related colonization and bacteraemia, this study demonstrated that infection rates may depend more on non-catheter-related factors, such as adherence to infection control standards, selection of insertion site, duration of CVC placement, and dressing change frequency. As microbial resistance increases, clinicians should make maximal use of these processes to reduce catheter-related infections.     

Hospital infection prevention in an intensive care unit

Aim of the study was to evaluate the efficacy of the hospital infection preventive procedures adopted in the intensive care unit (ICU) of the "S. Camillo-Forlanini" hospital in Rome. First the following prevention protocols were analysed: invasive procedures (intubation, CVC and urinary catheter), surveillance cultures, infection management and antimicrobial prophylaxis. Comparison with international guidelines was carried out and protocols enforcement by the personnel was verified. Secondly a one year longitudinal surveillance study was performed in order to monitor the following site-specific infection rates: pneumonia (PNE), blood stream infections (BSI), urinary tract infections (UTI), surgical site infections (SSI). According to CDC definitions all patients developing infection 48 hours or more after ward admission were included. Furthermore risk factors (i.e. age, sex, SAPS II), invasive procedures (i.e. endotracheal intubation, vascular and urinary catheterisation), microbiological isolates and their antibiotic susceptibility were screened. Overall 302 patients (191 men and 111 women) were admitted; age 55.1 +/- 20.7 years (mean), SAPS II 42.4 +/- 16.2 (mean) and average ward stay 12.5 +/- 21.7 days. Crude mortality was 15.9%. Results showed a total of 37 infection episodes (20 PNE , 7 BSI, 8 UTI and 2 SSI) in 33 patients (10.9%). Infection and mortality rates were among the lowest registered in other italian ICU's. Standardized infection rates associated to invasive procedures were: Ventilator-associated PNE rate (7.8/1000), central venous catheter-associated BSI rate (2.2/1000), urinary catheter-associated UTI rate (2.1/1000). The first (PNE) was higher than the NNIS mean rate, whwreas BSI and urinary catheter associated rates were minor than the mean rates reported by NNIS. Gram-negatives were 61.7%, gram-positives 27.6% and Candida spp. 10.6%. The results confirm the ICU successful preventive strategy.     

Catheter related sepsis during long-term parenteral nutrition in paediatric gastroenterology patients: a study of 185 consecutive central venous catheters

We report the results of a prospective study of catheter-related sepsis (CRS) in 154 gastroenterology paediatric patients treated for medical (n = 102) or surgical (n = 52) disorders. Over 2 years, 185 central venous catheters (CVC) were placed, including 155 Broviac and 30 Jonathan Shaw CVC. CVC remained in place 13,331 days (6,539 days of cyclic parenteral nutrition), with a mean catheter life of 72 days. Forty-eight episodes of CRS occurred, most of them due to coagulase-negative staphylococci (n = 29) and Staphylococcus aureus (n = 17). CRS rate was 0.26, with an overall incidence of 1 infection per 278 days of parenteral nutrition (PN). Factors significantly associated with CRS were: age 1-5 years (p < 0.01), a medical indication for treatment (p < 0.001) and summer months of PN (p < 0.01). Interestingly, CRS occurred predominantly (65%) within the first 2 months following CVC placement and the risk of infection correlated with local haemorrhage at the time of insertion (p < 0.01). Appropriate systemic therapy, without removing the catheter, permitted resolution of 90.9% (40 44 ) of all CRS and 100% (28 28 ) of CRS due to coagulase-negative staphylococci.     

Cuff Cath: an initial experience of cuffed polyurethane central venous catheters in children.

The tendency of medium- and long-term silicone central venous catheters (CVCs) to block, fracture, and become displaced has led to the evaluation of a polyurethane CVC, Cuff Cath (Viggo Spectramed, Swindon, Wilts, United Kingdom) as a possible alternative because polyurethane is smoother and stronger. We report the first prospective study of polyurethane cuffed CVCs in children. Sixty Cuff Caths were placed in 53 children, mean age 4.7 years (range, 4 days to 16.3 years), mean weight 15.6 kg (range, 3.1 to 58 kg). All CVCs were tunnelled (mean tunnel length, 12 cm; range, 5 to 20 cm) and inserted either into the subclavian vein (n = 28) or internal jugular vein (n = 32). In a total of 6363 catheter days (mean, 111 days per patient; range, 15 to 364 days), three (5%) CVCs had to be removed because of sepsis and one (2%) because of blockage. All other Cuff Caths remained patent to infusion and blood sampling. No Cuff Caths were pulled or fell out, fractured, or migrated. This study demonstrates significant advantages of polyurethane compared with previous series using silicone CVCs with respect to blockage, fragmentation, and dislodgement. A prospective, randomized, controlled trial of Cuff Cath compared with a silicone CVCs in children is required.     

Morbidity associated with central venous catheter-use in a cohort of 212 hospitalized subjects with HIV infection

Technical complications and nosocomial bloodstream infections associated with short-term central venous catheterization remain a heavy burden in terms of morbidity, mortality and cost in HIV-positive subjects. Between 1994 and 1997, 327 central venous catheters (CVCs) inserted in 212 patients for a total of 5005 catheter days were investigated. Forty-two technical complications (13%) occurred in 40 patients. Logistic regression analysis revealed that a high APACHE III score was associated with development of CVC-related complications (P = 0.01). One hundred and eight of 327 CVCs (33%) were suspected as being infected. However only 61 episodes (61/327, 19%) were finally diagnosed as CVC-related sepsis. Three variables affecting the rate of CVC-related sepsis were identified: 1) administration of TPN (P = 0.01); 2) low number of circulating CD4+ cells (P = 0.04); 3) high APACHE III score (P = 0. 04). Doctors responsible for AIDS patients should carefully consider the relative risks and benefits of CVC insertion in an individual patient.     

Surveillance of nosocomial infections in geriatric patients

Prospective surveillance of hospital-acquired infections was undertaken in the geriatric ward of the University Hospital, Utrecht, the Netherlands. The medical records of 300 patients were studied for the presence of nosocomial infections using the criteria defined by the Centers for Disease Control (CDC), Atlanta, Georgia, USA. Data were collected from patients with and without infection, which allowed for the analysis of risk factors for nosocomial infection. In 100 out of 300 patients (33·3%), a total of 126 infections was diagnosed. The incidence of nosocomial infections was 16·9 per 1000 days of stay in the hospital. The mean length of stay of patients with infection was 39 days, while that of patients without infection was 17·8 days. Infections developed after an average stay of 13·3 days in the hospital. Patients with infections were 2·6 years older than patients without infections (P = 0·005). Dehydration was shown to be a major risk factor for infection (RR = 2·1, 95% CI: 1·4–3·2). Of the infections, 58·7% were urinary tract infections (UTIs, asymptomatic and symptomatic). The most important risk factor for an asymptomatic UTI was an indwelling urinary catheter (RR = 7·3, 95% CI: 3·1–17·1). The duration of use of the indwelling urinary catheter was of significant influence in the development of a UTI. Seventy percent of the patients with an asymptomatic UTI were treated with anti-biotics. Infections of the gastrointestinal tract accounted for 19·8% of all nosocomial infections. The majority of these infections were due to an outbreak of Clostridium difficile. In conclusion, the length of stay may be prolonged by a nosocomial infection. In this study, the main risk factors for developing a nosocomial infection were age, dehydration and the presence of an urinary catheter. Our observations showed that age is a predisposing factor for nosocomial infection and that the risk increases with each year, even for geriatric patients.     

Outbreak of Mycobacterium mucogenicum bacteraemia due to contaminated water supply in a paediatric haematology-oncology department

We describe an outbreak of bloodstream infections due to Mycobacterium mucogenicum involving five patients in a paediatric haematology-oncology ward over a six-month period. Specimens from faucets on the floor indicated that an automatic faucet was the probable source of infection and identity between strains was confirmed using molecular techniques. Levels of chlorine in the water were intermittently low and may have contributed towards bacterial growth. A review of infection control practices revealed that the exit sites of central venous catheters (CVCs) of children were not properly covered during bathing, which may have facilitated CVC colonisation. Replacing the contaminated faucets, optimal water chlorination and proper coverage of the CVC exit site using impermeable dressings terminated the outbreak. This investigation emphasises the three major factors that should be investigated in outbreaks due to a waterborne pathogen: source of the infection, water supply and infection control practices.     

Surveillance of infections acquired in intensive care: usefulness in clinical practice

Nosocomial infection surveillance is common in the USA and in some European countries but in Italy few hospitals use it. In order to evaluate its usefulness in clinical practice we performed a one year prospective epidemiological study that included 178 patients, admitted to an intensive care unit (ICU) for more than 48 h. Median ICU stay was 16 days. Trauma and neurological diseases accounted for 65% of admissions. The selected population had high severity scores and required a large number of invasive procedures for diagnosis and therapy. The most common infections were: pneumonia 46/1000 ventilator-days; urinary tract infections 17/1000 catheter-days; central venous catheter infections 14.5/1000 catheter-days with 1.7/1000 CVC-related sepsis; bacteraemic sepsis 12/1000 ICU-days. The most frequent pathogens were Staphylococcus aureus,Pseudomonas aeruginosa, other Gram-negative aerobes and Candida spp. Antimicrobial resistance was substantial, with 68% methicillin-resistance in S. aureus and 76% of P. aeruginosa displaying antibiotic resistance. Severe sepsis or septic shock occurred in 30 patients (8/1000 ICU-days), and three patients died from septic shock of unknown origin (10% case fatality rate). There were no case fatalities for pneumonia and bacteraemic sepsis. Overall, ICU-acquired infections were not associated with an increased risk of death.     

Outcomes of nosocomial bloodstream infections in adult neutropenic patients: a prospective cohort and matched case-control study.

OBJECTIVE: To examine the clinical and epidemiologic features, excess length of stay, extra costs, and mortality attributable to bloodstream infection (BSI) in neutropenic patients with hematologic malignancies. DESIGN: Prospective cohort and matched case-control study. PATIENTS: All adult neutropenic patients with hematologic malignancies admitted to Cologne University Hospital between May 1, 1997, and April 30, 1998, were prospectively observed. Case-patients were defined as patients with nosocomial BSI; control-patients were selected among patients without BSI. RESULTS: During the study period, the BSI rate in neutropenic patients was 14.3 per 100 neutropenic episodes. Eighty-four case-patients were included. Matching was successful for 96% of the cohort; 81 matched pairs were studied. The mean total length of stay was significantly longer for patients with BSI than for control-patients (37 vs 29 days; P = .002). Extra costs attributable to the infection averaged 3,200 dollars (U.S.) per patient. The crude mortality rates of case-patients and control-patients were 16% and 4%, respectively (P = .013), with an attributable mortality of 12% (odds ratio, 11). Eighty-seven percent of patients met the criteria for sepsis according to the American College of Chest Physicians/Society of Critical Care Medicine. Severe sepsis or septic shock occurred in 13% of patients and was correlated with mortality (55% vs 10% in patients without severe sepsis or septic shock; P = .01). CONCLUSIONS: Nosocomial BSI in neutropenic patients is significantly associated with an excess length of hospital stay, extra costs, and excess mortality. Severe sepsis and septic shock are closely correlated with an adverse outcome.     

An outbreak of bloodstream infections in an outpatient hemodialysis center.

OBJECTIVES: Investigate and control an increase in bloodstream infections (BSIs) in an outpatient hemodialysis center. PATIENTS AND DESIGN: A retrospective cohort study was conducted for patients receiving dialysis at the center from February 2000 to April 2001. A case-control study compared microbiological data for all BSIs that occurred during the study period with those for BSIs that occurred during a baseline period January 1999 to January 2000). BSI rates before and after a 1-month intervention (May 2001) were assessed. A case was defined as a new BSI during the study period. RESULTS: The outbreak was polymicrobial, with approximately 30 species. The baseline BSI rate was 0.7 per 100 patient-months. From February 2000 to April 2001, the BSI rate increased to 4.2 per 100 patient-months. Overall, 75% of the BSIs were associated with central venous catheters (CVCs), but CVC use did not fully explain the increase in BSIs. In January 2000, when the center changed ownership, prepackaged CVC dressing kits and biweekly infection control monitoring were discontinued. Beginning in May 2001, staff were educated on CVC care, chlorhexidine replaced povidone-iodine for cutaneous antisepsis, gauze replaced transparent dressings, antimicrobial ointments containing polyethylene glycol at CVC exit sites were discontinued, and patients with CVCs were educated on cutaneous hygiene. After the intervention period, by October 2001, rates decreased to less than 1 BSI per 100 patient-months. CONCLUSIONS: Proper cutaneous antisepsis and access site care is crucial in preventing BSIs in patients receiving hemodialysis. Infection control programs, staff and patient education, and use of optimal antisepsis agents or prepackaged kits are useful toward this end.     

Catheter-related infection in patients on home parenteral nutrition: results of a prospective survey

BACKGROUND & AIMS: Central venous catheter (CVC) infection is the most frequent complication during home parenteral nutrition (HPN). We prospectively assessed incidence and catheter-related sepsis (CRS)-associated factors in the 42 adult patients enrolled in our HPN centre since its opening. METHODS: Age, frequency of infusions, CVC type, autonomy or nurse/family aid, underlying disease, involved infectious organism(s), hospital stay, efficacy of antibiotic-lock and other infectious complications, were studied. RESULTS: CRS occurred 39 times (3/1000 days of HPN). In 37/39 cases, it was proven by both peripheral and central blood cultures. In 56% of patients, clinical signs were discrete, delaying diagnosis. Individual factors like learning potency, underlying disease (especially chronic intestinal obstruction with bacterial overgrowth), and length of remaining colon and small intestine, were slightly associated with higher CRS incidence. Usually, one organism (S. epidermidis; 51%) was detected. A total of 14 CVC were immediately removed. In the others, antibiotic-lock was more effective in patients having tunnelled catheters (TC, 50%) than implanted devices (25%; P<0.05). Mean hospital stay was 22+/-15 days, which was influenced by 3 patients presenting associated osteomyelitis. CONCLUSIONS: CRS incidence was 3/1000 days of HPN. Clinical symptoms were often discrete, suggesting importance of rigorous survey. Individual apprenticeship and risk for higher bacterial translocation seem associated to higher CRS incidence. CVC sterilization was more frequent in patients with TC.