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Background Nosocomial bloodstream infections associated with intravascular catheters pose significant financial burden, morbidity, and mortality. There is much debate about whether or not blood cultures should be drawn through central venous catheters, and while guidelines advocate for catheter-drawn cultures when catheter infection is suspected, there is variable practice in this regard. Methods We performed a retrospective cohort study assessing episodes of positive catheter-drawn blood cultures with concomitant negative percutaneously-drawn cultures in tertiary care hospitals in the United States and Spain. Results We identified 143 episodes in 122 patients meeting inclusion criteria. Thirty percent of such episodes revealed growth of potential pathogens such as Staphylococcus aureus. Overall, 21% of follow-up percutaneously-drawn blood cultures obtained within 48 hours revealed growth of the same microbe after an episode of positive catheter-drawn blood cultures with negative concomitant percutaneously-drawn cultures (33% when potential pathogens were isolated; 16% when common skin contaminants were isolated). Patients with cultures growing pathogenic organisms were more likely to receive targeted antimicrobial therapy and have their catheters removed sooner. Conclusions Many episodes of positive catheter-drawn blood cultures with concomitant negative percutaneously-drawn cultures lead to growth from percutaneously-drawn follow-up blood cultures. Thus, such initial discordant results should not be disregarded. Our findings advocate for a nuanced approach to blood culture interpretation, emphasizing the value of catheter-drawn blood cultures in clinical decision making and management. [ABSTRACT FROM AUTHOR]

Home parenteral nutrition (HPN) is increasingly prescribed for patients with advanced cancer. This therapy improves free-fat mass, quality of life and survival, but it is not free from complications, especially catheter-related bloodstream infections (CRBSIs). The use of commercial multichamber bags in HPN has not been extensively explored in oncologic patients and their association with complications is not well known. In this prospective cohort study, we included 130 patients with advanced cancer and HPN. We compared the effects of individual compounded bags (n = 87) vs. commercial multichamber bags (n = 43) on complications. There were no differences in any complication, including thrombosis (p > 0.05). There were 0.28 episodes of CRBSI per 1000 catheter days in the individual compounded bag group and 0.21 in the multichamber bag group (p > 0.05). A total of 34 patients were weaned off HPN, 22 with individual bags and 12 with multichamber bags (p = 0.749). Regarding survival when on HPN, the group with individual bags showed a median of 98 days (95% CI of 49–147), whereas those with multichamber bags showed a median of 88 days (95% CI of 43–133 (p = 0.913)). In conclusion, commercial multichamber bags for HPN in patients with advanced cancer are non-inferior when compared to individual compounded bags in terms of complications. [ABSTRACT FROM AUTHOR]

Most patients with chronic kidney disease (CKD) require renal replacement therapy. Majority of hemodialysis initiation is done through a dialysis catheter access. The use of catheters double lumen (CDL) for hemodialysis has several potential complications, including infection. Catheter related bloodstream infection (CRBSI) is associated with increased morbidity and mortality in CKD patients. CRBSI therapy should not be delayed, including delays due to waiting for culture results to confirm the diagnosis. Several studies have reported the use of clinical findings and routine blood count parameters to predict CRBSI. This case series reported three cases with suspected CRBSI consisting of one woman and two men with mean age of 44.67 ± 8.21 years, mean catheter days 13 ± 6.97, and mean hemodialysis duration of 10.5 ± 13.79 month. Diagnosis CRBSI was suspected from clinical clue, i.e symptoms such as fever and chills, pain at the CDL site, and physical examination i.e body temperature and local CDL site signs. Laboratory parameters in this case series reported elevations for PLR, NLR and SIRI supporting the suspicion of bloodstream infection. All patients in this case series improved after CDL removal and antibiotics therapy. Investigation of clinical findings and routine blood count parameters can be an alternative diagnosis of CRBSI that enables prompt treatment in areas with limited facilities. Keywords: chronic kidney disease, catheter related bloodstream infection, diagnosis

Abstract Introduction Bacteremia caused by Serratia rubidaea is seldom mentioned in comparison with other Enterobacteriaceae species. It primarily affects immunocompromised patients undergoing invasive procedures. Furthermore, the incidence, clinical features, and microbiological profile of this pathogen in the intensive care unit are rarely described. Case presentation We present four North African case studies of bacteremia in four young female patients admitted to the intensive care unit for ketoacidosis with a history of diabetes mellitus. All four patients developed catheter-related infections complicated by deep vein thrombosis. The catheter site was femoral in all cases, and the main clinical manifestation was poorly tolerated fever. The pathogen was isolated in multiple peripheral blood cultures (> 4) for each patient, showing a similar profile in all cases: resistance to third-generation cephalosporins and sensitivity to aminoglycosides, piperacillin, fluoroquinolones, and folate-pathway inhibitors. Targeted treatment consisted of a combination of ciprofloxacin 400 mg twice per day and trimethoprim/sulfamethoxazole 400/80 mg thrice per day for all four cases. However, in one case, this regimen was switched to amikacin due to adverse effects. The outcomes were favorable in the majority of cases. The patients described in this study were 21, 66, 22, and 27-year-old North African women. Conclusion Most of the reported cases shared common risk factors and clinical aspects. Notably, a case of thrombosis complicating a catheter infection caused by Serratia rubidaea has not been previously reported in the literature. Furthermore, this bloodstream infection typically affects deeply immunocompromised patients. However, our four cases, admitted to the intensive care unit for ketoacidosis, only had a history of diabetes mellitus.

There is no practical way to definitively diagnose a catheter-related bloodstream infection in situ if blood cultures are only obtained percutaneously unless there is the rare occurrence of purulent drainage from a central venous catheter insertion site. That is why the Infectious Diseases Society of America guidelines for diagnosis and management of catheter-related bloodstream infections and Infectious Diseases Society of America guidelines for evaluation of fever in critically ill patients both recommend drawing blood cultures from a central venous catheter and percutaneously if the catheter is a suspected source of infection. However, central venous catheter–drawn blood cultures may be more likely to be positive reflecting catheter hub, connector, or intraluminal colonization, and many hospitals in the United States discourage blood culture collection from catheters in an effort to reduce reporting of central-line associated bloodstream infections to the Centers for Disease Control and Prevention. As such, clinical decisions are made regarding catheter removal or other therapeutic interventions based on incomplete and potentially inaccurate data. We urge clinicians to obtain catheter-drawn blood cultures when the catheter may be the source of suspected infection. [ABSTRACT FROM AUTHOR]

Objective To analyze the main factors affecting early using enteral nutrition and the effect of enteral nutrition within 72 h after burning on outcomes by presenting a retrospective cohort study of 11 years of hospitalization data, to provide evidence for enteral nutrition regimens for severe burn patients. Methods A retrospective study analyzed adult extensive burn patients between January 2009 and December 2020. Patients enrolled in this study who admitted to the burn department within 24 h after burning and with a burned area of more than 30%. Univariate and multiple regression were used to analyze the main factors affecting early using enteral nutrition in patients with severe burn. Non parametric Mann-Whitney U test was used to compare the main influencing factors of enteral nutrition implementation within or after 72 h, as well as the impact on the treatment outcomes such as 28-day survival rate and in hospital survival rate. Results The univariate analysis found that total burn area, full-thickness burn area, burn type, and inhalation injury were the main factors of the time to initation of enteral nutrition in patients with severe burn (P0.05），but was associated with the lower incidence of bacteria positive in intravenous catheters (P=0.001) and the lower rate of parenteral nutrition treatment used within 7 d after burning (P=0.001). Conclusions The main factor for influencing early implement enteral nutrition in patients with severe burn were large area of full-thickness burn and inhalation injury. Enteral nutrition using within 72 h after burning reduces the incidence of catheter infection and the use of parenteral nutrition, thereby reducing the risk of treatment in patients with severe burn.

An ideal technique for peritoneal dialysis (PD) catheter insertion should provide a long-term functioning catheter until permanent renal replacement therapy becomes available. We developed a technique using the nephroscope-assisted single-trocar approach in 2011. In this study, we report the outcomes, learning curve analysis and cost-effectiveness analysisof the nephroscopic approach compared with the traditional laparoscopic approach. Between January 2005 and December 2020, we retrospectively reviewed 511 patients who received PD catheter insertions using the laparoscopic or nephroscopic approach. We compared the baseline characteristics of the patients, surgical outcomes, and complications of the two groups. We further analyzed the nephroscopic group to determine the cost-effectiveness analysis, learning curve and the complication frequency between the learning and mastery periods of the nephroscopic approach. A total of 208 patients underwent laparoscopic PD catheter insertion, whereas 303 patients received nephroscopic surgery. The median catheter survival in the nephroscopic group is significantly longer (43.1 vs. 60.5 months, p = 0.019). The incidence of peritonitis (29.3% vs.20.8%, p = 0.035) and exit site infection (12.5% vs. 6.6%, p = 0.019) were significantly lower in the nephroscopic group. The cost-effectiveness analysis showed a medical expense reduction of 16000 USD annually by using the nephroscopic technique. There was no difference in the frequency of surgical complications between the learning and mastery phases when examining the learning curve analysis for the nephroscopic technique. Compared with the traditional laparoscopic approach, the nephroscopic technique effectively prolonged catheter survival and reduces health care cost by reducing infectious complications. The low complication rate during the learning phase of surgery makes the procedure safe for patients and surgeons. [ABSTRACT FROM AUTHOR]

Introduction: Bacteremia caused by Serratia rubidaea is seldom mentioned in comparison with other Enterobacteriaceae species. It primarily affects immunocompromised patients undergoing invasive procedures. Furthermore, the incidence, clinical features, and microbiological profile of this pathogen in the intensive care unit are rarely described. Case presentation: We present four North African case studies of bacteremia in four young female patients admitted to the intensive care unit for ketoacidosis with a history of diabetes mellitus. All four patients developed catheter-related infections complicated by deep vein thrombosis. The catheter site was femoral in all cases, and the main clinical manifestation was poorly tolerated fever. The pathogen was isolated in multiple peripheral blood cultures (> 4) for each patient, showing a similar profile in all cases: resistance to third-generation cephalosporins and sensitivity to aminoglycosides, piperacillin, fluoroquinolones, and folate-pathway inhibitors. Targeted treatment consisted of a combination of ciprofloxacin 400 mg twice per day and trimethoprim/sulfamethoxazole 400/80 mg thrice per day for all four cases. However, in one case, this regimen was switched to amikacin due to adverse effects. The outcomes were favorable in the majority of cases. The patients described in this study were 21, 66, 22, and 27-year-old North African women. Conclusion: Most of the reported cases shared common risk factors and clinical aspects. Notably, a case of thrombosis complicating a catheter infection caused by Serratia rubidaea has not been previously reported in the literature. Furthermore, this bloodstream infection typically affects deeply immunocompromised patients. However, our four cases, admitted to the intensive care unit for ketoacidosis, only had a history of diabetes mellitus. [ABSTRACT FROM AUTHOR]

Abstract Background Hemodialysis tunneled catheters are prone to failure due to infection or thrombosis. Prediction of catheter dysfunction chance and finding the predisposing risk factors might help clinicians to prolong proper catheter function. The multidimensional mechanism of failures following infection or thrombosis needs a multivariable and comprehensive analytic approach. Methods A longitudinal cross-sectional study was implemented on 1048 patients admitted for the first hemodialysis tunneled catheterization attempt between 2013 and 2019 in Shahid Hasheminejdad hospital, Tehran, Iran. Patients’ information was extracted from digital and also paper records. Based on their criteria, single and multiple variable analyses were done separately in patients with catheter dysfunction due to thrombosis and infection. T-test and Chi-square test were performed in quantitative and categorical variables, respectively. Competing risk regression was performed under the assumption of proportionality for infection and thrombosis, and the sub-distributional hazard ratios (SHR) were calculated. All statistical inferences were made with a significance level of 0.05. Results Four hundred sixty-six patients were enrolled in the analysis based on study criteria. Samples’ mean (SD) age was 54(15.54), and 322 (69.1%) patients were female. Three hundred sixty-five catheter dysfunction cases were observed due to thrombosis 123(26.4%) and infection 242(52%). The Median (range) time to catheter dysfunction event was 243(36–1131) days. Single variable analysis showed a statistically significant higher proportion of thrombosis in females (OR = 2.66, 95% CI: 1.77–4.00) and younger patients, respectively. Multivariate competing risk regression showed a statistically significant higher risk of thrombosis in females (Sub-distributional hazard (SHR) = 1.81), hypertensive (SHR = 1.82), and more obese patients (BMI SHR = 1.037). A higher risk of infection was calculated in younger (Age SHR = 0.98) and diabetic (SHR = 1.63) patients using the same method. Conclusion Female and hypertensive patients are considerably at higher risk of catheter thrombosis, whereas diabetes is the most critical risk factor for infectious catheter dysfunction. Competing risk regression analysis showed a comprehensive result in the assessment of risk factors of catheter dysfunction.

Hemodialysis catheter-related infections are associated with increased morbidity and mortality in end-stage renal disease patients. Here we present a case of an end-stage renal disease patient who presented with fever and weakness. During workup, we found a deeply inserted jugular vein double lumen catheter into the inferior vena cava that was complicated by infection.

Background: Hemodialysis tunneled catheters are prone to failure due to infection or thrombosis. Prediction of catheter dysfunction chance and finding the predisposing risk factors might help clinicians to prolong proper catheter function. The multidimensional mechanism of failures following infection or thrombosis needs a multivariable and comprehensive analytic approach.Methods: A longitudinal cross-sectional study was implemented on 1048 patients admitted for the first hemodialysis tunneled catheterization attempt between 2013 and 2019 in Shahid Hasheminejdad hospital, Tehran, Iran. Patients' information was extracted from digital and also paper records. Based on their criteria, single and multiple variable analyses were done separately in patients with catheter dysfunction due to thrombosis and infection. T-test and Chi-square test were performed in quantitative and categorical variables, respectively. Competing risk regression was performed under the assumption of proportionality for infection and thrombosis, and the sub-distributional hazard ratios (SHR) were calculated. All statistical inferences were made with a significance level of 0.05.Results: Four hundred sixty-six patients were enrolled in the analysis based on study criteria. Samples' mean (SD) age was 54(15.54), and 322 (69.1%) patients were female. Three hundred sixty-five catheter dysfunction cases were observed due to thrombosis 123(26.4%) and infection 242(52%). The Median (range) time to catheter dysfunction event was 243(36-1131) days. Single variable analysis showed a statistically significant higher proportion of thrombosis in females (OR = 2.66, 95% CI: 1.77-4.00) and younger patients, respectively. Multivariate competing risk regression showed a statistically significant higher risk of thrombosis in females (Sub-distributional hazard (SHR) = 1.81), hypertensive (SHR = 1.82), and more obese patients (BMI SHR = 1.037). A higher risk of infection was calculated in younger (Age SHR = 0.98) and diabetic (SHR = 1.63) patients using the same method.Conclusion: Female and hypertensive patients are considerably at higher risk of catheter thrombosis, whereas diabetes is the most critical risk factor for infectious catheter dysfunction. Competing risk regression analysis showed a comprehensive result in the assessment of risk factors of catheter dysfunction. [ABSTRACT FROM AUTHOR]

A 40-year-old Japanese woman, who underwent total thyroidectomy, had suffered from repeated episodes of fever and microscopic hematuria for 3 years, which had started 3 months after central venous port catheter insertion. On admission, she had malaise and low-grade fever, and was found to have microscopic hematuria, urinary red blood cell casts, multiple pulmonary nodules, and positivity of proteinase 3-anti-neutrophil cytoplasmic antibody (PR3-ANCA), which were suggestive to the presence of ANCA-associated small vessel vasculitis. However, her blood culture and subsequent gene analysis revealed the positivity of Tsukamurella pulmonis, and she was diagnosed with Tsukamurella pulmonis bacteremia accompanying PR3-ANCA positivity. Her condition improved after the removal of the catheter and antibiotic treatment. Tsukamurella species are categorized to the order Actinomycetales and can be misidentified as other Actinomycetales without genetic analyses. This case illustrates that chronic Tsukamurella pulmonis infection can cause ANCA production and nephritis, which mimics ANCA-associated vasculitis. Thus, it is critical to diagnose these cases correctly to avoid misdiagnosis and inappropriate treatment, such as immunosuppressive treatment.

Pannonibacter phragmitetus (P. phragmitetus) is rarely related with human disease. We reported a case of catheter-related infection caused by P. phragmitetus in a 68-year-old woman on hemodialysis. The patient developed recurrent fever during hemodialysis and blood cultures were positive for P. phragmitetus. The patient's body temperature returned to normal after intravenous cefoperazone/sulbactam treatment, and the hemodialysis catheter was locked with gentamicin and urokinase. The potential anti-infective treatment against P. phragmitetus was discussed. [ABSTRACT FROM AUTHOR]

Hemodialysis catheter-related infections are associated with increased morbidity and mortality in end-stage renal disease patients. Here we present a case of an end-stage renal disease patient who presented with fever and weakness. During workup, we found a deeply inserted jugular vein double lumen catheter into the inferior vena cava that was complicated by infection. [ABSTRACT FROM AUTHOR]

This white paper identifies knowledge gaps and new challenges in healthcare epidemiology research, assesses the progress made toward addressing research priorities, provides the Society for Healthcare Epidemiology of America (SHEA) Research Committee's recommendations for high-priority research topics, and proposes a road map for making progress toward these goals. It updates the 2010 SHEA Research Committee document, "Charting the Course for the Future of Science in Healthcare Epidemiology: Results of a Survey of the Membership of SHEA," which called for a national approach to healthcare-associated infections (HAIs) and a prioritized research agenda. This paper highlights recent studies that have advanced our understanding of HAIs, the establishment of the SHEA Research Network as a collaborative infrastructure to address research questions, prevention initiatives at state and national levels, changes in reporting and payment requirements, and new patterns in antimicrobial resistance.

Fungal endocarditis (FE) is a rare but fatal disease. The incidence of infective endocarditis (IE) in hemodialysis patients with catheters is thought to be obviously higher than that in the general population. We reported a case of IE caused by Aspergillus flavus (A. flavus) in a 36-year-old woman on hemodialysis. Because the blood cultures were persistently negative, so we used mNGS (Metagenomic next generation sequencing) for early clinical diagnosis. After treatment with voriconazole, the patient's condition improved rapidly. She continued oral voriconazole treatment 1 year after discharge and is in good condition. The diagnosis and treatment strategies of FE in hemodialysis patients were discussed.

BackgroundCentral line-associated bloodstream infection (CLABSI) is a national target for mandatory reporting and a Centers for Medicare and Medicaid Services target for value-based purchasing. Differences in chart review versus claims-based metrics used by national agencies and groups raise concerns about the validity of these measures.ObjectiveEvaluate consistency and reasons for discordance among chart review and claims-based CLABSI events.MethodsWe conducted 2 multicenter retrospective cohort studies within 6 academic institutions. A total of 150 consecutive patients were identified with CLABSI on the basis of National Healthcare Safety Network (NHSN) criteria (NHSN cohort), and an additional 150 consecutive patients were identified with CLABSI on the basis of claims codes (claims cohort). All events had full-text medical record reviews and were identified as concordant or discordant with the other metric.ResultsIn the NHSN cohort, there were 152 CLABSIs among 150 patients, and 73.0% of these cases were discordant with claims data. Common reasons for the lack of associated claims codes included coding omission and lack of physician documentation of bacteremia cause. In the claims cohort, there were 150 CLABSIs among 150 patients, and 65.3% of these cases were discordant with NHSN criteria. Common reasons for the lack of NHSN reporting were identification of non-CLABSI with bacteremia meeting Centers for Disease Control and Prevention (CDC) criteria for an alternative infection source.ConclusionSubstantial discordance between NHSN and claims-based CLABSI indicators persists. Compared with standardized CDC chart review criteria, claims data often had both coding omissions and misclassification of non-CLABSI infections as CLABSI. Additionally, claims did not identify any additional CLABSIs for CDC reporting. NHSN criteria are a more consistent interhospital standard for CLABSI reporting.

Abstract Introduction Two opening methods are used for injection needle products: the “peel-apart method” where the adhesive surface of the packaging mount is peeled off, and the “push-off top method,” where the needle hub is pressed against the mount to break it. However, the risks of bacterial contamination as a result of opening method remain unknown. The aim of our study was to evaluate the bacterial contamination of needle hubs upon the opening of injection needles by the peel-apart or push-off top method under various conditions. Methods Bacterial contamination upon the opening of injection needles was examined in two materials, paper and plastic. Various concentrations of Staphylococcus aureus were applied to the mount and were maintained under wet or dry conditions. Injection needles were opened using the peel-apart or push-off top method. Needle hub contamination was examined using agar medium colony counting. Clinically assumed conditions (the hands and saliva of anesthesiologists) were also evaluated. Data were statistically examined using the Cochran-Mantel-Haenszel, Jonckheere, and Fisher’s exact tests. Results The lateral surfaces of needle hubs were contaminated using the push-off top method, but not by the peel-apart method, in a manner that was dependent on S. aureus concentrations. No significant differences were observed between mount materials. Needle hub contamination was significantly more severe for the wet than for the dry opening portion. The clinically assumed condition study revealed that the lateral and bottom surfaces of the needle hub were contaminated significantly more in the saliva contamination group than in the dry and wet hand groups. Conclusions The bacterial contamination of needle hubs may occur upon the opening of injection needles when the push-off top method is used and may be affected by hands contaminated with saliva under clinical conditions.

Cancer patients frequently require central venous catheters for therapy and parenteral nutrition and are at high risk of central venous catheter–related infections (CRIs). Moreover, CRIs prolong hospitalization, cause an excess in resource utilization and treatment cost, often delay anti-cancer treatment, and are associated with a significant increase in mortality in cancer patients. We therefore summoned a panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and updated our previous guideline on CRIs in cancer patients. After conducting systematic literature searches on PubMed, Medline, and Cochrane databases, video- and meeting-based consensus discussions were held. In the presented guideline, we summarize recommendations on definition, diagnosis, management, and prevention of CRIs in cancer patients including the grading of strength of recommendations and the respective levels of evidence. This guideline supports clinicians and researchers alike in the evidence-based decision-making in the management of CRIs in cancer patients. [ABSTRACT FROM AUTHOR]

BackgroundPatients with newly acquired methicillin-resistant Staphylococcus aureus (MRSA) have significant risks of short-term morbidity and mortality due to this pathogen. We were interested in assessing whether long-term carriers have persistent risks of disease and whether all carriers, regardless of the duration of carriage, should be considered to be reasonable candidates for interventions to reduce the risk of infection.MethodsWe conducted a single-center retrospective cohort study to evaluate the risk of subsequent MRSA infection and death among patients known to have harbored MRSA for at least 1 year (i.e., prevalent carriers).ResultsAmong 281 prevalent carriers, 65 (23%) developed a total of 96 discrete and unrelated MRSA infections in the year after their identification as prevalent carriers. The most common infections were pneumonia (accounting for 39% of MRSA infections), soft-tissue infection (14%), and central venous catheter infection (14%). Twenty-four percent of all infections involved bacteremia. Thirty-eight MRSA infections occurred during a new hospitalization, and 32 (84%) of these infections were the reason for admission to the hospital. MRSA contributed to 14 deaths, with 6 of these deaths deemed to be attributable to MRSA. Harboring MRSA for 1 year are at high risk for subsequent MRSA morbidity and mortality and should be considered to be targets for intervention, in addition to individuals who have newly acquired this pathogen.

Peritoneal catheter infections : data from the French language peritoneal dialysis registry (RDPLF), risk factors The French Language Peritoneal Dialysis Registry (RDPLF) record since 1997 all data dealing with peritoneal catheter insertion and follow up. The aim of this study is to analyze catheter infections on 10801 catheters in 144 centres from January 1, 1997 and December 31, 2018. Infections are more common in the first month and 50% occur before the tenth month. The risk of infection increases in case of wall hematoma, initial fluid leakage, and obesity. It decreases with the use of prophylactic antibiotics at the time of catheter insertion, with experienced operator, if the first dressing is delayed for 7 days, and with mupirocin as exit-site prophylaxis. During last two decades the percentage of Staphylococcus aureus infections has decreased, whereas the proportion of Pseudomonas, Corynebacterium and other Gram + cocci increased. The incidence of catheter infections is low compared to literature data: it decreased to 0.16 episodes per year for the 2013-2017 period. Adherence to ISPD guidelines: preoperative antibioprophylaxis is the most followed guideline (70.7% of catheter implantations in 2018). Local antibioprophylaxis concerns only 15.6% of catheters, and remains concentrated in a few centres ; mupirocin is the most frequently used agent. Screening for nasal carriage of S. aureus is performed in only 42% of cases. The catheter section of the RDPLF has allowed the follow-up of clinical practices incidence of infections and ecology for 21 years, both at the national and center level Our study confirms a wide variability in clinical practices, compared to ISPD guidelines.

Abstract Background No independent comparisons, with midterm follow-up, of standard arteriovenous grafts (SAVGs) and immediate-access arteriovenous grafts (IAAVGs) exist. The goal of this study was to compare "real-world" performance of SAVGs and IAAVGs. Methods Consecutive patients who underwent placement of a hemodialysis graft between November 2014 and April 2016 were retrospectively identified from the electronic medical record and Vascular Quality Initiative database at two tertiary centers. Only primary graft placements were included for analysis. Patients were divided into two groups based on the type of graft implanted. Patients' comorbidities, graft configuration, operative characteristics, and follow-up were collected and analyzed with respect to primary and secondary patency. Additional outcomes included graft-related complications, time to first cannulation, time to tunneled catheter removal, catheter-related complications, and overall survival. Patency was determined from the time of the index procedure; χ 2, Kaplan-Meier, and Cox regression analyses were used, with the P value set as significant at <.05. Results There were 210 grafts identified, 148 SAVGs and 62 IAAVGs. At baseline, the patients' characteristics were similar between groups, except for a greater prevalence of preoperative central venous occlusions in the IAAVG group (16.3% vs 6.8%; P <.04). Of the IAAVG group, 50 were Acuseal (W. L. Gore & Associates, Flagstaff, Ariz) and 12 were Flixene (Atrium Medical Corporation, Hudson, NH). Primary patency was similar at both 1 year (SAVG, 39.4%; IAAVG, 56.7%; P =.4) and 18 months (SAVG, 29.0%; IAAVG, 43.7%; P =.4). Secondary patency was similar at 1 year (SAVG, 50.7%; IAAVG, 52.1%; P =.73) and 18 months (SAVG, 42.3%; IAAVG, 46.3%; P =.73). Overall survival was 48% at 24 months. IAAVG patients required fewer overall additional procedures to maintain patency (mean number of procedures, 0.99 for SAVGs vs 0.61 for IAAVGs; P =.025). There was no difference in occurrence of steal syndrome (SAVG, 6.8%; IAAVG, 8.1%; P =.74) or graft infection (SAVG, 19.0%; IAAVG, 12.0%; P =.276). Seventy-five percent of all grafts were successfully cannulated, with shorter median time to first cannulation in the IAAVG group (6 days; interquartile range [IQR], 1-19 days) compared with the SAVG group (31 days; IQR, 26-47 days; P <.01). Of all pre-existing catheters, 65.75% were removed, with a shorter median time until catheter removal in the IAAVG cohort at 34 days (IQR, 22-50 days) vs 49 days (IQR, 39-67 days) in the SAVG group (P <.01). Catheter-related complications occurred less frequently in the IAAVG group (16.4% vs 2.9%; P <.045). Conclusions IAAVGs allow earlier cannulation and tunneled catheter removal, thereby significantly decreasing catheter-related complications. Patency and infection rates were similar between SAVGs and IAAVGs, but fewer secondary procedures were performed in IAAVGs. [ABSTRACT FROM AUTHOR]

Summary– Infective endocarditis (IE) is a serious infectious condition with high morbidity and mortality in patients with end-stage renal disease (ESRD). It has been particularly associated with recurrent bacteremia due to vascular access via lumen catheters. The most common pathogen is Staphylococcus (S.) aureus, and most affected valve is mitral valve, which frequently calcified. Two patients with ESRD who received hemodialysis treatment via tunneled catheters, aged 56 and 88 years, were admitted with fever and high troponin level. Blood cultures revealed growth of S. aureus. Good quality transthoracic echocardiography (TTE) displayed calcified mitral and aortic valves with no vegetation or abscess formation. Myocardial necrosis as result of catheter infection was considered. Both patients had persistent positive blood cultures 3 and 5 days after initiation of antibiotic treatment. Therefore, transesophageal echocardiogram (TEE) was scheduled. Results revealed perivalvular abscess in the older patient, and highly mobile vegetation in the younger patient. The older patient refused surgery and died soon after due to refractory shock. Mitral valve surgery was planned for the other patient; however, she developed left ventricular failure and bleeding, and also subsequently died as result of refractory shock. Patient evaluations were particularly unfavorable: they had catheter infection as primary focus, and TTE did not detect vegetation or annular abscess. Diagnosis of IE in patients with ESRD using Duke criteria is problematic; we have to keep use of TEE in mind to detect vegetation or abscess formation when there is clinical suspicion regarding ESRD patients even after good quality TTE.

The use of endovascular catheters is a routine practice in secondary and tertiary care level hospitals. The short-term use of peripheral catheters has been found to be associated with the risk of nosocomial bacteraemia, resulting in morbidity and mortality. Staphylococcus aureus is mostly associated with peripheral catheter insertion. This Consensus Document has been prepared by a panel of experts of the Spanish Society of Cardiovascular Infections, in cooperation with experts from the Spanish Society of Internal Medicine, Spanish Society of Chemotherapy, and the Spanish Society of Thoracic-Cardiovascular Surgery, and aims to define and establish guidelines for the management of short duration peripheral vascular catheters. The document addresses the indications for insertion, catheter maintenance, registering, diagnosis and treatment of infection, indications for removal, as well as placing an emphasis on continuous education as a drive toward quality. Implementation of these guidelines will allow uniformity in use, thus minimizing the risk of infections and their complications.

Background and Objectives: An effective flushing technique is essential to reduce intravenous (IV)-related complications and improve patient care. New technology should contribute to such improvements, while reducing costs and increasing care efficiency. This study evaluated the efficacy, safety, and convenience of a new flushing technique using a Baro Flush™ controller. Materials and Methods: We evaluated the efficacy and safety of Baro Flush™ by measuring the infusion flushing volume and pressure in vitro. Afterwards, we prospectively enrolled 3000 patients with flushing and assigned 1500 patients with a new technique for flushing and 1500 with a conventional flushing method, which was performed by 48 registered nurses (RNs) at the Gil Medical Center in June 2018. The efficacy, safety, and convenience of the new flushing method were evaluated though a questionnaire survey. Results: The average flushing pressure was 12.5 ± 0.6 psi (86.18 ± 4.14 kPa) with 1.2 ± 0.2 mL per flush, as recommended by the Centers for Disease Control and Prevention based on 85 experiments. No IV-catheter-related complications were reported by the RNs during the study. More than 80% of the RNs reported that the new flushing method was easier to learn, improved care efficacy, and was more convenient than conventional flushing. Conclusions: The new flushing method using a Baro Flush™ controller showed improved efficacy, safety, and convenience compared with the conventional flushing method, and no IV-catheter-related complications occurred, including occlusion and inflammation. The new flushing method promises to reduce IV-catheter-related complications and shows improved efficacy, safety, and convenience.

We aimed to describe the infectious risk during the dwell time for different catheter types. Furthermore, we wanted to identify risk factors for infections from catheters in place for >10 days. We performed a post hoc analysis using prospectively collected data from four randomized controlled trials. First, we evaluated the infectious risk after 10 days of analysing the significance of the interaction between dwell time and catheter type in a Cox model. Second, we investigated risk factors for infection in catheters in place for >10 days using multivariable marginal Cox models. We included 15 036 intravascular catheters from 24 intensive care units. Infections occurred in 46 (0.7%) of 6298 arterial catheters (ACs), 62 (1.0%) of 6036 central venous catheters (CVCs) and 47 (1.7%) of 2702 short-term dialysis catheters (DCs). The interaction between dwell time beyond 10 days and catheter type was significant for CVCs (p 0.008) and DCs (p < 0.001), thus indicating an increased risk of infection after 10 days. The interaction was not significant for ACs (p 0.98). Therefore, we selected 1405 CVCs and 454 DCs in place for >10 days for further analyses. In the multivariable marginal Cox model, we observed an increased hazard ratio (HR) for infection for femoral CVC (HR, 6.33; 95% CI, 1.99–20.09), jugular CVC (HR, 2.82; 95% CI, 1.13–7.07), femoral DC (HR, 4.53; 95% CI, 1.54–13.33) and jugular DC (HR, 4.50; 95% CI, 1.42–14.21) compared with subclavian insertions. We showed that the risk of catheter infection for CVCs and DCs increased 10 days after insertion, thus suggesting routine replacement for nonsubclavian catheters in situ for >10 days. [ABSTRACT FROM AUTHOR]

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Background: Protection of the catheter site by antimicrobial agents is one of the most important factors in the prevention of infection. Povidone iodine and chlorhexidine gluconate are the most common used agents for dressing. The purpose of this study was to compare the effects of povidone iodine, chlorhexidine gluconate and octenidine hydrochloride in preventing catheter related infections. Materials and Methods: Patients were randomized to receive; 4% chlorhexidine gluconate, 10% povidone iodine or octenidine hydrochlorodine for cutaneous antisepsis. Cultures were taken at the site surrounding catheter insertion and at the catheter hub after removal to help identify the source of microorganisms. Results: Catheter related sepsis was 10.5% in the povidone iodine and octenidine hydrochlorodine groups. Catheter related colonization was 26.3% in povidone iodine group and 21.5% in octenidine hydrochlorodine group. Conclusion: 4% chlorhexidine or octenidine hydrochlorodine for cutaneous disinfection before insertion of an intravascular device and for post-insertion site care can reduce the catheter related colonization.

Strains of Staphylococcus aureus with reduced susceptibility to glycopeptides have been reported from Japan, the United States, Europe, and the Far East. Although isolates with homogeneous resistance to vancomycin (MICs = 8 µg/mL) continue to be rare, there are increasing reports of strains showing heteroresistance, often with vancomycin MICs in the 1-4 µg/mL range. Most isolates with reduced susceptibility to vancomycin appear to have developed from preexisting methicillin-resistant S. aureus infections. Many of the isolates with reduced susceptibility to glycopeptides have been associated with therapeutic failures with vancomycin. Although nosocomial spread of the vancomycin-intermediate S. aureus (VISA) strains has not been observed in U.S. hospitals, spread of VISA strains has apparently occurred in Japan. Broth microdilution tests held a full 24 hours are optimal for detecting resistance in the laboratory; however, methods for detecting heteroresistant strains are still in flux. Disk-diffusion tests, including the Stokes method, do not detect VISA strains. The Centers for Disease Control and Prevention and other groups have issued recommendations regarding appropriate infection control procedures for patients infected with these strains.

A 57-year-old man on dialysis presented with fever due to Pseudomonas septicemia. Workup revealed very high triglycerides and serum ferritin levels. A bone marrow examination showed hemophagocytosis. A diagnosis of hemophagocytic lymphohistiocytosis (HUH) was made and steroids were started. He was put on automated peritoneal dialysis. Patients' condition continued to deteriorate and he succumbed to his illness. This case illustrates the development of HLH secondary to infections which are increasingly being recognized in the literature. Often this diagnosis is missed as it becomes difficult to differentiate between sepsis and HLH. The presence of high ferritin, hypertriglyceridemia, and hemophagocytosis in the bone marrow confirms the diagnosis. [ABSTRACT FROM AUTHOR]

We present evidence-based recommendations on diagnosis, management and prevention of central venous catheter-related infections (CRI) in cancer patients. Distinguishing between definite, probable and possible CR blood stream infections removal of the catheter is recommended if the patient's clinical state deteriorates or if S. aureus, Gram-negative bacilli or Candida spp. are isolated from blood cultures while the catheter may be preserved in selected cases.Background Cancer patients are at increased risk for central venous catheter-related infections (CRIs). Thus, a comprehensive, practical and evidence-based guideline on CRI in patients with malignancies is warranted. Patients and methods A panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) has developed a guideline on CRI in cancer patients. Literature searches of the PubMed, Medline and Cochrane databases were carried out and consensus discussions were held. Results Recommendations on diagnosis, management and prevention of CRI in cancer patients are made, and the strength of the recommendation and the level of evidence are presented. Conclusion This guideline is an evidence-based approach to the diagnosis, management and prevention of CRI in cancer patients. [ABSTRACT FROM PUBLISHER]

Compared to enteral or hypocaloric oral nutrition, the use of PN (parenteral nutrition) is not associated with increased mortality, overall frequency of complications, or longer length of hospital stay (LOS). The risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, bone demineralisation, catheter infections) can be minimised by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN. Occuring complications are e.g. the refeeding-syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are necessary in patients with altered renal function, electrolyte-free substrate intake, lipid infusions, and in intensive care patients. The metabolic monitoring of patients under long-term PN should be carried out according to standardised procedures. Monitoring metabolic determinants of bone metabolism is particularly important in patients receiving long-term PN. Markers of intermediary, electrolyte and trace element metabolism require regular checks.

Abstract: Central venous catheters (CVCs) have become indispensable in the treatment of neonates and patients undergoing chemotherapy or hemodialysis. A CVC provides easy access to the patient’s circulation, thus enabling facile monitoring of hemodynamic parameters, nutritional support, or administration of (cytostatic) medication. However, complications with CVCs, such as bacterial bloodstream infection or thromboembolism, are common. Bloodstream infections, predominantly caused by Staphylococcus aureus, are notoriously difficult to prevent and treat. Furthermore, patients receiving infusion therapy through a CVC are at risk for deep-vein thrombosis, especially of the upper limbs. Several recent clinical trials have shown that prophylactic anticoagulation (low-molecular-weight heparin or vitamin K antagonists) is not effective. Here, we report on the systematic development of a new bifunctional coating concept that can –uniquely– be applied to make CVC surfaces antimicrobial and antithrombogenic at the same time. The novel coating consists of a moderately hydrophilic synthetic copolymer of N-vinylpyrrollidinone (NVP) and n-butyl methacrylate (BMA), containing embedded silver nanoparticles (AgNPs) and sodium heparin. The work demonstrates that the AgNPs strongly inhibit adhesion of S. aureus (reference strain and clinical isolates). Surprisingly, heparin not only rendered our surfaces practically non-thrombogenic, but also contributed synergistically to their biocidal activity. [ABSTRACT FROM AUTHOR]

Background. Susceptibility to infection and thrombosis of intravascular catheters is increased by surface irregularities, which might be prevented by coating. Methods. BaSO4 release from conventional haemodialysis catheters (CC) and modified catheters (MC) which had been coated with a surface-modifying additive (SMA) was assessed in vivo and in vitro. For the in vivo part, patients were randomized to receive a temporary CC or MC, with crossover after 1 week. After retrieval, catheters were examined using scanning electron microscopy to assess surface integrity, and an in vitro model of catheter exposure to the bloodstream was used to evaluate surface morphology and susceptibility to bacterial adhesion and proliferation. Results. BaSO4 moieties covered 14.7 ± 3.7% of the surface of unused CC. After in vivo use in 16 patients, 62.7 ± 32.9 × 103 holes/mm2 were detected, indicating BaSO4 detachment from 3.3 ± 1.7% of the catheter surface. No defects were observed in unused CC and in MC, whether used or unused. After incubation of four catheters (two of each type) with Staphylococcusepidermidis, the two degraded CC showed an immediate and strong bacterial growth as indicated by an increase in medium impedance of 0.512%/10 min compared to −0.021%/10 min in MC (P < 0.001). Conclusions. Short-term exposure of CC to the bloodstream causes BaSO4 particle release, resulting in surface irregularities predisposing to bacterial proliferation. BaSO4 release can be prevented by SMA coating. [ABSTRACT FROM AUTHOR]

Summary: Background: Patients on long-term hemodialysis are at a significantly higher risk for catheter-related bloodstream infections (BSI) than the general population. These infections are generally caused by Gram-positive organisms, especially Staphylococcus aureus. In the present study, we evaluated the antimicrobial susceptibility patterns of S. aureus causing BSI in dialysis patients compared to those causing BSI in other patient populations. Methods: The potencies of daptomycin and various comparator agents were evaluated by reference broth microdilution methods for S. aureus bloodstream isolates from dialysis patients (606 strains) in 43 hospitals in North America and Europe. Susceptibility patterns for the dialysis isolate set were compared to those S. aureus causing BSI in other patient populations in the same hospitals and time period. Results: Daptomycin was highly potent against S. aureus causing bacteremia in dialysis patients (MIC50/MIC90, 0.25/0.5μg/ml). Vancomycin (MIC50/MIC90, 1/1μg/ml) and linezolid (MIC50/MIC90, 2/2μg/ml) showed similar potency, and overall susceptibility rates for the three antibiotics were 99.8–100.0% susceptible. Linezolid and vancomycin were four- to eight-fold less potent than daptomycin. Conclusions: The overall susceptibility patterns of S. aureus strains from dialysis patients were very similar to those of non-dialysis patients. [Copyright &y& Elsevier]

Compared to enteral or hypocaloric oral nutrition, the use of PN (parenteral nutrition) is not aßociated with increased mortality, overall frequency of complications, or longer length of hospital stay (LOS). The risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, bone demineralisation, catheter infections) can be minimised by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN. Occuring complications are e.g. the refeedingsyndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis. Efficient monitoring in all types of PN can result in reduced PN-aßociated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are neceßary in patients with altered renal function, electrolyte-free substrate intake, lipid infusions, and in intensive care patients. The metabolic monitoring of patients under long-term PN should be carried out according to standardised procedures. Monitoring metabolic determinants of bone metabolism is particularly important in patients receiving longterm PN. Markers of intermediary, electrolyte and trace element metabolism require regular checks. [ABSTRACT FROM AUTHOR]

This retrospective study investigated the clinical significance and impact of Stenotrophomonas maltophilia bacteraemia in 49 haematology and oncology patients at a tertiary referral medical centre in Taipei between July 1999 and December 2003. Sixteen patients had 24 episodes of central venous catheter (CVC)-related bacteraemia, with the main clinical characteristics being a nosocomial bacteraemia (100%), preceding antibiotic therapy (94%), bacteraemia developed in a general ward (87%), immunosuppressive therapy (75%), in-situ CVC-related bacteraemia (75%), and neutropenia (63%). Only four (25%) patients had inflammatory signs at the CVC site following diagnosis of bacteraemia. Five patients had recurrent bacteraemia, with risk-factors being long-lasting (>10 days) neutropenia (p 0.036) and an initial failure to remove the CVC (p 0.001). These cases did not involve re-infection, as the same S. maltophilia strain was identified following random amplified polymorphic DNA (RAPD) analysis of the initial and subsequent isolates. However, relapses could occur after long latency periods (maximum, 200 days). Most patients were cured after removal of the CVC, even without appropriate antibiotic treatment. Physicians should have a high index of suspicion for CVC-related bacteraemia with haematology and oncology patients with CVCs and S. maltophilia bacteraemia. In addition to appropriate antibiotic therapy, removal of the CVC is crucial for successful treatment of CVC-related S. maltophilia bacteraemia and prevention of relapses. [ABSTRACT FROM AUTHOR]