Practices and intravascular catheter infection during on- and off-hours in critically ill patients

Background The potential relationship between intravascular catheter infections with their insertion during weekend or night-time (i.e., off-hours or not regular business hours) remains an open issue. Our primary aim was to describe differences between patients and catheters inserted during on- versus off-hours. Our secondary aim was to investigate whether insertions during off-hours influenced the intravascular catheter infectious risks. Methods We performed a post hoc analysis using the databases from four large randomized-controlled trials. Adult patients were recruited in French ICUs as soon as they required central venous catheters or peripheral arterial (AC) catheter insertion. Off-hours started at 6 P.M. until 8:30 A.M. during the week; at weekend, we defined off-hours from 1 P.M. on Saturday to 8.30 A.M. on Monday. We performed multivariable marginal Cox models to estimate the effect of off-hours (versus on-hours) on major catheter-related infections (MCRI) and catheter-related bloodstream infections (CRBSIs). Results We included 7241 patients in 25 different ICUs, and 15,208 catheters, including 7226 and 7982 catheters inserted during off- and on-hours, respectively. Catheters inserted during off-hours were removed after 4 days (IQR 2, 9) in median, whereas catheters inserted during on-hours remained in place for 6 days (IQR 3,10; p < 0.01) in median. Femoral insertion was more frequent during off-hours. Among central venous catheters and after adjusting for well-known risk factors for intravascular catheter infection, we found a similar risk between off- and on-hours for MCRI (HR 0.91, 95% CI 0.61–1.37, p = 0.65) and CRBSI (HR 1.05, 95% CI 0.65–1.68, p = 0.85). Among central venous catheters with a dwell-time > 4 or > 6 days, we found a similar risk for MCRI and CRBSI between off- and on-hours. Similar results were observed for ACs. Conclusions Off-hours did not increase the risk of intravascular catheter infections compared to on-hours. Off-hours insertion is not a sufficient reason for early catheter removal, even if femoral route has been selected.

Cutaneous abscess related to peritoneal catheter tunnel infection

Some peritoneal dialysis catheter infections cannot be detected via a physical examination. Ultrasonography can aid in the diagnosis of such infections.

Infections of Port Access Catheters in Children

Background: The most important complication of port access catheters (PAC) compared to peripheral lines is a higher incidence of infections. Objectives: This study investigated the frequency of catheter infection and related factors in Dr. Sheikh Children Hospital (SCH). Methods: This is a retrospective descriptive study at Sheikh children’s hospital, Mashhad, Iran. The data of children with an operation for PAC surgery were gathered from hospital files and completed by calling the parents. The definition of PAC infection was based on clinical signs of catheter infection and any positive blood culture (peripheral or catheter sample) or the resolution of signs of infection after the extraction of the catheter in the absence of positive blood cultures. Results: During six years, 70 children received PAC, all of whom (except five) were followed by telephone calls. Forty percent of them were younger than two years, and 71.4% had malignant disease. Catheter infection occurred in 16 (22.8%) cases. Signs of catheter infection were fever and cellulitis over the port in nine (56%) cases (pocket infection), chills and fever during catheter usage (without port infection) in six (37.5%) cases, and persistent fever in one patient (6.2%). Blood culture was positive in 75% (12 cases) of catheter infections, and the responsible organisms were Gram-negative bacilli (five cases), Coagulase-negative staphylococci (three cases), Candida (three cases), and group B streptococci (GBS). The success rate for “medical therapy per se” was 68% in catheter infections. The catheter was removed in 22 (31.4%) patients, which was due to infection in half of them. The mean time to removal was 15.3 months. Conclusions: The incidence of catheter infection, especially pocket infection, is high in this population, which necessities revision in all procedures of catheter implantation and care.

Vascular Access for Lipid Apheresis: A Challenge in Young Children With Homozygous Familial Hypercholesterolemia

Background Homozygous familial hypercholesterolemia (HoFH) is a rare genetic disorder leading to extremely increased LDL-cholesterol (LDL-C), resulting in high cardiovascular risk in early childhood. Lipid apheresis (LA) is an effective treatment and should be started as early as possible to prevent premature cardiovascular events. As peripheral punctures in children can be challenging due to small vessels and anxiety, this study aimed to evaluate central venous catheters (CVCs) as vascular access for LA in young children with hoFH.MethodsRetrospective analysis (2016-2019) on four children with hoFH aged 3-5, performing weekly or biweekly LA with a CVC.ResultsLDL-C decreased by> 60%. In three children, the use of a permanent CVC for 698, 595, and 411 days, respectively, avoided difficult peripheral access, without the occurrence of occlusion or thrombosis. Unfortunately, one child had recurrent CVC-related infections and needed an arteriovenous fistula from the age of 5. Although the mean dwell time per catheter was 212 days, there were, as expected, severe side effects of early catheter infections with sepsis and accidental self-removal. Starting LA at an early age improved or stabilized carotid intima-media thickness (IMT) in all children. Finally, IMT did increase in one child caused by intolerance to peripheral punctures and LA interruption.ConclusionsPermanent CVCs are a viable temporary access choice for LA in young children with hoFH until peripheral venipuncture is practicable. The risk of CVC-related infections needs to be taken into account.

Local signs at insertion site and catheter-related bloodstream infections: an observational post hoc analysis using individual data of four RCTs

Background Little is known on the association between local signs and intravascular catheter infections. This study aimed to evaluate the association between local signs at removal and catheter-related bloodstream infections (CRBSI), and which clinical conditions may predict CRBSIs if inflammation at insertion site is present. Methods We used individual data from four multicenter randomized controlled trials in intensive care units (ICUs) that evaluated various prevention strategies for arterial and central venous catheters. We used multivariate logistic regressions in order to evaluate the association between ≥ 1 local sign, redness, pain, non-purulent discharge and purulent discharge, and CRBSI. Moreover, we assessed the probability for each local sign to observe CRBSI in subgroups of clinically relevant conditions. Results A total of 6976 patients and 14,590 catheters (101,182 catheter-days) and 114 CRBSI from 25 ICUs with described local signs were included. More than one local sign, redness, pain, non-purulent discharge, and purulent discharge at removal were observed in 1938 (13.3%), 1633 (11.2%), 59 (0.4%), 251 (1.7%), and 102 (0.7%) episodes, respectively. After adjusting on confounders, ≥ 1 local sign, redness, non-purulent discharge, and purulent discharge were associated with CRBSI. The presence of ≥ 1 local sign increased the probability to observe CRBSI in the first 7 days of catheter maintenance (OR 6.30 vs. 2.61 [> 7 catheter-days], pheterogeneity = 0.02). Conclusions Local signs were significantly associated with CRBSI in the ICU. In the first 7 days of catheter maintenance, local signs increased the probability to observe CRBSI.

Development and Evaluation of a Structured Tool to Assess the Preventability of Hospital-Onset Bacteremia and Fungemia

Background: Hospital-onset bacteremia and fungemia (HOB) may be a preventable hospital-acquired condition and a potential healthcare quality measure. We developed and evaluated a tool to assess the preventability of HOB and compared it to a more traditional consensus panel approach. Methods: A 10-member healthcare epidemiology expert panel independently rated the preventability of 82 hypothetical HOB case scenarios using a 6-point Likert scale (range, 1= “Definitively or Almost Certainly Preventable” to 6= “Definitely or Almost Certainly Not Preventable”). Ratings on the 6-point scale were collapsed into 3 categories: Preventable (1–2), Uncertain (3–4), or Not preventable (5–6). Consensus was defined as concurrence on the same category among ≥70% expert raters. Cases without consensus were deliberated via teleconference, web-based discussion, and a second round of rating. The proportion meeting consensus, overall and by predefined HOB source attribution, was calculated. A structured HOB preventability rating tool was developed to explicitly account for patient intrinsic and extrinsic healthcare-related risks (Fig. 1). Two additional physician reviewers independently applied this tool to adjudicate the same 82 case scenarios. The tool was iteratively revised based on reviewer feedback followed by repeat independent tool-based adjudication. Interrater reliability was evaluated using the Kappa statistic. Proportion of cases where tool-based preventability category matched expert consensus was calculated. Results: After expert panel round 1, consensus criteria were met for 29 cases (35%), which increased to 52 (63%) after round 2. Expert consensus was achieved more frequently for respiratory or surgical site infections than urinary tract and central-line–associated bloodstream infections (Fig. 2a). Most likely to be rated preventable were vascular catheter infections (64%) and contaminants (100%). For tool-based adjudication, following 2 rounds of rating with interim tool revisions, agreement between the 2 reviewers was 84% for cases overall (κ, 0.76; 95% CI, 0.64–0.88]), and 87% for the 52 cases with expert consensus (κ, 0.79; 95% CI, 0.65–0.94). Among cases with expert consensus, tool-based rating matched expert consensus in 40 of 52 (77%) and 39 of 52 (75%) cases for reviewer 1 and reviewer 2, respectively. The proportion of cases rated “uncertain“ was lower among tool-based adjudicated cases with reviewer agreement (15 of 69) than among cases with expert consensus (23 of 52) (Fig. 2b). Conclusions: Healthcare epidemiology experts hold varying perspectives on HOB preventability. Structured tool-based preventability rating had high interreviewer reliability, matched expert consensus in most cases, and rated fewer cases with uncertain preventability compared to expert consensus. This tool is a step toward standardized assessment of preventability in future HOB evaluations.Funding: NoneDisclosures: None