Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants With Late-Onset Infection.

Importance: Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown. Objective: To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites. Design, Setting, and Participants: A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants. Exposures: Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis. Main Outcomes and Measures: The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset. Results: In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks' completed gestation did not reduce the association of the nSOFA score with infection-related mortality. Conclusions and Relevance: The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.

Exit site infection and peritonitis due to Serratia species in patients receiving peritoneal dialysis: Epidemiology and clinical outcomes.

AIM: To study the epidemiology and clinical outcomes of catheter-related infections of Serratia species in peritoneal dialysis (PD) patients. METHODS: We retrospectively reviewed the patient characteristics, antibiotics susceptibility/resistance patterns and treatment outcomes of exit site infection (ESI) and peritonitis due to Serratia in PD patients during the period of 2004 to 2017. RESULTS: One hundred and sixty-one patients had Serratia ESI, of which 10 (6.2%) progressed to tunnel tract involvement and 11 (6.8%) developed PD peritonitis. Nineteen (11.8%) patients with Serratia ESI failed to respond to medical treatment and required catheter removal. Fifty-six (34.8%) patients had repeat Serratia ESI, which occurred at 12.9 ± 13.6 months after the previous episode. Twenty-two patients had Serratia peritonitis, which accounted for 1% of peritonitis during the study period. Ten (45.5%) patients responded to medical treatment while 12 (54.5%) patients required catheter removal. Nine patients (36.4%) failed to resume PD and were converted to long-term haemodialysis. Two patients had repeat peritonitis at 2 months and 3 years, respectively, after the initial episode. Serratia species in PD patients showed high rates of resistance to ampicillin, and first- and second-generation cephalosporins, but were generally susceptible to aminoglycosides, carboxy-/ureido-penicillins and carbapenems. CONCLUSION: Our results suggest that Serratia ESI show low risk of progression to peritonitis and favourable response to medical therapy, while Serratia peritonitis was associated with high rates of catheter removal and peritoneal failure.

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.

Nocardia bacteremia: A single-center retrospective review and a systematic review of the literature.

OBJECTIVES: Nocardia bacteremia is a rare but severe disease associated with high mortality. This systematic review is the largest and most comprehensive review performed over the past 20 years. METHODS: A single-center retrospective review of Nocardia bacteremia was performed using hospital microbiology records from January 1, 2010 to December 31, 2017. A systematic literature review was also performed to identify cases of Nocardia bacteremia described in the NCBI PubMed database in English between January 1, 1999 and December 31, 2018. RESULTS: Four new cases of Nocardia bacteremia are described. The systematic review identified 134 cases with sufficient information available for analysis. Of the total 138 cases, the median age was 58 years (interquartile range (IQR) 44-69 years) and 70% were male. Eighty-one percent were immunocompromised (corticosteroid use (49%), hematological malignancy (20%), solid organ transplant (20%), solid organ malignancy (19%), and hematopoietic stem cell transplantation (15%)) and 29% had endovascular devices. Pulmonary infection was the most common concurrent site of clinical disease (67%). The median incubation time to the detection of Nocardia bacteremia was 4 days (IQR 3-6 days). Blood cultures were the only positive microbiological specimen in 38% of cases. The median total duration of treatment was 75 days (IQR 25-182 days). Thirty-day all-cause mortality was 28% and overall all-cause mortality was 40%. CONCLUSIONS: Nocardia bacteremia is most frequently identified in immunocompromised patients and those with intravascular devices. Although rare, it represents a serious infection with high associated overall mortality.

Skin colonization at peripheral intravenous catheter insertion sites increases the risk of catheter colonization and infection.

BACKGROUND: Peripheral intravenous catheters (PIVCs) break the skin barrier, and preinsertion antiseptic disinfection and sterile dressings are used to reduce risk of catheter-related bloodstream infection (CRBSI). In this study, the impact of PIVC skin site colonization on tip colonization and the development of CRBSI was investigated. METHODS: A total of 137 patients' PIVC skin site swabs and paired PIVC tips were collected at catheter removal, cultured, and bacterial species and clonality were identified. RESULTS: Of 137 patients, 45 (33%) had colonized skin sites and/or PIVC tips. Of 16 patients with paired colonization of both the skin site and PIVC tips, 11 (69%) were colonized with the same bacterial species. Of these, 77% were clonally related, including 1 identical clone of Pseudomonas aeruginosa in a patient with systemic infection and the same organism identified in blood culture. CONCLUSIONS: The results demonstrate that opportunistic pathogen colonization at the skin site poses a significant risk for PIVC colonization and CRBSI. Further research is needed to improve current preinsertion antiseptic disinfection of PIVC skin site and the sterile insertion procedure to potentially reduce PIVC colonization and infection risk.

Vascular access for hemodialysis: A perpetual challenge.

Vascular access for hemodialysis has a long and rich history. This article highlights major innovations and milestones in the history of angioaccess for hemodialysis. Advances in achievement of lasting hemodialysis access, swift access transition, immediate and sustaining access to vascular space built the momentum at different turning points of access history and shaped the current practice of vascular access strategy. In the present era, absent of large-scale clinical trials to validate practice, the ever-changing demographic and comorbidity makeup of the dialysis population pushes against stereotypical angioaccess goals. The future of hemodialysis vascular access would benefit from proper randomized clinical trials and acclimatization to clinical contexts.

Catheter related recurrent blood stream infection caused by linezolid-resistant, methicillin resistant Staphylococcus haemolyticus; an emerging super bug.

A 61 year male, admitted in Combined Military Hospital Rawlpindi on 12th March 2017, operated for diverticulitis became colonized with Staphylococcus haemolyticus. Patient suffered repeated septic episodes caused by the same organism during his stay in hospital. The strain was identified as methicillin resistant Staphylococcus haemolyticus (MRSH) also resistant to Linezolid by analytical profile index for Staphylococcus (API Staph) and VITEK 2 Gram positive cocci panel. The isolate was cultured from blood cultures, Central Venous Catheter (CVC) tip and skin swabs. Patient was successfully treated with injectable vancomycin and skin decolonization was acheived with chlorhexidine bath after which no episode of MRSH infection occurred. Patient had an uneventful recovery and was discharged on 21st June. His follow up visit showed clinical improvement.

Association of Thoracic Epidural Pain Management with Urinary Retention after Complex Abdominal Wall Reconstruction.

The association of thoracic epidural analgesia and urinary retention after complex abdominal wall reconstruction (CAWR) is unknown. The purpose of this study was to investigate the association between the presence of a thoracic epidural, timing of Foley catheter removal, and the rates of urinary retention and catheter-associated urinary tract infections (CAUTIs) in patients undergoing CAWR. All patients undergoing CAWR, who had an epidural catheter for postoperative pain management at our institution from September 2015 through April 2016, were prospectively followed. Patients were divided into two groups. Group 1 had their Foley catheters removed on postoperative day one, whereas Group 2 had their Foley catheters removed after epidural removal. The incidence of urinary retention and CAUTI were compared between the two groups. A total of 67 patients met inclusion criteria; 27 (40.3%) patients were in Group 1. Patients in Group 1 were significantly more likely to experience urinary retention requiring Foley catheter replacement (P = 0.02). There was no statistically significant difference in the rate of CAUTI between the two groups (P = 0.51). Patients undergoing CAWR with thoracic epidural pain management are at risk of experiencing postoperative urinary retention. Foley catheter removal after epidural removal does not place the patient at an increased risk for CAUTI and therefore should be strongly considered in this patient population.

Physiopathological approach to infective endocarditis in chronic hemodialysis patients: left heart versus right heart involvement.

Infectious endocarditis (IE), a complication that is both cardiac and infectious, occurs frequently and is associated with a heavy burden of morbidity and mortality in chronic hemodialysis patients (CHD). About 2-6% of chronic hemodialysis patients develop IE and the incidence is 50-60 times higher among CHD patients than in the general population. The left heart is the most frequent location of IE in CHD and the different published series report a prevalence of left valve involvement varying from 80% to 100%. Valvular and perivalvular abnormalities, alteration of the immune system, and bacteremia associated with repeated manipulation of the vascular access, particularly central venous catheters, comprise the main factors explaining the left heart IE in CHD patients. While left-sided IE develops in altered valves in a high-pressure system, right-sided IE on the contrary, generally develops in healthy valves in a low-pressure system. Right-sided IE is rare, with its incidence varying from 0% to 26% depending on the study, and the tricuspid valve is the main location. Might the massive influx of pathogenic and virulent germs via the central venous catheter to the right heart, with the tricuspid being the first contact valve, have a role in the physiopathology of IE in CHD, thus facilitating bacterial adhesion? While the physiopathology of left-sided IE entails multiple and convincing mechanisms, it is not the case for right-sided IE, for which the physiopathological mechanism is only partially understood and remains shrouded in mystery.

Spinal Infections Among Patients With Long-Term Central Venous Catheters for Home Parenteral Nutrition.

Spinal infections are a rare yet serious metastatic complication of bacteremia among patients with long-term central venous catheters (CVCs) for which clinicians must remain vigilant. We performed a retrospective review of all cases of spinal infection occurring in the context of a CVC for long-term parenteral nutrition (PN) managed in our department between January 2010 and October 2013, a cohort of 310 patients over this time period. Six patients were identified (mean age, 65 years; 5 male). One hundred percent of patients presented with spinal pain (5/6 cervical, 1/6 thoracic). Organisms were cultured from the CVC in 5 of 6 patients. In all cases, the white blood cell count was normal, and in 5 of 6, C-reactive protein was normal. All diagnoses were confirmed on magnetic resonance imaging (MRI), and in 3 of 6 cases, an MRI was repeated (on the advice of neurosurgical colleagues) to confirm resolution of changes after a period of antimicrobial therapy. There was no clear correlation between duration of PN or number of days following CVC insertion and onset of infection. The CVC was replaced in 4 of 6 patients at the time of diagnosis, delayed removal in 1 of 6, and salvaged in the remaining case. Although rare, a high index of suspicion is needed in patients receiving long-term PN who present with spinal pain. Peripheral inflammatory markers may not be elevated. MRI should be performed and patients should be treated with antibiotics alongside involvement of local microbiology and neurosurgical teams. Multidisciplinary discussion on CVC salvage in these cases is important, especially in cases of challenging vascular anatomy.

Surgical Management of Complications with Peritoneal Dialysis.

This report reviews the most common surgical interventions and complications of chronic peritoneal dialysis (PD) patients. Based on the current knowledge as well as our experience we detail the role of these surgical procedures. We supplement the reported knowledge in the field with our own experience in this area. The areas discussed include early complications such as surgical wound hemorrhage, bleeding from the catheter, intestinal perforation and urinary bladder perforation, dialysate leakage through the wound, as well as late complications including catheter kinking or occlusion, retention of fluid in the peritoneal recess, hernias and hydrothorax, and encapsulating peritoneal sclerosis. We also briefly cover the surgical aspects of exit-site infection and peritonitis. An understanding by nephrologists of the role for surgical intervention in PD patients will improve their care and outcomes.

Faecal Microbiota Transplantation for Clostridium Difficile - a local perspective.

Clostridium Difficile represents one of the major challenges of the antimicrobial era with associated significant morbidity. Treatment options are limited to a number of specific antibiotics with significant failure rates. Faecal Microbiota Transplantation has been recognised as a possible treatment option when standard therapy fails. We report a local case of Clostridium Difficile Infection ultimately requiring Faecal Microbiota Transplantation with good success. While no formal service providing the treatment is available within Northern Ireland it is a feasible treatment option for Clostridium Difficile Infection.

Chlorhexidine-Impregnated Dressings and Prevention of Catheter-Associated Bloodstream Infections in a Pediatric Intensive Care Unit.

BACKGROUND: Bloodstream infections related to use of catheters are associated with increased morbidity and mortality rates, prolonged hospital lengths of stay, and increased medical costs. OBJECTIVES: To compare the effectiveness of chlorhexidine-impregnated dressings with that of standard dressings in preventing catheter-related bloodstream infections. METHODS: A total of 100 children were randomly divided into 2 groups of 50 each: a chlorhexidine group and a standard group. Patient care was provided in accordance with prevention bundles. Patients were followed up for development of catheter-related bloodstream infections. RESULTS: Catheter colonization occurred in 4 patients in the standard group (8%) and in 1 patient in the chlorhexidine group (2%). Catheter-related bloodstream infections occurred in 5 patients in the standard group (10%) and in 1 patient in the chlorhexidine group (2%). Although more patients in the standard group had catheter-related bloodstream infections, the difference in infection rates between the 2 groups was not significant (P = .07). CONCLUSIONS: Use of chlorhexidine-impregnated dressings reduced rates of catheter-related bloodstream infections, contamination, colonization, and local catheter infection in a pediatric intensive care unit but was not significantly better than use of standard dressings.

A Cross-Sectional Study of Patients' Satisfaction With Totally Implanted Access Ports.

BACKGROUND: Totally implanted access ports (PACs) are valuable tools for the treatment of patients with cancer because they ease the administration of chemotherapy, stem cells, and supportive care by reducing the rate of peripheral vein punctures. OBJECTIVES: The purpose of this study was to evaluate the satisfaction and impairments of activities of daily living of ambulatory patients with PAC systems receiving chemotherapy. METHODS: This cross-sectional, questionnaire-based study evaluated 202 patients with PAC systems in a comprehensive cancer center and cancer rehabilitation center. From November 2012 to August 2013, patients were invited to answer a questionnaire concerning quality of life and satisfaction with their PAC devices. Data regarding PAC-related complications were collected retrospectively by searching patients' medical history. FINDINGS: A total of 202 patients with 230 PAC devices were included. Median time from PAC implantation to inclusion in the study was nine months. Surgical complications occurred in some cases, with bleeding and hematoma being the most frequently observed events. Late complications consisted of infections, drug extravasation, PAC malposition, PAC malfunction, and thrombosis. A third of the patients reported that their PAC interfered with activities of daily living. However, most agreed that PAC systems alleviated the burden of chemotherapy administration, and the vast majority said they would choose the implantation of a PAC system for chemotherapy administration again.

[Tunnelled central venous line-associated infections in patients with pulmonary arterial hypertension treated with intravenous prostacyclin]. / Infections liées aux cathéters veineux centraux tunnélisés chez les patients ayant une hypertension artérielle pulmonaire traitée par prostacycline intraveineuse.

Intravenous prostacyclins are a valuable treatment for patients with severe pulmonary arterial hypertension, leading to improved exercise capacity, haemodynamics, quality of life and survival. Unfortunately, due to the short half-life of these drugs, they need to be administered continuously through central venous catheters. Despite aseptic technique, regular dressing changes, tunneled central venous catheters and patient education, patients are exposed to central venous catheter associated infections. These infections cause significant morbidity and mortality. The clinical presentation, microbiology, consequences and management of these central venous catheter associated infections in pulmonary arterial hypertension patients treated with intravenous prostacyclins are discussed.

Comparison of short-term mortality and morbidity between parenteral and enteral nutrition for adults without cancer: a propensity-matched analysis using a national inpatient database.

BACKGROUND: Proper artificial nutrition for patients who are unable to eat normally is an ongoing, unresolved concern in geriatric medicine and home medical care. Controversy surrounds prognostic differences between parenteral and enteral nutrition, 2 methods for artificial nutrition. OBJECTIVES: Short-term outcomes of parenteral and enteral nutrition for patients who are unable to eat normally were compared and analyzed. DESIGN: Data were acquired from patients selected from a national inpatient database covering 1057 hospitals in Japan. Participants had received artificial nutrition between April 2012 and March 2013, were aged ≥20 y, and did not have cancer. They were separated into 2 groups: those who received parenteral nutrition and those who received enteral nutrition. We performed one-to-one propensity score matching between the groups. The primary outcome measurements were mortality rates at 30 and 90 d after the start of the procedure. The secondary outcomes were postprocedural complications, pneumonia, and sepsis. We analyzed survival length of stay after the procedure with the use of a Cox proportional hazards model. RESULTS: There were 3750 patients in the parenteral group and 22,166 patients in the enteral group. Propensity score matching created 2912 pairs in the 2 groups. Patients with a similar propensity score (probability of being assigned to the enteral group) calculated from the baseline condition were matched. Mortality rates at 30 and 90 d after start of treatment were 7.6% and 5.7% (P = 0.003) and 12.3% and 9.9% (P = 0.002) in the parenteral and enteral groups, respectively. In Cox regression analysis, the HR for the enteral group relative to the parenteral group was 0.62 (95% CI: 0.54, 0.71; P < 0.001). The incidences of postprocedural pneumonia and sepsis were 11.9% and 15.5% (P < 0.001) and 4.4% and 3.7% (P = 0.164) for the parenteral and enteral groups, respectively. CONCLUSION: The present analysis showed the better survival rate with enteral compared with parenteral nutrition for adults who were not suffering from cancer. This trial was registered at clinicaltrials.gov as NCT02512224.

Body surface infrared thermometry in patients with central venous cateter-related infections.

OBJECTIVE: To evaluate if body surface temperature close to the central venous catheter insertion area is different when patients develop catheter-related bloodstream infections. METHODS: Observational cross-sectional study. Using a non-contact infrared thermometer, 3 consecutive measurements of body surface temperature were collected from 39 patients with central venous catheter on the following sites: nearby the catheter insertion area or totally implantable catheter reservoir, the equivalent contralateral region (without catheter), and forehead of the same subject. RESULTS: A total of 323 observations were collected. Respectively, both in male and female patients, disregarding the occurrence of infection, the mean temperature on the catheter area minus that on the contralateral region (mean ± standard deviation: -0.3±0.6°C versus-0.2±0.5ºC; p=0.36), and the mean temperature on the catheter area minus that on the forehead (mean ± standard deviation: -0.2±0.5°C versus-0.1±0.5ºC; p=0.3) resulted in negative values. Moreover, in infected patients, higher values were obtained on the catheter area (95%CI: 36.6-37.5ºC versus 36.3-36.5ºC; p<0.01) and by temperature subtractions: catheter area minus contralateral region (95%CI: -0.17 - +0.33ºC versus -0.33 - -0.20ºC; p=0.02) and catheter area minus forehead (95%CI: -0.02 - +0.55ºC versus-0.22 - -0.10ºC; p<0.01). CONCLUSION: Using a non-contact infrared thermometer, patients with catheter-related bloodstream infections had higher temperature values both around catheter insertion area and in the subtraction of the temperatures on the contralateral and forehead regions from those on the catheter area.