The efficacy of cuff-shaving combined with negative pressure wound therapy in refractory exit-site and tunnel infections: a single center experience.

BACKGROUND: Refractory exit-site infections (ESIs) and tunnel infections (TIs) are challenging complications for patients undergoing peritoneal dialysis (PD). This study compared the outcomes of surgical intervention, notably the cuff-shaving (CS) procedure coupled with negative-pressure wound therapy (NPWT), and conservative management strategies for patients with refractory ESI and TI. METHODS: We retrospectively reviewed patients who underwent PD at our center, focusing on the incidence and management of ESI and TI. We evaluated and compared treatment outcomes, including ESI scores, frequency of ESI and/or TI, identification of causative microorganisms, and duration of catheter survival or time until removal. RESULTS: We identified 97 episodes of catheter-related ESI and/or TI across 71 patients with an incidence rate of 0.15 episodes per patient-year. Of the 23 patients with refractory ESI and/or TI, surgical intervention was performed in 8, while 15 chose conservative management. In the one-month follow-up, patients who underwent CS combined with NPWT showed no complications such as leakage, and their local symptoms resolved completely. The mean PD catheter survival time was significantly longer in the surgical group (29.38 ± 7.25 months) than in the conservative group (7.86 ± 2.13 months). Surgical intervention demonstrated a significantly higher therapeutic efficacy and extended catheter survival. CONCLUSIONS: The combination of CS and NPWT as a surgical approach is crucial for eradicating infectious foci and significantly improving the longevity of PD catheter function. This integrated surgical strategy offers a promising solution for the management of refractory ESI and TI in patients undergoing PD.

Consensus document of the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Intensive Care (SECIP) for the diagnosis and treatment of central venous catheter-related infections in paediatric care.

Intravascular devices are essential for the diagnostic and therapeutic approach to multiple diseases in paediatrics, and central venous catheters (CVCs) are especially important. One of the most frequent complications is the infection of these devices, which is associated with a high morbidity and mortality. These infections are highly complex, requiring the use of substantial resources, both for their diagnosis and treatment, and affect vulnerable paediatric patients admitted to high-complexity units more frequently. There is less evidence on their management in paediatric patients compared to adults, and no consensus documents on the subject have been published in Spain. The objective of this document, developed jointly by the Spanish Society of Paediatric Infectious Diseases (SEIP) and the Spanish Society of Paediatric Intensive Care (SECIP), is to provide consensus recommendations based on the greatest degree of evidence available to optimize the diagnosis and treatment of catheter-related bloodstream infections (CRBSIs). This document focuses on non-neonatal paediatric patients with CRBSIs and does not address the prevention of these infections.

Tunnel ultrasound can guide the use of peritoneal dialysis catheter exit site relocation by external splicing and cuff removal in refractory tunnel infection.

BACKGROUND: Peritoneal dialysis (PD) catheter related infections continue to be a major cause of morbidity and transfer to hemodialysis (HD) in PD patients. The treatment of tunnel infection (TI) could be challenging, especially when the infection involves the superficial cuff requiring the removal of the catheter. To spare the patient the loss of the catheter and the transfer to HD, several mini-invasive surgical techniques have been proposed as rescue therapy. Furthermore, nowadays, the rapid growth of digital technology has enormously increased the diagnostic sensibility of the echo signal allowing to accurately defines the extent of the infectious process along the PD catheter tunnel. METHODS: Between 1st January 2020 and 31st December 2021 seven patients who underwent exit-site relocation by external splicing and cuff removal at our institution due to refractory TI were included in the study. All patients were followed until 12 months after the procedure. As soon as TI was defined refractory to the medical therapy, an ultrasonographic examination of the catheter tunnel was performed to define the extent of the infectious episode. RESULTS: Among the 7 infectious episodes, 4 were caused by P. aeruginosa, and 3 by S. aureus. Around the superficial cuff the hypo/anechoic collections detected by ultrasounds showed a mean diameter of 3.05 ± 0.79 mm. The exit-site relocation by external splicing and cuff removal was successful in all cases (7/7, 100%). CONCLUSIONS: In our experience the use of exit site relocation by external splicing and cuff removal as rescue therapy for TI with positive ultrasounds for TI limited to superficial cuff involvement and without secondary peritonitis, yielded to promising results with a success rate of 100%. This preliminary experience underlines the paramount usefulness of tunnel echography in accurately defining the extent of TI and, consequently, guiding the choice of the therapeutical approach in refractory TI.

Haemodialysis vascular catheter-related blood stream infection: Organism types and clinical outcomes.

Catheter-related bloodstream infection (CRBI) is an important complication of catheter use for haemodialysis, but it remains unclear whether clinical outcomes following CRBI are influenced by organism type. This study aims to compare clinical outcomes following CRBI from Gram-positive and non-Gram-positive organisms. This was a retrospective cohort study of patients with kidney failure receiving haemodialysis (HD) via vascular catheters who had a documented episode of CRBI in Western Australia between 2005 and 2018. The associations between organism type, likelihood of hospitalization, catheter removal and death from CRBI were examined using adjusted logistic regression models. There were 111 episodes of CRBI in 99 patients (6.1 episodes per 1000-catheter-days at risk). Of the study cohort, 53 (48%) were male and 38 (34%) identified as Aboriginal or Torres Strait Islander. Gram-positive organisms were identified in 73 (66%) CRBI episodes, most commonly Staphylococcus aureus. Of those with non-Gram-positive CRBI, 9 (24%) were attributed to Pseudomonas aeruginosa. One-hundred and two (92%) episodes of CRBI required hospitalization and 15 (13%) patients died from CRBI. Compared with non-Gram-positive CRBI, Gram-positive CRBI was associated with an increased risk of hospitalization and catheter removal, with adjusted odds ratio of 9.34 (95% CI 1.28-68.03) and 3.47 (95% CI 1.25-9.67), respectively. There was no association between organism type and death from CRBI. Staphylococcus aureus remains the most common organism causing CRBI in HD patients. CRBI is associated with substantial morbidity, particularly CRBI attributed to Gram-positive organisms.

A pig model of tunneled dialysis catheter (TDC) infection and dysfunction: Opportunities for therapeutic innovation.

BACKGROUND: Although tunneled dialysis catheters (TDC) are far from ideal, they still represent the main form of vascular access for most patients beginning dialysis. Catheters are easy to place and allow patients instant access to dialysis, but regardless of these benefits, catheters are associated with a high incidence of significant complications like bloodstream infections, central venous stenosis, thrombosis, and dysfunction. In the present study, we aim to describe and characterize a swine model of catheter dysfunction and bloodstream infection, that recreates the clinical scenario, to help to serve as a platform to develop therapeutic innovations for this important clinical problem. METHODS: Six Yorkshire cross pigs were used in this study. Non-coated commercial catheters were implanted in the external jugular recreating the main features of common clinical practice. Catheters were aseptically accessed twice a week for a mock dialysis procedure (flushing in and out) to assess for and identify catheter dysfunction. Animals were monitored daily for infections; once detected, blood samples were collected for bacterial culture and antibiograms. Study animals were euthanized when nonresponsive to treatment. Tissue samples were collected in a standardized fashion for macroscopic inspection and histological analysis. RESULTS: The data analysis revealed an early onset of infection with a median time to infection of 9 days, 40% of the isolates were polymicrobial, and the average time to euthanasia was 20.16 ± 7.3 days. Median time to catheter dysfunction onset was 6 days post-implantation. Postmortem dissection revealed external fibrin sheath and internal thrombosis as the main causes of catheter dysfunction. There was also evidence of central venous stenosis with positive cells for αSMA, CD68, Ki67, Smoothelin, and Vimentin within the venous neointima. CONCLUSIONS: The described model represents a reliable and reproducible large animal model of catheter dysfunction and bloodstream infection, which recreates all the main complications of TDC's and so could be used as a validated large animal model to develop new therapies for TDC related infection, thrombosis/dysfunction and central venous stenosis.

The predictors of catheter-related bloodstream infections in patients undergoing hemodialysis: A single center experience.

BACKGROUND: Here we aimed to investigate the predictors of catheter-related bloodstream infections (CRBSI) in patients with acute kidney injury or chronic kidney disease who required renal replacement therapy through a non-tunneled hemodialysis catheter. METHODS: A total of 111 patients who received non-tunneled hemodialysis catheters were retrospectively evaluated. Patients were divided into two groups; those who developed CRBSI and those who did not. Patient's demographic data, laboratory results at admission, information regarding catheter infections, and culture results were obtained from electronic medical records. RESULTS: The mean age of the patients was 64 ± 16 years, and 51 of them were male. CRBSI occurred in 14 patients (12.6%). Admission serum albumin level (OR: 0.119, 95% CI: 0.019-0.756, p = 0.024), admission mean platelet volume (OR: 2.207, 95% CI: 1.188-4.100, p = 0.012) and catheter duration (OR: 1.580, 95% CI: 1.210-2.064, p = 0.001) were independent predictors for the CRBSI development. ROC curve analysis demonstrated that a catheter duration of 22 days was predictive for presence of CRBSI (78% sensitivity, 76% specificity, AUC: 0.825, 95% CI: 0.724-0.925, p < 0.001). CONCLUSIONS: Prolonged catheter duration, low serum albumin, and high mean platelet volume independently predict the development of CRBSI in patients undergoing hemodialysis for acute kidney injury or chronic kidney disease.

Subcutaneously anchored securement for peripherally inserted central catheters: Immediate, early, and late complications.

BACKGROUND: An adequate stabilization of a vascular device is an important part of insertion bundles and is an effective strategy in reducing complications. Dislodgment has a relevant clinical impact and an increase in healthcare costs. METHOD: We have retrospectively investigated the safety and efficacy of Subcutaneously Anchored Securement (SAS) for Peripherally Inserted Central Catheters (PICC) in cancer patients. RESULTS: We analyzed 639 patients who had a PICC inserted and secured with SAS, over the past 3 years (2018-2020). No immediate complications during SAS placement were reported. In the first 24-48 h, a slight local ecchymosis was reported in 24 cases with rapid spontaneous resolution. No cases of bleeding or hematoma of the exit site were reported. The total number of catheter days was 93078. Dislodgment occurred only in seven cases (1.1%). In 16 patients, the PICC was removed because of catheter-related bloodstream infection (CRBSI): the overall incidence of CRBSI was 0.17 per 1000 catheter days. Symptomatic venous thrombosis was documented in 12 patients (1.9%) and treated with low molecular weight heparin without PICC removal. We had no cases of irreversible lumen occlusion. In 17 patients, local discomfort-including device-related pressure ulcers and painful inflammation-was reported: these cases were treated without SAS removal or PICC removal. CONCLUSION: In this retrospective analysis, subcutaneously anchored securement of PICCs was a safe and effective strategy for reducing the risk of dislodgment.

A scoping review of Clinical Studies, Hospital Group Reports and National Strategic Documents on vascular access devices in cancer patients.

INTRODUCTION: The extent of vascular/venous access device (VAD) research output from the Island of Ireland is unknown. The identification of the papers available is important to create a future research agenda. OBJECTIVES: The main objective of this study is to answer three questions: What is the number and descriptive quality of reported Vascular Access Device literature from the Island of Ireland? Is the reporting of Catheter Related Infection rates for cancer patients common in Irish Hospital Groups, National Cancer Reports and Publication Outputs? What are the implications for future research in this area? METHODS: We used a scoping review and searched selected databases, grey literature and hospital regulatory bodies websites following the Joanna Briggs Institute Guidelines 2017. A data charting form was developed based on a template from the Joanna Briggs Institute and this was used to extract data from the included reports. RESULTS: A total of 660 reports were screened. Sixty-one full text articles were reviewed from which 20 reports were included for data extraction. Of the reports included the following designs were used: nine retrospective study designs, four guidelines, two prospective study designs, two literature reviews and one of the following; survey, case study and cross sectional analysis designs. We did not identify any randomised controlled trials, systematic reviews, meta-analysis, meta-synthesis and scoping reviews. Five studies included catheter related infection rates. Gaps in the research include the collection of data sets and the need to establish a VAD registry; develop core outcomes for VADs; assessment and evaluation of VAD care bundles among cancer patients; and, the inclusion of public and patient involvement in future VAD research. CONCLUSION: The reporting of VAD outcomes in published literature regarding cancer patients receiving treatment in Ireland is inconsistent and varied with no interventional studies addressing vascular access complications in cancer care.

Midline peripheral catheters inserted in the superficial femoral vein at mid-thigh: Wise choice in COVID-19 acute hypoxemic respiratory failure patients with helmet continuous positive airway pressure.

BACKGROUND: During coronavirus disease 2019 (COVID-19) pandemic, Helmet Continuous Positive Airway Pressure (h-CPAP) has been widely used to treat Acute Hypoxemic Respiratory Failure (AHRF). In COVID-19 patients undergoing h-CPAP a simple short peripheral catheter could be insufficient. According to the European Recommendations for Proper Indication and Use of Peripheral venous access consensus, a stable peripheral Vascular Access Device is indicated for intravenous treatment compatible with the peripheral route scheduled for more than 1 week. OBJECTIVE: The aim of this prospective study was to evaluate the performance and the potential complications of superficial femoral midline catheters (SFMC) inserted in the Superficial Femoral Vein by direct Seldinger technique with peripheral tip (Arrow®, Teleflex; 20 cm length four FR single lumen and seven FR dual lumen) in AHRF COVID-19 patient. Complications were divided in early (accidental puncture of superficial femoral artery (APSFA); accidental saphenous nerve puncture (ASNP); bleeding) and late (Catheter Related Thrombosis (CRT); Catheter-Related Bloodstream Infections (CRBSI); Accidental Removal (AR); persistent withdrawal occlusion (PWO)). METHODS: From 1st October 2020 to 30th June 2021 we conducted a prospective observational study in COVID-19 sub-intensive wards at Luigi Sacco Hospital (Milan). RESULTS: Hundred seventy five SFMC (mean dwell time 11.1 ± 9.8 days) were implanted in COVID-19 patients, 107 (61.1%) during h-CPAP treatment (10.5 ± 8.9 days), the remaining 68 (38.9%) in patients with severe disease. We recorded two minor immediate/early complications (APSFA without sequelae) and no major complications.The long-term follow-up registered four CRBSI (2.3%-2.5/1000 catheters days (CD)), five CRT (2.9%: 2.6/1000 CD), 22 AR (12.6%; 11.4/1000 CD), 38 PWO (36.5%), 34 of which occurred due to fibroblastic sleeve (32.7%). CONCLUSIONS: SFMC proved to be safe, easy and time-saving. It could be implemented, after a careful benefits and risks evaluation, in particular settings such as h-CPAP, delirium, bleeding risk factors and palliative care patients.

Catheter salvage using revision for a peritoneal dialysis catheter with intractable exit site and/or tunnel infections.

BACKGROUND: In case of intractable exit site and/or tunnel infections, peritoneal dialysis (PD) catheter removal and re-insertion are recommended. Previous studies have reported the possibility of catheter salvage before removal, but they were either case-series or had a small sample size. METHODS: We identified all incident patients with PD who underwent revision at a tertiary medical center. In intractable exit site and/or tunnel infections, we tried catheter revision using a method with cuff shaving, using an original catheter, and creating a new tunnel. Revision success was defined as complete remission over more than 1 month after revision. We evaluated the infection-free and catheter survival rates. RESULTS: In total, 52 patients with PD underwent revision. The median age at the time of revision in the patients undergoing PD was 51 (21) years. There were 43 (82.7%) cases of revision success. Infection-free survival rates at 6 and 12 months were 57.0% and 35.1%, respectively. Catheter survival rates at 12 and 36 months were 72.5% and 56.2%, respectively. CONCLUSION: The present study demonstrated that catheter revision can be a useful bridging method for original catheter salvage before catheter removal in intractable exit site and/or tunnel infections.

Early removal of a permanent catheter during the acute management of the unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection: a multi-disciplinary survey and review of the literature.

There are no guidelines for the optimal manner and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infections (CRBSI). Our goals were to examine current practices of permanent central catheter management and choice of removal in the hemodynamically unstable pediatric patient with suspected CRBSI among practitioners in diverse subspecialties. We performed a literature review on the subject, and conducted a multi-disciplinary survey included pediatric oncologists, pediatric emergency medicine physicians, and pediatric intensive care physicians whom we queried about their choice of permanent central catheter management and removal while treating the hemodynamically unstable pediatric patient with suspected CRBSI. Most of the 78 responders (n = 47, 59%) preferred to utilize the existing permanent central catheter for initial intravenous access rather than an alternative access. There were no significant differences between physician subspecialties (p = 0.29) or training levels (p = 0.14). Significantly more pediatric emergency medicine physicians preferred not to remove the permanent central catheter at any time point compared to the pediatric hemato-oncologists, who preferred to remove it at some point during the acute presentation (44.4% vs. 9.4%, respectively, p = 0.02). CONCLUSION: Our study findings reflect the need for uniform guidelines on permanent central catheter use and indications for its removal in the hemodynamically unstable pediatric patient. We suggest that permanent central catheter removal should be urgently considered in a deteriorating patient who failed to be stabilized with medical treatment. WHAT IS KNOWN: • There are no guidelines for the optimal choice and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection (CRBSI). WHAT IS NEW: • We found variations in practices among pediatricians from diverse subspecialties and conflicting data in the literature. • There is a need for prospective studies to provide uniform guidelines for optimal management of suspected CRBSI in the hemodynamically unstable pediatric patient.

Successful Management of Recurrent Tunneled Dialysis Catheter Infections with the Hemodialysis Reliable Outflow Graft Device.

The hemodialysis reliable outflow (HeRO) graft was designed for patients with failed arteriovenous accesses caused by an obstructed central venous outflow or patients who have exhausted all upper arm options. We describe a patient with severe stenosis of the superior vena cava (SVC) who experienced recurrent episodes of infection of permanent tunneled catheters, resulting in repeated hospitalizations. We successfully used the HeRO graft after angioplasty of the SVC. This indication for placing the HeRO graft has not been emphasized and mentioned previously in the literature. We also reviewed the literature regarding comparisons of this technique with other options.

Are salvage techniques safe and effective in the treatment of peritoneal dialysis catheter-related exit-site and tunnel infections? A systematic review and description of the authors' preferred technique.

BACKGROUND: Peritoneal dialysis catheter (PDC)-related infections account for significant morbidity, PD disruptions and costs. Patients with refractory exit-site or tunnel track infections without peritonitis may need catheter removal and reinsertion which can be complicated by bleeding, organ injury, catheter failure or malposition. Some patients may need to switch to haemodialysis in such a setting. An alternative is a salvage procedure. The purpose of this systematic review is to evaluate the safety and efficacy of salvage techniques. METHODS: A comprehensive search of PubMed, Medline and Scopus databases was performed from inception to December 2021 in accordance with PRISMA guidelines. After a broad search, articles were stratified into two main categories for assessment: (1) cuff-shaving (CS) techniques and its variations of en-bloc resection (BR) and/or catheter diversion (CD) and (2) partial reimplantation with CD. RESULTS: A total of 409 patients (445 salvage procedures) from 20 studies were included in analysis. Of 409 patients, 234 patients (57.2%) underwent 251 (56.4%) CS procedures and its variations, 163 patients (39.9%) underwent 182 (40.9%) partial PDC reimplantations with CD and 12 patients (2.7%) underwent local curettage. Overall PDC salvage rate after intervention was 73.2%. Overall PDC removal rate attributable to infection was 26.8%. Overall complication rate attributable to the procedures was 2.7%, with the most common complication being dialysate leakage (n = 10) followed by PDC laceration (n = 1) and subcutaneous haematoma (n = 1). We also included a description of our technique of BR of infected tissue, CS and CD. In a series of six patients, the PDC salvage rate was 83.3% and median PDC survival after intervention was 10 months. CONCLUSION: PDC salvage techniques are relatively safe and provide reasonable catheter salvage rates in selected patients. Results of this review should lend weight to consideration of a salvage-first approach as an option in selected patients.

Management of home parenteral nutrition catheter-related bloodstream infections in hospitals outside of a specialized intestinal failure center.

INTRODUCTION: Catheter-related bloodstream infections (CRBSIs) remain the commonest complication associated with home parenteral nutrition (HPN). Although the management outcomes of CRBSIs have been extensively reported by specialized intestinal failure (IF) centers, there are minimal data reporting CRBSI outcomes for HPN-dependent patients admitted to nonspecialized hospitals. METHOD: This was an observational study from a prospectively maintained database of CRBSIs in HPN-dependent patients managed outside of a specialized IF center. RESULTS: Three hundred and six patients from a total cohort of 1066 HPN-dependent patients suffered from 489 CRBSI events from 2003 to 2021; after 2017, 71 of these events were managed at the patient's local, nonspecialized hospital and the remainder at the specialized IF center. From 2017 to 2021, salvage of the central venous catheter (CVC) with antimicrobial therapy was attempted in 32 out of 71 (45.1%) patients admitted to the nonspecialized hospital, with successful salvage recorded in 23 (71.8%) cases. Notably, CVC salvage was attempted more commonly (77 out of 103 [74.8%]; P = 0.004 vs nonspecialized hospital), with a better salvage success rate (64 out of 77 [83.1%] P = 0.01 vs nonspecialized hospital) in patients who were admitted to the specialized IF center. CONCLUSION: In some instances, CRBSIs can be effectively managed when patients presenting to a nonspecialized hospital; however, overall salvage is more likely to be successful in the specialized setting. Further development of clinical and educational networks between IF centers and patients' local hospitals aimed at standardizing care may lead to improved CRBSI outcomes.

Human monoclonal antibodies against Staphylococcus aureus surface antigens recognize in vitro and in vivo biofilm.

Implant-associated Staphylococcus aureus infections are difficult to treat because of biofilm formation. Bacteria in a biofilm are often insensitive to antibiotics and host immunity. Monoclonal antibodies (mAbs) could provide an alternative approach to improve the diagnosis and potential treatment of biofilm-related infections. Here, we show that mAbs targeting common surface components of S. aureus can recognize clinically relevant biofilm types. The mAbs were also shown to bind a collection of clinical isolates derived from different biofilm-associated infections (endocarditis, prosthetic joint, catheter). We identify two groups of antibodies: one group that uniquely binds S. aureus in biofilm state and one that recognizes S. aureus in both biofilm and planktonic state. Furthermore, we show that a mAb recognizing wall teichoic acid (clone 4497) specifically localizes to a subcutaneously implanted pre-colonized catheter in mice. In conclusion, we demonstrate the capacity of several human mAbs to detect S. aureus biofilms in vitro and in vivo.

Persistent colonization of exit site is associated with modality failure in peritoneal dialysis.

Exit-site infections (ESIs) increase the risk of developing peritoneal dialysis (PD) peritonitis and PD technique failure. There are no clear guidelines on how to monitor exit site (ES) after ESI with Staphylococcus aureus or Pseudomonas. We report on a 1-year observational study of 23 patients who developed an ESI with one of these serious pathogens. After completing initial antibiotic treatment, swabs were taken every month for 3 months. Primary treatment cure occurred in 19/23 (83%). Colonization of ES after primary cure occurred in 8/19 (42%) patients. In the eight colonized patients, five had subsequent PD technique failure due to infections. By contrast, during an average follow-up period of 7.2 months, none of the 11 patients who were proven noncolonized developed PD technique failure from infections; HR (colonized vs. noncolonized) = 10.89, 95% CI 2.6-45.43, p < 0.05. In conclusion, colonization significantly increased the risk of catheter loss. Increased surveillance and aggressive treatment may ameliorate this risk.

Preservation of native sigmoid colon for secondary continent cystostomy after multivisceral transplantation for chronic intestinal pseudo-obstruction.

Chronic intestinal pseudo-obstruction (CIPO) is characterized by severe digestive +/- urinary dysmotility. If the conservative management fails, multivisceral transplantation (MVT) may be needed. However, urinary dysmotility remains after MVT and requires to continue urinary catheterizations and/or drainage. We report on a boy with severe CIPO complicated by (1) chronic intestinal obstruction requiring total parenteral nutrition, decompression gastrostomy, and ileostomy; (2) recurrent line infections; (3) hepatic fibrosis; and (4) distension of the bladder and upper urinary tract, and recurrent urinary infections, leading to non-continent cystostomy for urinary drainage. He underwent MVT at the age of 5 years. The transplant included the liver, stomach, duodenum and pancreas, small bowel, and right colon. The distal native sigmoid colon was preserved. Fifteen months later, he underwent a pull through of the transplanted right colon (Duhamel's procedure), together with a tube continent cystostomy (Monti's procedure) using the native sigmoid. Postoperative course was uneventful, and the remaining ileostomy was closed 3 months later. Five years post-transplant, he is alive and well. He is fed by mouth with complementary gastrostomy feeding at night. He has 3-6 stools per day, with occasional soiling. The cystostomy is used for intermittent urinary catheterization 4 times/day and continuous drainage at night. He is dry, with rare afebrile urinary infections, normal renal function, and un-dilated upper urinary tract. Conclusion: in severe CIPO with urinary involvement, preservation of the distal native sigmoid colon during MVT allows secondary creation of a continent tube cystostomy, which is useful to manage persistent urinary disease.

Central Venous Catheter Salvage in Ambulatory Central Line-Associated Bloodstream Infections.

BACKGROUND: Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. METHODS: This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. RESULTS: A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CONCLUSIONS: CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.

The diagnostic value of [18F]FDG-PET/CT in detecting septic thrombosis in patients with central venous catheter-related Staphylococcus aureus bacteremia.

PURPOSE: Septic thrombosis often complicates Staphylococcus aureus bacteremia (SAB) in patients with a central venous catheter. Currently there is no reference standard for diagnosis. We describe the diagnostic value of [18F]FDG-PET/CT imaging in a patient cohort and the potential contribution of quantitative measurements in detecting septic thrombosis. METHODS: We selected patients with catheter-related SAB from our institutional database (2013-2020). The contribution of [18F]FDG-PET/CT on clinical diagnosis of septic thrombosis was evaluated. Standardized Uptake Values (SUV) were measured and compared with a composite reference standard (clinical signs, initial [18F]FDG-PET/CT result, Multidisciplinary Team (MDT) meeting outcome) to identify a cut-off value for detecting septic thrombosis. RESULTS: We identified 93 patients with a catheter-related SAB. Quantitative measurements were possible for 43/56 patients in whom a [18F]FDG-PET/CT scan was performed. Septic thrombosis was clinically diagnosed in 30% (13/43) of the cases. In 85% of these cases, significant [18F]FDG-PET/CT uptake at the site of the thrombus was the deciding factor for diagnosis of septic thrombosis during the MDT meeting. All mean SUV's of thrombotic lesions were higher in patients with clinically proven septic thrombosis compared to patients in whom this diagnosis was rejected (p < 0.001). A SUVpeak thrombus/SUVmean blood ratio of 1.6 (AUC-ROC value 0.982) as cut-off to differentiate between septic thrombosis and non-septic thrombosis had a sensitivity of 92% (95% CI 64-100) and specificity of 89% (95% CI 65-99). An algorithm was designed to guide diagnosis of septic thrombosis. CONCLUSION: Quantitative [18F]FDG-PET/CT-derived parameters seem helpful to differentiate between septic and non-septic thrombosis in patients with catheter-related SAB.

Management of enterococcal central line-associated bloodstream infections in patients with cancer.

OBJECTIVE: Enterococcus species are the third most common organisms causing central line-associated bloodstream infections (CLABSIs). The management of enterococcal CLABSI, including the need for and timing of catheter removal, is not well defined. We therefore conducted this study to determine the optimal management of enterococcal CLABSI in cancer patients. METHODS: We reviewed data for 542 patients diagnosed with Enterococcus bacteremia between September 2011 to December 2018. After excluding patients without an indwelling central venous catheter (CVC), polymicrobial bacteremia or with CVC placement less than 48 h from bacteremia onset we classified the remaining 397 patients into 3 groups: Group 1 (G1) consisted of patients with CLABSI with mucosal barrier injury (MBI), Group 2 (G2) included patients with either catheter-related bloodstream infection (CRBSI) as defined in 2009 Clinical Practice Guidelines for the Diagnosis and Management of Intravascular Catheter-Related Infection by the Infectious Diseases Society of America (IDSA) or CLABSI without MBI, and Group 3 (G3) consisted of patients who did not meet the CDC criteria for CLABSI. The impact of early (< 3 days after bacteremia onset) and late (3-7 days) CVC removal was compared. The composite primary outcome included absence of microbiologic recurrence, 90-day infection-related mortality, and 90-day infection-related complications. RESULTS: Among patients in G2, CVC removal within 3 days of bacteremia onset was associated with a trend towards a better overall outcome than those whose CVCs were removed later between days 3 to 7 (success rate 88% vs 63%). However, those who had CVCs retained beyond 7 days had a similar successful outcome than those who had CVC removal < 3 days (92% vs. 88%). In G1, catheter retention (removal > 7 days) was associated with a better success rates than catheter removal between 3 and 7 days (93% vs. 67%, p = 0.003). In non-CLABSI cases (G3), CVC retention (withdrawal > 7 days) was significantly associated with a higher success rates compared to early CVC removal (< 3 days) (90% vs. 64%, p = 0.006). CONCLUSION: Catheter management in patients with enterococcal bacteremia is challenging. When CVC removal is clinically indicated in patients with enterococcal CLABSI, earlier removal in less than 3 days may be associated with better outcomes. Based on our data, we cannot make firm conclusions about whether earlier removal (< 3 days) could be associated with better outcomes in patients with Enterococcal CLABSI whose CVC withdrawal is clinically indicated. In contrast, it seemed that catheter retention was associated to higher success outcome rates. Therefore, future studies are needed to clearly assess this aspect.