Ultrasonographic Findings of Catheter-Related Bloodstream Infection in Pediatric Patients.

BACKGROUND: Catheter removal is essential for treating catheter-related bloodstream infection (CRBSI); however, clinicians are sometimes hesitant to remove catheters in pediatric patients due to the difficulty of securing vascular access. Confirming the diagnosis of CRBSI is important to justify catheter removal. The purpose of this study was to describe the sonographic findings of CRBSI. MATERIALS AND METHODS: We included patients with a central venous catheter (CVC) or peripherally inserted central catheter (PICC) who had a positive blood culture and underwent ultrasound. The patients were classified as with or without CRBSI. Sonographic findings, such as the presence/absence of thrombus, venous wall thickening, hyperechogenicity, and fluid collection around the vein were compared using Fisher's exact test. RESULTS: Of the 58 patients, 38 (66%) were diagnosed with CRBSI. The presence of thrombus (19/38 vs 3/20, P = .011); and hyperechogenicity around the vein (14/38 vs 2/20, P = .035) differed significantly, but There was no significant difference in the presence of venous wall thickening (10/38 vs 1/20, P = .077), and fluid collection around the vein (5/38 vs 0/20, P = .153), did not differ significantly in patients with and without CRBSI, respectively. One-third of patients with CRBSI, including 11 (42.3%) patients with CVC, and 2 (16.7%) patients with PICC, did not have abnormal sonographic findings. CONCLUSION: Ultrasound findings are useful for diagnosing CRBSI. However, the sensitivity of sonographic findings is low and abnormal sonographic findings are sometimes absent in children with CRBSI; therefore, physicians should not rule out CRBSI based on normal sonographic findings, especially in patients a CVC and a positive blood culture.

Utility of ultrasonographic examination in catheter-related infections in peritoneal dialysis: a clinical approach.

Peritoneal dialysis- (PD) related infections continue to be a major cause of morbidity and mortality in patients on renal replacement therapy via PD. However, despite the great efforts in the prevention of PD-related infectious episodes, approximately one third of technical failures are still caused by peritonitis. Recent studies support the theory that ascribes to exit-site and tunnel infections a direct role in causing peritonitis. Hence, prompt exit site infection/tunnel infection diagnosis would allow the timely start of the most appropriate treatment, thereby decreasing the potential complications and enhancing technique survival. Ultrasound examination is a simple, rapid, non-invasive and widely available procedure for tunnel evaluation in PD catheter-related infections. In case of an exit site infection, ultrasound examination has greater sensitivity in diagnosing simultaneous tunnel infection compared to the physical exam alone. This allows distinguishing the exit site infection, which will likely respond to antibiotic therapy, from infections that are likely to be refractory to medical therapy. In case of a tunnel infection, the ultrasound allows localizing the catheter portion involved in the infectious process, thus providing significant prognostic information. In addition, ultrasound performed after two weeks of antibiotic administration allows monitoring patient response to therapy. However, there is no evidence of the usefulness of ultrasound examination as a screening tool for the early diagnosis of tunnel infections in asymptomatic PD patients.

Hepatic Liquoric Cyst as a Complication of Ventriculoperitoneal Shunt Insertion: A Case Report

Background The ventriculoperitoneal shunt (VPS) procedure is still themost used technique for management of hydrocephalus. This article reports a case of hepatic cerebrospinal fluid (CSF) pseudocyst as a rare, but important, complication of the VPS insertion. Case Description An 18-year-old male presented to the hospital complaining of temporal headache and visual turbidity for approximately 3 months with a history of VPS insertion for treatment of hydrocephalus and revision of the valve in adolescence. The diagnosis was based on abdominal imaging, demonstrating an extra-axial hepatic CSF pseudocyst free from infection. Following the diagnosis, the management of the case consisted in the removal and repositioning of the catheter on the opposite site of the peritoneum. Conclusion The hepatic CSF pseudocyst is an infrequent complication of VPS procedure, but it needs to be considered when performing the first evaluation of the patient. Several techniques are considered efficient for the management of this condition, the choice must be made based on the variables of each individual case.

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.

Line days as a determinant of central line-associated bloodstream infections in pediatric patients with tunneled femoral peripherally inserted central catheters.

BACKGROUND: Ultrasound (US)-guided tunneled femoral peripherally inserted central catheters (PICCs) are a safe central venous access option in infants and neonates. Studies have shown, however, that femoral central venous access has the potential for high central line-associated bloodstream infection (CLABSI) rates with a significant increase in risk around line day 30, though no studies have evaluated these risks exclusively for tunneled femoral PICCs. OBJECTIVE: The primary purpose of this study was to evaluate the relationship between line duration and the risk of CLABSI in tunneled femoral PICCs in children. MATERIALS AND METHODS: Four hundred forty-five patients (196 females, 249 males; median age: 49.4 days; median weight: 3.7 kg) who underwent 573 tunneled femoral PICC placements or exchanges from Jan. 1, 2017, to Jan. 31, 2020, were included in the study. All tunneled femoral PICCs were placed using US technique and catheter specifications, including catheter size (French) and length (cm), were retrieved from the electronic medical record. The location of the PICC placement, the number of lumens, the laterality of placement, and the patient's age and weight were also recorded. Only non-mucosal barrier injury CLABSIs, according to the Centers for Disease Control and Prevention (CDC) definitions, were counted as CLABSI for this study. The number of central line days until a CLABSI event was analyzed with an accelerated failure time model using the exponential, Weibull, and log-normal distributions to determine the probability of a CLABSI over time, taking into consideration the recorded covariates. RESULTS: Tunneled femoral PICC placements accounted for 14,855 line days, during which 20 non-mucosal barrier injury CLABSIs (CLABSI rate of 1.35 per 1,000 line days) occurred during the study period. The highest CLABSI rate occurred in PICCs placed in the neonatal intensive care unit (NICU) at 2.01 per 1,000 line days and the lowest occurred in PICCs placed in interventional radiology at 0.26 per 1,000 line days. Overall, PICCs placed outside of interventional radiology had a CLABSI rate of 1.72 per 1,000 line days. The CLABSI rate during the first 30 days a line was in situ was lower than the rate after 30 days (0.51 per 1,000 line days vs. 3.06 per 1,000 line days, respectively). Statistical modeling and hazard estimation using the Akaike information criterion corrected for small sample size (AICc)-average of log-normal, Weibull and exponential distributions demonstrate the daily risk of CLABSI rapidly increases from day 1 to day 30, with the risk remaining high for the duration of line days. CONCLUSION: While tunneled femoral PICCs are a relatively safe and effective central venous access alternative, the rate of CLABSI appears to rapidly increase with increasing line days until around day 30 and then remains high thereafter.

Central venous catheter insertion: Review of recent evidence.

Guidelines for prevention of catheter-related bloodstream infection (CR-BSI) describe a series of recommendations for correct insertion and handling of central venous catheters (CVCs). Since their implementation, quality programs such as "Zero bacteremia" have achieved a reduction in CR-BSI rates, but there is still room for further improvement. New evidence is emerging regarding, e.g., antiseptic-antimicrobial impregnated catheters or the use of passive disinfection of closed connectors. These examples of new tools among others might help to further decrease infection rates. This article aims to review new evidence-based strategies to reduce catheter insertion-related infection.

Valoración del orificio de inserción del catéter tunelizado para hemodiálisis mediante el uso de cámara térmica acoplada a smartphone: estudio piloto / Assessment of tunneled hemodialysis catheter insertion site using a thermal camera attached to smartphone: A pilot study

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Use of ultrasounds in PD catheter-related infections: indications and clinical implications / Utilizzo degli ultrasuoni nelle infezioni da catetere peritoneale: indicazioni e risvolti clinici

Peritoneal dialysis (PD) related infections continue to be a major cause of morbidity and mortality in patients undertaking renal replacement therapy with PD. Nevertheless, despite the great effort invested in the prevention of PD infective episodes, almost one third of technical failures are still caused by peritonitis. Recent studies support the idea that there is a direct role of exit-site (ESIs) and tunnel infections (TIs) in causing peritonitis. Hence, both the prompt ESI/TI diagnosis and correct prognostic hypothesis would allow the timely start of an appropriate antibiotic therapy decreasing the associated complications and preserving the PD technique. The ultrasound exam (US) is a simple, rapid, non-invasive and widely available procedure for the tunnel evaluation in PD catheter-related infections. In case of ESI, the US possesses a greater sensibility in diagnosing a simultaneous TI compared to the clinical criterions. This peculiarity allows to distinguish the ESI episodes which will be healed with antibiotic therapy from those refractories to medical therapy. In case of TI, the US permits to localize the catheter portion involved in the infectious process obtaining significant prognostic information; while the US repetition after two weeks of antibiotic allows to monitor the patient responsiveness to the therapy. There is no evidence of the US usefulness as screening tool aimed to the precocious diagnosis of TI in asymptomatic PD patients.

Catheter-related infection due to Papiliotrema laurentii in an oncologic patient: Case report and systematic review

ABSTRACT Background: Papiliotrema laurentii is one of several non-neoformans cryptococci that have rarely been associated with human infection, since it was previously considered saprophyte and thought to be non-pathogenic to humans. Nevertheless, increasing number of reports of human infection have emerged in recent years, mostly in oncologic patients. Aim: To report a case of a female patient with pyloric obstructive cancer with a catheter-related Papiliotrema laurentii blood stream infection and systematically review the available evidence on P. laurentii infection in humans. Methods: Retrieval of studies was based on Medical Subject Headings and Health Sciences Descriptors, which were combined using Boolean operators. Searches were run on the electronic databases Scopus, Web of Science, MEDLINE (PubMed), BIREME (Biblioteca Regional de Medicina), LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Library for Systematic Reviews and Opengray.eu. There was no language or date of publication restrictions. The reference lists of the studies retrieved were searched manually. Results: The search strategy retrieved 1703 references. In the final analysis, 31 references were included, with the description of 35 cases. Every patient but one had a previous co-morbidity - 48.4 % of patients had a neoplasm. Amphotericin B was the most used treatment and only a single case of resistance to it was reported. Most patients were cured of the infection. Conclusion: P. laurentii infection in humans is usually associated to neoplasia and multiple co-morbidities, and amphotericin B seems to be a reliable agent for treatment.

Catheter-related infection due to Papiliotrema laurentii in an oncologic patient: Case report and systematic review.

BACKGROUND: Papiliotrema laurentii is one of several non-neoformans cryptococci that have rarely been associated with human infection, since it was previously considered saprophyte and thought to be non-pathogenic to humans. Nevertheless, increasing number of reports of human infection have emerged in recent years, mostly in oncologic patients. AIM: To report a case of a female patient with pyloric obstructive cancer with a catheter-related Papiliotrema laurentii blood stream infection and systematically review the available evidence on P. laurentii infection in humans. METHODS: Retrieval of studies was based on Medical Subject Headings and Health Sciences Descriptors, which were combined using Boolean operators. Searches were run on the electronic databases Scopus, Web of Science, MEDLINE (PubMed), BIREME (Biblioteca Regional de Medicina), LILACS (Latin American and Caribbean Health Sciences Literature), Cochrane Library for Systematic Reviews and Opengray.eu. There was no language or date of publication restrictions. The reference lists of the studies retrieved were searched manually. RESULTS: The search strategy retrieved 1703 references. In the final analysis, 31 references were included, with the description of 35 cases. Every patient but one had a previous co-morbidity - 48.4 % of patients had a neoplasm. Amphotericin B was the most used treatment and only a single case of resistance to it was reported. Most patients were cured of the infection. CONCLUSION: P. laurentii infection in humans is usually associated to neoplasia and multiple co-morbidities, and amphotericin B seems to be a reliable agent for treatment.

[Peritoneal dialysis catheter infection with abscess of the abdominal wall in a ADPKD patient].

Infections to the peritoneal catheter are common in Peritoneal Dialysis (PD). We report the clinical case of a 49-year-old male patient in PD, who showed an atypical manifestation of tunnel infection caused by Staphylococcus aureus. The infection was characterized by a little abscess, on the left pararectal abdominal line, 6 cm far from exit-site of the peritoneal catheter. The diagnosis was made using ultrasonography (US), which showed a fistulous communication from subcutaneous cuff to the skin. We treated the infection conservatively by performing cuff-shaving and drainage of the abscess, associated to antibiotic therapy (teicoplanin). Due to the persistence of the infection, we added oral and topical rifampicin, and advanced medication with freez-dried collagen plant impregnated with extended-release gentamicin. The complete resolution of the infection allowed us to avoid removing the catheter.

Mycobacterium abscessus bloodstream infection: Unexpected catheter tunnel infection localized by PET/CT.

Mycobacterium abscessus is an emerging cause of invasive infection in the immunosuppressed population. We report a case of M. abscessus bloodstream and catheter tunnel infection localized by positron emission tomography/computer tomography (PET/CT) in an allogeneic haematopoietic stem cell transplant recipient. This case highlights the difficulties in treating invasive M. abscessus infection and the potential role of PET/CT in localizing infection and guiding therapy in this population.

Infected multilocular hydrocephalus treated by rigid and flexible endoscopes with electromagnetic-guided neuronavigation: a case report.

BACKGROUND: Endoscopic surgery assisted by a navigation system has greatly aided treatment of infected multilocular hydrocephalus, especially in children. CASE REPORT: We describe a 2-year-old boy with multilocular hydrocephalus caused by repeated shunt infection, presenting with fever and vomiting. Magnetic resonance images (MRI) showed extraventricular cysts and severe ventricular deformity. There were three ventriculoperitoneal shunts and one residual ventricular catheter. With a flexible endoscope, we fenestrated the wall of extraventricular cysts and removed the residual catheter. We then used a rigid endoscope to fenestrate ventricular components. Both procedures were guided by electromagnetic (EM) navigation, and hydrocephalus was controlled with one ventricular catheter. CONCLUSION: We have successfully treated a case suffered from infected multilocular hydrocephalus in infants using rigid and flexible endoscopes combined with EM navigation.

Endocarditis infecciosa asociada a catéter de hemodiálisis: hallazgos clínicos y ecocardiográficos / Infective endocarditis associated with hemodialysis catheters: clinical and ehocardiographic findings

Resumen: Hallazgos clínicos y ecocardiográficos en pacientes con endocarditis infecciosa (E.I.) asociada a catéter de hemodiálisis (CHD) fueron comparados con sujetos controles con E.I. "habitual". Pacientes y métodos: Del total de registros ecocardiográficos de una Clínica privada de Antofagasta entre 2009 y 2014, 4 pacientes presentaban E.I. asociada CHD (E.I.-CHD) y 16 otro tipo de E.I. (controles). Se compararon ambos grupos clínicamente y en las distintas modalidades de ecografía, para evaluar el aporte de cada una de ellas en el diagnóstico, manejo y comprensión del mecanismo de producción de la E.I. Resultados: El periodo del inicio de los síntomas hasta la hospitalización y el comprendido entre ésta hasta el fallecimiento fue variable, con tendencia a fallecimiento más precoz en el grupo E.I.-CHD (promedio 14,6 vs 20,6 días en el grupo control). La edad en E.I.-CHD fue mayor (65 versus 62.2 años), con mayor incidencia de las 3 comorbilidades más frecuentes: hipertensión arterial (100% versus 56,25%), diabetes mellitus (75% versus 50%) e insuficiencia cardíaca (75% versus 31,25%). La mortalidad fue 18.75% en el grupo control y 75% en la E.I.-CHD. En los pacientes con E.I.-CHD se aisló: Cándida (50%), Bacilos gram negativo (Stenotrophomonas maltophilia) (25%) y SAMR (25%) mientras que en el grupo control fueron aislados Enterococcus faecalis (25%), Streptococcus viridans (12.5%), Streptococcus spp (6.25%), Staphylococcus aureus (6.25%), Streptococcus grupo C (6.25%), Abiotrophia defectiva (6.25%) y Streptococcus pneumoniae (6.25). En 31.25% de los casos los hemocultivos fue-ron negativos. La localización más frecuente de las vegetaciones en los pacientes con E.I.-CHD correspondió a la pared de AD, sitio de impacto del jet del CHD, en un 100%, seguida por CHD 50%, tricúspide 25% y aórtica 25%. En los controles las localizaciones fueron 75% en válvula aórtica y 25% en válvula mitral. En el grupo de E.I.-CHD, la mitad presentó disfunción sistólica e insuficiencia valvular, mientras que en el grupo control fue predominante la insuficiencia valvular (62,5%) seguida por la perforación de velo (25%). Conclusión: En las E.I.-CHD se aislaron gérmenes asociados a un peor pronóstico (hongos o bacterias atípicas), con altísima mortalidad. La localización principal de las vegetaciones fue en la pared de la aurícula derecha (AD), alrededor de la desembocadura de la vena cava inferior (VCI), sitio de impacto del jet del CHD, y en el tercio distal del catéter. Clinical and echocardiographic findings in patients with infective endocarditis (I.E.) associated to the presence of hemodialysis catheters (HDC) were compared to those in subjects with other types of I.E.

Abstracts: Methods: Between 2009 and 2014 an echocardiographic diagnosis of I.E. was established in 4 subjects with a hemodialysis catheter in place and 16 patients had a common variety of I.E. (controls). Clinical and echocardiographic findings, including echocardiographic modalities were compared between groups. Results: Time from onset of symptoms and time to patient death were shorter in I.E.-HDC patients compared to controls (mean 14.6 vs 20.6 days, respectively. I.E. -HDC patients tended to be older (65.0 vs 62.2 years old). The incidence of main comorbidities was higher in I.E.-HDC: hypertension (100% vs 56.2%), diabetes (75 vs 59%) and heart failure (75% vs 31.2%), respectively. Mortality was much higher in I.E-HDC (74% vs 18%). Infective agents also differed between groups: I.E.-HDC was associate to C albicans (50%), Gram negative rods (Stenotrophomonas maltophilia) (25%) y SAMR (25%). In contrast, the agents involved in controls were E faecalis (25%), S viridans (12.5%), S. group C (6.25%), S aureus (6,25%), group C Streptococcus (6.25%), Abiotrophic defectiva (6.25%) and S pneumoniae (6.25%). Overall, blood cultures were negative in 31.2% patients. Among patients with I.E.-HDC vegetations were most commonly found at the right atrial wall (100%), on the catheter (50%), at the tricuspid valve (25%) and at the aortic valve (25%). In non I.E.-HDC, vegetations were located at the aortic valve (75%) and the mitral valve (25%). Half the patients with I.E.- HDC patients presented ventricular dysfunction and valvular regurgitation while control patients had predominantly valvular insufficiency (62.5%) or leaflet perforation (25%). Conclusion: Mortality in I.E.-HDC patients was very high, associated to the presence of aggressive microbial or fungal agents. Vegetations were most commonly located at the right atrial wall, around de junction with the inferior vena cava and on the catheter itself.

The Incidence of Totally Implantable Venous Access Devices Insertion and the Associated Abnormalities in Patients With Cancer Revealed in 18F-FDG PET-CT Imaging.

RATIONALE AND OBJECTIVES: The purpose of this retrospective study was to evaluate the incidence of totally implantable venous access devices, also called ports, implantation and the associated abnormalities in 2-[18F]-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography-computed tomography (PET-CT) images for patients with cancer, and to determine the percentage of abnormalities identified in the original reports. MATERIALS AND METHODS: The study aimed to perform a retrospective review of all FDG PET-CT imaging in a 3-year period. Cases of port-associated abnormalities found on the FDG PET-CT images were identified and then correlated with X-ray reports and clinical treatment or follow-up. RESULTS: In total, 2442 FDG PET-CT scans were retrospectively reviewed. Among them, 897 (897 of 2442, 36.7%) demonstrated port implantation. Abnormalities, including 22 port fractures (22 of 897, 2.45%), 14 malposition (1.56%), one infection (0.11%), and one embraced by a fibrin sheath or tumor (0.11%) were found. Only the infectious one had clinical symptoms. Among the 22 fractured ports, eight fractured catheters migrated and became dislodged. All of the malpositioned ports, except two in the contralateral subclavian vein, were found in the ipsilateral jugular vein. Both the port infection and the port embraced by a fibrin sheath or tumor occurred at the tips of the devices, which demonstrated FDG uptake in the mediastinal region. Only seven of the 38 (18.42%) images of port abnormalities had been identified in the original reports. CONCLUSIONS: Based on this study, we recommend that the interpretation of FDG PET-CT scans should include a checklist to record all metallic device implantations and to interpret the whole-body X-ray topography as a standard part of PET-CT image report.

[Pragmatic study on the role of ultrasounds in the management infectious complications of peritoneal catheter].

The role of ultrasound (US) is extremely important in the early detection (diagnosis) of peritoneal catheter tunnel infection (TI) in subjects with catheter exit-site infection (ESI), also for the therapeutic follow up of tunnel infection and in particular to evaluate (assess) the prognosis in cases of deep infection. ESI is the major cause of peritonitis because it is associated to bacterial migration and overgrowth which involve deep cuff and then the tunnel. The use of US is now widely recognized, it allows the identification of persistent foci as hypoechoic pericatheter areas and specially to evaluate response to antibiotic therapy. Between January 2012 and Dicember 2015 eight patients with infectious complication (ESI-PERITONITIS) underwent to US- Color Doppler examination of peritoneal catheter. This study describes how peritoneal catheter follow up associated to color Doppler can prevent peritonitis ESI correlated, because the use of color Doppler allows to differenziate exudative areas from those areas of intense vascular proliferation, suggesting timing for cuff shaving surgery and external cuff removal, to prevent infectious propagation, potential peritonitis, as well as to save catheter.

A Novel Mouse Model of Staphylococcus aureus Vascular Graft Infection: Noninvasive Imaging of Biofilm Development in Vivo.

Staphylococcus aureus causes very serious infections of vascular grafts. Knowledge of the molecular mechanisms of this disease is largely lacking because of the absence of representable models. Therefore, the aim of this study was to set up a mouse model of vascular graft infections that closely mimics the human situation. A catheter was inserted into the right carotid artery of mice, which acted as a vascular graft. Mice were infected i.v. using 8 different S. aureus strains, and development of the infection was followed up. Although all strains had varying abilities to form biofilm in vitro and different levels of virulence in mice, they all caused biofilm formation on the grafts. This graft infection was monitored using magnetic resonance imaging (MRI) and 18F-fluordeoxyglucose positron emission tomography (FDG-PET). MRI allowed the quantification of blood flow through the arteries, which was decreased in the catheter after infection. FDG-PET revealed high inflammation levels at the site of the catheter after infection. This model closely resembles the situation in patients, which is characterized by a tight interplay between pathogen and host, and can therefore be used for the testing of novel treatment, diagnosis, and prevention strategies. In addition, combining MRI and PET with microscopic techniques provides an appropriate way to characterize the course of these infections and to precisely analyze biofilm development.