Adherence to National Consensus Guidelines and Association with Clinical Outcomes in Patients with Candidemia

Background: National consensus guidelines outline recommendations for best practices in treating patients with candidemia. This study evaluated the impact of receiving care adherent to the best practice recommendations on clinical outcomes in patients with candidemia. Methods: This retrospective, multicenter study included patients with candidemia from 2010 to 2015 at 9 hospitals. The primary outcome was the composite of 30-day in-hospital mortality and 90-day candidemia recurrence. Outcomes were compared between those receiving and not receiving care adherent to the guideline recommendations. Inverse probability weights with regression adjustment were utilized to determine the average treatment effect of adherent care on the composite outcome Results: 295 patients were included with 14.2% meeting criteria for the composite outcome (11.9% mortality and 2.4% recurrence). The average treatment effect of adherent care was not significant ( P = .75). However, receiving appropriate initial antifungal treatment and central venous catheter removal were both associated with the composite (average treatment effect of −17.5%, P = .011 and −8.8%, P = .013, respectively). In patients with a source of infection other than the central line, central venous catheter removal was not associated with the composite ( P = .95). The most common reason for failure to receive appropriate initial antifungal treatment was omission of the loading dose. Conclusions: Central venous catheter removal and appropriate initial antifungal treatment were associated with a lower incidence of the composite of mortality and recurrence. Additional studies are needed to determine the optimal duration of therapy following candidemia clearance.

Antibiotic Administration Prior to Central Venous Catheter Removal in Neonates

Background: Central venous catheter infection and sepsis are significant causes of morbidity and mortality in neonatal intensive care unit patients. This complication may result in a significant cost burden, prolonged antibiotic treatment, and increased length of stay. Objectives: The objective of this study was to determine the difference in post-catheter removal clinical sepsis (PCRCS) in neonatal intensive care unit patients who received antibiotics prior to central venous catheter removal when compared to those who did not. Methods: This was a retrospective cohort study of 200 critically ill neonates comparing those who received one-time doses of vancomycin and cefazolin prior to central venous catheter removal to those who did not. Results: There was no statistically significant association between antibiotic treatment and PCRCS when the analysis was controlled for gender, time the catheter was in place, birth weight, gestational age, or type of central catheter (OR 1.19; 95% CI: 0.18-8.00; P = .8558). No statistical difference was seen in adverse renal outcomes or total antibiotic treatment received for the treatment of PCRCS. Conclusions: Administration of one-time doses of vancomycin and cefazolin did not reduce the incidence of PCRCS when administered to critically ill neonates prior to umbilical venous catheter or peripherally inserted central catheter removal.

Point-of-care ultrasound for assessing arteriovenous fistula maturity in outpatient hemodialysis

Background: Point-of-care ultrasound in end-stage renal disease is on the rise. Presently the decision to cannulate an arteriovenous fistula is based on its duration since surgery and physical exam. This study examines the effects of point-of-care ultrasound on decreasing the time to arteriovenous fistula cannulation, time spent with a central venous catheter, and the complications and infections that arise. Methods: Prospective point-of-care ultrasound patients were recruited between January 2015 and January 2018, while retrospective data (non-point-of-care ultrasound) were collected via chart review from patients who had fistula creation between November 2011 and May 2014. Patients had point-of-care ultrasound within 3 weeks after arteriovenous fistula creation and were followed for 1 year. Arteriovenous fistula cannulation was initiated when the following parameters were met: diameter > 6 mm (with no depreciable narrowing of more than 20% throughout), depth < 6 mm, and length > 6 cm. Demographic data, as well as time to cannulation and central venous catheter removal, number of infections, complications, and interventions were compared between point-of-care ultrasound and non-point-of-care ultrasound groups using unpaired t-test, chi-square, and Fisher exact test statistical analysis. Results: A total of 37 patients with new arteriovenous fistulas were followed by point-of-care ultrasound compared to 29 non-point-of-care ultrasound patients. Point-of-care ultrasound patients had earlier cannulations (35.5 vs 63.3 days, p < 0.05), shorter central venous catheter duration (68.2 vs 98.3 days, p < 0.05), and less infections (12 vs 19) without differences in complication compared to the non-point-of-care ultrasound. Conclusion: Point-of-care ultrasound facilitates early and safe arteriovenous fistula cannulation leading to a reduction in central venous catheter time and risk of infection. Point-of-care ultrasound may also aid in earlier identification of complications and difficult cannulations.

120. The Impact of Early Central Venous Catheter Removal in the Management of Enterococcus Central Line-Associated Bloodstream Infections

Background There has been a rise in Enterococcus species Central Line-Associated Bloodstream Infections (CLABSI) ranking as the third overall causative organism according to the Center for Disease Control and Prevention (CDC) report issued in 2014. Central Venous Catheter (CVC) management including the need and timing of CVC removal is not well defined for enterococcus bacteremia (EB) in the 2009 Infectious Diseases Society of America (IDSA) management guidelines given the paucity of studies addressing CVC management. Methods We conducted a retrospective chart review on 543 patients diagnosed with EB between 2010 and 2018. We excluded patients without an indwelling CVC and those with mucosal barrier injury (MBI). We further evaluated 90 patients with EB that met the CDC definition for CLABSI without MBI or the IDSA definition for catheter-related bloodstream infections (CRBSI) and 90 patients with an indwelling CVC in place with documented non-CLABSI with another source. Results Early CVC removal (within 3 days of EB) was significantly higher in the CLABSI without MBI/CRBSI group compared with the non-CLABSI (43% vs. 27%; P = 0.02). Microbiological eradication associated with early CVC removal within 3 days of EB was significantly higher in the CLABSI without MBI/CRBSI group compared with the non-CLABSI (78% vs. 48%; P = 0.016). Complications were lower in the CLABSI without MBI/CRBSI compared with the non-CLABSI group (0% vs. 18%; P = 0.017). Defervescence, mortality (all-cause and infection-related mortality) and relapse were similar in both groups. Within each group, the outcome was similar irrespective of CVC management (removal within 3 days vs. retention). Conclusion In cases of EB, early CVC removal within 3 days of bacteremia is associated with a favorable outcome in the CLABSI without MBI/CRBSI group compared with the non-CLABSI group. Disclosures All authors: No reported disclosures.

Impact of Catheter Management on Clinical Outcome in Adult Cancer Patients With Gram-Negative Bacteremia

Objective Gram-negative organisms have become a major etiology of bloodstream infections. We evaluated the effect of central venous catheter management on cancer patients with gram-negative bloodstream infections. Method We retrospectively identified patients older than 14 years with central venous catheters who were diagnosed with gram-negative bloodstream infections to determine the effect of catheter management on outcome. Patients were divided into 3 groups: Group 1 included patients with central line-associated bloodstream infections (CLABSI) without mucosal barrier injury and those whose infection met the criteria for catheter-related bloodstream infection; group 2 included patients with CLABSI with mucosal barrier injury who did not meet the criteria for catheter-related bloodstream infection; and group 3 included patients with non-CLABSI. Results The study included 300 patients, with 100 patients in each group. Only in group 1 was central venous catheter removal within 2 days of bloodstream infection significantly associated with a higher rate of microbiologic resolution at 4 days compared to delayed central venous catheter removal (3–5 days) or retention (98% vs 82%, P = .006) and a lower overall mortality rate at 3-month follow-up (3% vs 19%, P = .01). Both associations persisted in multivariate analyses (P = .018 and P = .016, respectively). Conclusions Central venous catheter removal within 2 days of the onset of gram-negative bloodstream infections significantly improved the infectious outcome and overall mortality of adult cancer patients with catheter-related bloodstream infections and CLABSI without mucosal barrier injury.

Diagnosis and management of catheter-related bloodstream infections in patients on home parenteral nutrition

Catheter-related bloodstream infections (CRBSIs) commonly arise from a parenteral nutrition catheter hub. A target for a Nutrition Support Team is to have a CRBSI rate of less than 1 per 1000. The diagnosis of CRBSI is suspected clinically by a temperature shortly after setting up a feed, general malaise or raised blood inflammatory markers. It is confirmed by qualitative and quantitative blood cultures from the catheter and peripherally. Treatment of inpatients may involve central venous catheter removal and antibiotics for patients needing short-term parenteral nutrition, but catheter salvage is generally recommended for patients needing long-term parenteral nutrition, where appropriate.