Management of infections related to totally implantable venous-access ports: challenges and perspectives

A Prospective Pilot Clinical Study reveals a promising non-toxic anti-biofilm activity of gentamicin-EDTA-Na₂ Central Venous Catheter Lock Solution

OBJECTIVES

The treatment of long-term intravenous catheter-related bloodstream infections (LTIVC-related BSI) often requires catheter removal or conservative treatment using intra-catheter locks, with a 50-60% success rate. We previously demonstrated the synergistic effect of a combination of gentamicin and ethylenediaminetetraacetic acid disodium salt (EDTA-Na2) against bacterial biofilms. We conducted a phase 1/2 clinical trial to assess the tolerance and efficacy of genta-EDTA-Na2 locks for the conservative treatment of LTIVC-related BSI.

METHODS

Prospective study including adult patients with monomicrobial, uncomplicated LTIVC-related BSI caused by gentamicin-susceptible coagulase-negative staphylococci, Enterobacterales, or Pseudomonas aeruginosa.

PRIMARY OBJECTIVE

assess the safety and efficacy at genta-EDTA-Na2 locks at day 40 (D40) by evaluating the frequency of clinical and microbiological cure 30 days after the end of treatment (D40).

RESULTS

Eight patients were included. Complete follow-up was obtained for seven patients, six of whom met the criteria for cure. The single patient with incomplete follow-up met all criteria for cure at D23. A single microbiological failure occurred (relapse of P. aeruginosa LTIVC-related BSI). Two patients experienced at least one serious adverse event; none were attributed to the genta-EDTA-Na2 locks.

CONCLUSIONS

Genta-EDTA-Na2, used as intra-catheter locks, may be a promising anti-biofilm candidate for evaluation in a randomized controlled trial.

Central-venous-catheter-related bloodstream infections in adult patients with sickle cell disease: a retrospective, two-centre study

PURPOSE

Although catheter-related infections are the leading cause of bloodstream infections in patients with sickle cell disease (SCD), data are scarce in adult patients. The objectives of the present study were to describe central-venous-catheter-related bloodstream infections in patients with SCD and identify risk factors.

METHODS

We conducted a retrospective, observational study of adult patients with SCD diagnosed with central-venous-catheter-related bloodstream infections between 2011 and 2023 in two SCD reference centres. Each patient with SCD and a bloodstream infection related to a totally implantable venous access port was matched with two control patients with SCD and an infection-free totally implantable venous access port.

RESULTS

Thirty-five (6.6%) of the 534 patients experienced a total of 69 central-venous-catheter-related bloodstream infections. Concomitant vaso-occlusive crises were observed for 81.2% of the infections. The 30-day mortality rate was 2.8%, and the infection recurrence rate was 45.7%. We observed 26 totally implantable venous access port-related bloodstream infections in 19 patients, with an incidence rate of 0.31 per 1000 catheter-days. After adjustment, the frequency of hospital admission for a vaso-occlusive crisis (odds ratio (OR) [95% confidence interval (CI)] = 1.6 [1.2-2.4]) and the presence of a psychiatric comorbidity (19.8 [4.0-148.1]) remained significantly associated with totally implantable venous access port-related bloodstream infections. Suboptimal antibiotic levels were observed in five (39%) of the 13 patients having undergone therapeutic drug monitoring. The treatment failed in four (80%) of the five patients, who presented with glomerular hyperfiltration.

CONCLUSION

A central-venous-catheter-related bloodstream infection is a severe complication in adult patients with SCD and is associated with psychiatric comorbidities and severe SCD.

Assessing the time-to-removal of totally implantable venous access devices comparing valved-versus open-ended catheters in patients treated with chemotherapy

BACKGROUND

Totally IntraVenous Acess Devices (TIVAD) are used to have long-term bloodstream access. The catheter connected to the subcutaneous chamber may be valved (TIVAD-V) or open-ended (TIVAD-O). Infectious and occlusion complications require the removal of the TIVAD. We compared the two types of catheters (TIVAD-V and TIVAD-O) in terms of time-to-removal and complication rates.

METHODS

A retrospective study of 636 patients treated for any malignancy using a TIVAD were included. TIVAD complication was defined as the occurrence of infection or occlusion requiring TIVAD removal. Risk factors of complications and time-to-removal of TIVAD were assessed by a Cox proportional hazard analysis.

RESULTS

A total of 55 TIVADs (8.7%) were removed including 47 for infection and eight for occlusion in 54 months. There was no significant difference in the frequency of complications between TIVAD-V and TIVAD-O. There was no significant difference in time-to-removal between TIVAD-V and TIVAD-O (17.0 months, IQR [10.5-25.0] and 18.4 months, IQR [11.5-22.9], p = 0.345, respectively).

CONCLUSION

There was no difference between TIVAD with valved and open catheter in terms of complications and time-to-removal in patients treated by chemotherapy.

Clinical efficacy and safety of a new single-incision axillary vein puncture technique for totally implantable venous access ports

To assess the clinical efficacy of a new single-incision axillary vein puncture technique for implanting totally implantable venous access ports (TIVAPs). A retrospective review of patient data from January 2023 to June 2023 at The Affiliated Suzhou Hospital of Nanjing Medical University was conducted. The study included adult patients with solid malignancies scheduled for intravenous chemotherapy and TIVAPs implantation. Patients were categorized into single-incision group (Group S) and dual-incision group (Group D) based on different venous access approaches. Baseline information, primary tumors, immediate adverse events, indwelling time, and early and late adverse events were collected. A total of 338 patients were included in the analysis, with 117 in Group S. and 221 in Group D. Baseline characteristics were comparable between the groups. The technical success rate was 99.1% in Group S and 98.6% in Group D, demonstrating similarity. The mean operative time was 26 min in Group S, significantly shorter than the 36 min in Group D (p < 0.05). Group D experienced more occurrences of localised ecchymosis and painful. Overall, Group S exhibited superiority over Group D in terms of immediate adverse events (p < 0.05). Follow-up data revealed comparable adverse events rates between the two groups. In conclusion, the study indicates that the single-incision axillary vein puncture technique can be safely implemented by an experienced team with a low incidence of adverse events. This approach can serve as a valuable alternative for clinical TIVAPs placement.

Prospective, monocentric observational study on the clinical use and patient satisfaction of an implantable venous access Port

PURPOSE

Long-term totally implantable venous access ports (TIVAP) are essential for administering chemotherapy and parenteral nutrition in cancer patients. This study aimed to evaluate patient satisfaction and postoperative complications, compared to existing literature, emphasizing patient-reported outcomes (PRO) as a critical factor in treatment decisions.

METHODS

A prospective, monocentric observational study included 149 patients requiring TIVAP between April 13 and August 17, 2022. Patient satisfaction was assessed using a questionnaire covering four domains: overall satisfaction, willingness to choose the port again, cosmetic result, and pain experience. A meta-analysis of seven studies (1,035 patients) was performed to establish baseline data. The study assumed a non-inferiority margin of 12 points on a 0-100 scale (lower scores indicating better outcomes). Follow-ups were carried out at four weeks and six months.

RESULTS

Of the 149 patients (mean age 58.8 years, 96% with oncological diseases), 117 (78.5%) TIVAPs were implanted via the cut-down technique, primarily using the cephalic vein (84.6%). Out of 1,240 documented catheter accesses, 91.4% were complication-free. Satisfaction scores demonstrated non-inferiority across all domains compared to literature: overall satisfaction (18.5 vs. 35.6; p < 0.001), willingness to choose the port again (15.8 vs. 29.4; p < 0.001), cosmetic result (38.0 vs. 39.9; p = 0.003), and pain experience (17.1 vs. 31.5; p < 0.001).

CONCLUSION

The study demonstrated adequate patient satisfaction and non-inferiority of the investigated TIVAP system compared to other systems, though no superiority was found in cosmetic outcomes.

Salvage strategy for long-term central venous catheter-associated Staphylococcus aureus infections in children: a multi-centre retrospective study in France

OBJECTIVES

Catheter removal is recommended in adults with Staphylococcus aureus central-line-associated bloodstream infection (CLABSI) but is controversial in children with long-term central venous catheters (LTCVC). We evaluated the occurrence of catheter salvage strategy (CSS) in children with S. aureus LTCVC-associated CLABSI and assessed determinants of CSS failure.

METHODS

We retrospectively included children (<18 years) with an LTCVC and hospitalized with S. aureus CLABSI in eight French tertiary-care hospitals (2010-2018). CSS was defined as an LTCVC left in place ≥72 h after initiating empiric antibiotic treatment for suspected bacteraemia. Characteristics of patients were reviewed, and multi-variable logistic regression was performed to identify factors associated with CSS failure (i.e., persistence, recurrence or complications of bacteraemia).

RESULTS

We included 273 episodes of S. aureus LTCVC-associated CLABSI. CSS was chosen in 194 out of 273 (71%) cases and failed in 74 of them (38%). The main type of CSS failure was the persistence of bacteraemia (39 of 74 cases, 53%). Factors independently associated with CSS failure were: history of catheter infection (adjusted odds ratio (aOR) 3.18, 95% confidence interval (CI) 1.38-7.36), CLABSI occurring on an implantable venous access device (aOR 7.61, 95% CI 1.98-29.20) when compared with tunnelled-cuffed CVC, polymicrobial CLABSI (aOR 3.45, 95% CI 1.25-9.50), and severe sepsis at the initial stage of infection (aOR 4.46, 95% CI 1.18-16.82).

CONCLUSIONS

CSS was frequently chosen in children with S. aureus LTCVC-associated CLABSI, and failure occurred in one-third of cases. The identified risk factors may help clinicians identify children at risk for CSS failure.

Machine learning risk prediction model for bloodstream infections related to totally implantable venous access ports in patients with cancer

Objective

This study aimed to develop and validate a machine learning-based risk prediction model for catheter-related bloodstream infection (CRBSI) following implantation of totally implantable venous access ports (TIVAPs) in patients.

Methods

A retrospective cohort study design was employed, utilizing the R software package mlr3. Various algorithms including logistic regression, naive Bayes, K nearest neighbor, classification tree, and random forest were applied. Addressing class imbalance, benchmarks were used, and model performance was assessed using the area under the curve (AUC). The final model, chosen for its superior performance, was interpreted using variable importance scores. Additionally, a nomogram was developed to calculate individualized risk probabilities, enhancing clinical utility.

Results

The study involved 755 patients across both development and validation cohorts, with a TIVAP-CRBSI rate of 14.17%. The random forest model demonstrated the highest discrimination ability, achieving a validated AUC of 0.94, which was consistent in the validation cohort.

Conclusions

This study successfully developed a robust predictive model for TIVAP-CRBSI risk post-implantation. Implementation of this model may aid healthcare providers in making informed decisions, thereby potentially improving patient outcomes.

The Role of Nursing in the Management of Chemotherapy Extravasation: A Systematic Review Regarding Public Health

The scientific literature was reviewed with the aim of analysing the state of the art on the role of nursing in the management of chemotherapy extravasation, recognising the possible risk factors and identifying effective training programmes for nurses. WOS, Scopus, and PubMed databases were used to perform the searches. Papers that met the inclusion criteria and that had been published in the last 9 years were selected. The Effective Public Health Practice Project (EPHPP) instrument was applied to the selected studies. In addition, this research was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (ID: 512480). Out of the 23 initially selected articles, a total of 9 articles were eventually included, since they met the eligibility criteria that were established after a more exhaustive analysis, which included reading their abstracts and full texts. The results show that the management of chemotherapy extravasation is closely related to factors that largely depend on the nursing staff. Among the most relevant findings are factors including the identification of the nursing role in the management of extravasation due to chemotherapy; risk factors; and effective training programmes for nursing. Nurses play a crucial role throughout the entire process of treatment, prevention, and health education in chemotherapy treatment. Training programmes for nurses are fundamental, as they increase their professional competence and improve the safety of the patient. Adequate knowledge of chemotherapy treatment and the risk factors of extravasation are basic elements for the prevention of this type of injury, as well as for the improvement of the quality of life of patients under this kind of intravenous therapy.

Catheter-associated Bloodstream Infection in Children with Tunneled Central Venous Catheters: A Single-center Experience

Background

Tunnelled catheters improve venous access in haematological diseases and malignancies, but are associated with complications. We prospectively analysed the episodes of CABSI and its associated risk factors.

Aims

To study the incidence and risk factors for CABSI in children with tunnelled central venous catheters (both Hickmans and Chemoports).

Materials and Methods

This is a prospective observational study done at our institute. Children under the age of 18 who underwent insertion of a Hickman or Chemoport from March 2018 to Dec 2022 were enrolled. Episodes of CABSI were noted and its risk factors were analysed.

Results

In total, 258 catheters were inserted in 250 children. Age ranged from 1 month to 18 years (median 67 months) with 60% being boys. A total of 152 Hickmans, 106 chemoports were inserted. Indications for insertions were for requirement of BMT and chemotherapy in majority of cases. CABSI were seen in 28.6% of catheters. Younger children (< 4years), Neutropenia (counts < 1000) and use of TPN were significantly associated with CABSI(p value<0.05). Infection was more with externalized catheters (Hickman) than implantable ports (Chemoports) but was not statistical significant(p value>0.05). Almost 30% of catheters with CABSI required removal because of florid sepsis. Others could be salvaged with aggressive antibiotics.

Conclusions

CABSI is a serious complications related to tunnelled catheter. Smaller children (<4 years), neutropenia and usage of TPN is a risk factor for development of CABSI. It can be treated with appropriate antibiotics and required removal in almost a third of all the cases.

Predictive model for totally implanted venous access ports‑related long‑term complications in patients with lung cancer

Totally implanted venous access ports (TIVAPs), which are typically used in oncological chemotherapy and parenteral nutritional support, are convenient and safe, and thus offer patients a higher quality of life. However, insertion or removal of the device requires a minor surgical operation. Long-term complications (>30 days post insertion), such as catheter migration, catheter-related thrombosis and infection, are major reasons for TIVAP removal and are associated with a number of factors such as body mass index and hemoglobin count. Since management of complications is typically time-consuming and costly, a predictive model of such events may be of great value. Therefore, in the present study, a predictive model for long-term complications following TIVAP implantation in patients with lung cancer was developed. After excluding patients with a large amount of missing data, 902 patients admitted to The First Affiliated Hospital with Nanjing Medical University (Nanjing, China) were ultimately included in the present study. Of the included patients, 28 had complications, indicating an incidence rate of 3.1%. Patients were randomly divided into training and test cohorts (7:3), and three machine learning-based anomaly detection algorithms, namely, the Isolation Forest, one-class Support Vector Machines (one-class SVM) and Local Outlier Factor, were used to construct a model. The performance of the model was initially evaluated by the Matthew's correlation coefficient (MCC), area under curve (AUC) and accuracy. The one-class SVM model demonstrated the highest performance in classifying the risk of complications associated with the use of the intracavitary electrocardiogram method for TIVAP implantation in patients with lung cancer (MCC, 0.078; AUC, 0.62; accuracy, 66.0%). In conclusion, the predictive model developed in the present study may be used to improve the early detection of TIVAP-related complications in patients with lung cancer, which could lead to the conservation of medical resources and the promotion of medical advances.

Prevention and Risk Assessment of Cardiac Device Infections in Clinical Practice

The implantation of cardiac electronic devices (CIEDs), including pacemakers and defibrillators, has become increasingly prevalent in recent years and has been accompanied by a significant rise in cardiac device infections (CDIs), which pose a substantial clinical and economic burden. CDIs are associated with hospitalizations and prolonged antibiotic therapy and often necessitate device removal, leading to increased morbidity, mortality, and healthcare costs worldwide. Approximately 1-2% of CIED implants are associated with infections, making this a critical issue to address. In this contemporary review, we discuss the burden of CDIs with their risk factors, healthcare costs, prevention strategies, and clinical management.

Impact of insertion into the left internal jugular vein in chemoport-associated infections: a retrospective single-center study of 1690 cases

We analyzed chemoport insertion procedures to evaluate infectious morbidity and factors causing infection. This single-center retrospective study included 1690 cases of chemoport implantation between January 2017 and December 2020. Overall, chemoports were inserted in 1582 patients. The average duration of chemoport use was 481 days (range 1-1794, median 309). Infections occurred in 80 cases (4.7%), with 0.098 per 1000 catheter-days. Among the 80 cases in which chemoports were removed because of suspected infection, bacteria were identified in 48 (60%). Significantly more cases of left internal jugular vein punctures were noted in the infected group (15 [18.8%] vs. 147 [9.1%]; p = 0.004). Pulmonary embolism was significantly different between the infection groups (3 [3.8%] vs. 19 (1.2%), p = 0.048). The hazard ratio was 2.259 (95% confidence interval [CI] 1.288-3.962) for the left internal jugular vein, 3.393 (95% CI 1.069-10.765) for pulmonary embolism, and 0.488 (95% CI 0.244-0.977) for chronic obstructive pulmonary disease. Using the right internal jugular vein rather than the left internal jugular vein when performing chemoport insertion might reduce subsequent infections.

Comparison of Infection Rates between Single-Lumen and Double-Lumen Chest Ports among Patients with Cancer: A Propensity Score Matching Analysis

PURPOSE

To compare the port infection rate between single-lumen (SL) and double-lumen (DL) ports and to determine whether the use of a DL port is an independent risk factor for port infection among patients with cancer.

MATERIALS AND METHODS

This retrospective study included 2,573 adult oncologic patients (aged >18 years) who had either a SL (n = 841) or a DL (n = 1,732) chest port implanted between 2013 and 2020 at a single institution. Patients who had port infection, including port-site infection and port-related bloodstream infection, were identified through chart review. After propensity score matching based on 13 potentially confounding variables, a total of 493 pairs of patients with either SL (SL group) or DL (DL group) ports were subjected to analysis. The port infection rate was compared between the 2 groups using Poisson regression. Multivariate proportional subdistribution hazards regression (PSHREG) analysis was conducted to determine whether use of a DL port is an independent risk factor for port infection.

RESULTS

The cumulative follow-up period for the matched cohort was 371,853 catheter-days (median, 297 catheter-days per port; range, 0-1,903 catheter-days). The port infection rate of the DL group was significantly higher than that of the SL group (0.232 vs 0.113 infections per 1,000 catheter-days; P = .001). PSHREG analysis demonstrated that use of a DL port was an independent risk factor of port infection (subdistribution hazard ratio, 2.30; 95% CI, 1.33-3.78; P = .002).

CONCLUSIONS

DL ports were associated with a higher risk of port infection compared with SL ports in adult oncologic patients.

Correlation between catheter colonization of central venous catheters and clinical biochemical indicators: A retrospective analysis of the MIMIC‑IV database

BACKGROUND

Clinical studies have not fully assessed the potential impact of patients' biochemical indicators on the rate of positive for central venous catheter-tip microorganism culture (PCMC).

METHODS

Data were obtained from an online Medical Information Mart for Intensive Care IV database. Patients who were ≥18 years old and had central venous catheter-tip culture results without continuous renal replacement therapy were included in the study. A comparison of patient characteristics and their biochemical indicators was made between negative and positive culture results.

RESULTS

A total of 5,323 patients were included in the analysis, including 612 positive (PCMC group) and 4,711 negative culture results (negative for central venous catheter tip catheter-tip microorganism culture [NCMC] group). The only influence factor on PCMC in this study was the serum creatinine (Scr) (odds ratio: 1.312, 95% confidence interval: 1.084-1.590, P = .005), according to a binary logistic regression analysis. The cut-off value of Scr was 3.25 mg/dL. The prevalence of PCMC (27.1% vs 9.1%, P < .001) and Staphylococcus aureus (43.0% vs 18.6%, P < .001) for central venous catheter-tip culture results was much higher in patients with Scr ≥ 3.25 mg/dL than those Scr < 3.25 mg/dL.

CONCLUSIONS

We used the large dataset collected from Medical Information Mart for Intensive Care IV to show that patients with Scr ≥ 3.25 mg/dL had an increased risk for PCMC.

Comparing ethanol lock therapy versus vancomycin lock in a salvation strategy for totally implantable vascular access device infections due to coagulase-negative staphylococci (the ETHALOCK study): a prospective double-blind randomized clinical trial

OBJECTIVES

Little is known about efficacy and safety of ethanol lock therapy (ELT) to treat totally implantable venous access device (TIVAD) infections. The objective of this trial was to evaluate the effectiveness and safety profile of a local treatment with ELT without removal for TIVAD infection due to coagulase-negative staphylococci.

METHODS

We performed a prospective, multicenter, double-blind, randomized clinical trial comparing the efficacy of 40% ELT versus vancomycin lock therapy (VLT) in TIVAD infections due to coagulase-negative staphylococci, complicated or not by bloodstream infection.

RESULTS

Thirty-one patients were assigned to the ELT group and 30 to the VLT arm. Concomitant bacteremia was present in 41 patients (67.2%). Treatment success was 58.1 % (18 of 31) for the ELT arm and 46.7% (14 of 30) for the VLT arm (p = 0.37). The overall treatment success was 52.5% (32). The risk of treatment failure due to uncontrolled infections, superinfections, and mechanical complications did not differ significantly between participants receiving ELT (13 out of 31 [42%]) and those receiving VLT (16 out of 30 [53%]) with a hazard ratio of 0.70 (p = 0.343; 95% CI [0.34-1.46], Cox model). Catheter malfunctions were significantly more frequent in the ELT arm (11 patients versus 2 in the VLT group, p = 0.01).

CONCLUSIONS

We found an overall high rate of treatment failure that did not differ between the ELT arm and the VLT arm. TIVAD removal must be prioritized to prevent complications (uncontrolled infections, superinfections, and catheter malfunctions) except in exceptional situations.

Clinical application of ultrasound-guided totally implantable venous access ports implantation via the posterior approach of the internal jugular vein

BACKGROUND

To determine the feasibility and safety of ultrasound-guided totally implantable venous access port (TIVAP) implantation via the posterior approach of the internal jugular vein (IJV).

METHODS

From September 2021 to August 2022, 88 oncology patients underwent ultrasound-guided implantation of TIVAPs via the posterior approach of the IJV for the administration of chemotherapy. The catheter tip was adjusted to be positioned at the cavoatrial junction under fluoroscopic guidance. Clinical data including surgical success, success rate for the first attempt, intraoperative, and postoperative complications were all collected and analyzed.

RESULTS

All patients underwent successful surgery (100%), whereby 58 were via the right IJV and 30 via the left IJV, and the success rate for the first attempt was 96.59% (85/88). The operation time was 20 to 43 minutes, with an average of 26.59 ± 6.18 minutes with no intraoperative complications. The follow-up duration ranged from 1 to 12 months (mean = 5.28 ± 3.07) and the follow-up rate was 100%. The rate of postoperative complications was 4.55% (4/88), including port-site infection in two cases, fibrin sheath formation in one case, and port flip in one case. No other complications were observed during follow-up.

CONCLUSION

Ultrasound-guided TIVAP implantation via the posterior approach of the IJV is feasible, safe, and effective, with a low rate of intraoperative and postoperative complications. Not only was the curvature of the catheter device smooth, but patients were satisfied with the comfort and cosmetic appearance. Additionally, we could reduce the possible complications of pinching and kinking of the catheter by using this approach. Therefore, further large-sample, prospective, and randomized controlled trials are warranted.

Silver-Mixed Port Reduces Venous Access Port Related Infection Rate Compared to Non-Silver-mixed Port: A Single-center Retrospective Analysis

PURPOSE

Totally implantable venous access ports (TIVAPs) are increasingly used as safe and convenient central venous access devices. However, several TIVAP-related complications occur, with port/catheter infection being most common. Silver-mixed ports have recently been introduced in anticipation of reducing TIVAP infection. This study aimed to investigate the efficacy of this device in reducing port infection by examining groups with and without silver-mixed devices.

MATERIALS AND METHODS

From April 2017 to July 2022, silver-mixed ports (S group) and non-silver-mixed port group (NS group) were reviewed at our institution. The incidence of TIVAP-related infections, patient characteristics, and bacteriological data were evaluated. Univariate and multivariate analyses were used to evaluate risk factors for TIVAP-related infection.

RESULTS

A total of 607 patients (S group, n = 203; NS group, n = 404) were enrolled. The rates of TIVAP-related infection were 3.0% (n = 6) and 7.7% (n = 31) in the S and NS groups, respectively. The incidence of total infection per 1000 catheter-days were 0.114 and 0.214 the S and NS groups, respectively. In the entire group, the rates of infection were 6.1% (n = 37) and the incidence of total infection per 1000 catheter-days was 0.187. Univariate and multivariate analyses revealed a significantly lower TIVAP-related infection rate in S group than NS group (p = 0.0216, odds ratio = 2.88 confidence interval: 1.17-7.08). No gram-negative rods were detected in the S group as port infection.

CONCLUSION

Silver-mixed port may be feasible in preventing port infection.

LEVEL OF EVIDENCE

Level 3, Local non-random sample.

Risk factors and prognostic significance of infection of totally implantable vascular access port in solid tumor patients: A prospective cohort study

OBJECTIVES

Totally implantable venous access ports (TIVAP) are devices mainly used to deliver antineoplastic chemotherapies, of which the insertion may be complicated by TIVAP-related infection (TIVAP-RI). This study aims to provide data on the risk factors for TIVAP-RI and its influence on patient prognosis.

PATIENTS AND METHODS

Prospective observational study including adult patients with solid tumors, in whom a TIVAP was inserted to deliver antineoplastic chemotherapy between January 2018 and October 2019. Factors associated with TIVAP-RI and one-year mortality were determined using multiple logistic regressions.

RESULTS

More than a thousand (1014) patients were included, among whom 48 (4.7%) presented with TIVAP-RI. Gram-positive cocci and Gram-negative bacilli represented 51% and 41% of the pathogens isolated, respectively. Young age (odds ratio [OR] 0.67; 95% Confidence Interval [0.53-0.83] per 10-year increase), WHO performance status ≥ 1 (OR 3.24 [1.52-7.79]), chemotherapy administration in the month before TIVAP placement (OR 2.26 [1.17-4.26]), and radiation therapy of the homolateral chest wall (OR 3.28 [1.51-6.67]) were independently associated with TIVAP-RI occurrence. During the year following TIVAP insertion, 287 (28%) patients died. TIVAP-RI was not associated with one-year mortality (OR 1.56 [0.75-3.19]).

CONCLUSION

TIVAP insertion in adult patients with solid tumors is associated with a low infection rate, which did not influence one-year mortality. In addition to young age and impaired health status, TIVAP insertion in the month following initiation of the antineoplastic chemotherapy and TIVAP insertion in an irradiated area are two newly reported preventable TIVAP-RI risk factors.

A surveillance program for long-term central venous access-associated infections in outpatient chemotherapy services

OBJECTIVE

In this study, we described the first results of a surveillance system for infections associated with long-term central venous catheters (LT-CVC) in patients under outpatient chemotherapy.

DESIGN

This was a multicentric, prospective study.

SETTING

Outpatient chemotherapy services.

PARTICIPANTS

The study included 8 referral cancer centers in the State of São Paulo.

INTERVENTION

These services were invited to participate in a newly created surveillance program for patients under chemotherapy. Several meetings were convened to share previous experiences on LT-CVC infection surveillance and to define the surveillance method. Once the program was implemented, all bloodstream infection (LT-CVC BSIs), tunnel infection, and exit-site infections associated with LT-CVC were reported. Data from January to May 2021 were analyzed. The median monthly number of chemotherapy sessions per clinic was 925 (IQR, 270-5,855). We used Poisson regression to analyze the association of rates with the characteristics of the services.

RESULTS

In total, 107 LT-CVC infections were reported, of which 95% were BSIs, mostly associated with totally implantable devices (76%). Infections occurred a median of 4 days after the last catheter manipulation and 116 after the LT-CVC insertion. Also, 102 microorganisms were isolated from LT-CVC BSIs; the most common pathogen was Staphylococcus epidermidis, at 22%. Moreover, 44 infections (44%) fulfilled the criteria for CVC-related LT-CVC BSI and 27 infections (27%) met the criteria for mucosal barrier injury. The 1-year cumulative LT-CVC BSI rate was 1.94 per 1,000 CVC days of use. The rates were higher in public hospitals (IRR, 6.00; P < .001) and in hospitals that already had in place surveillance for LT-CVC infections (IRR, 2.01; P < .01).

CONCLUSION

Our study describes an applicable surveillance method for infections in cancer outpatients using LT-CVC.

Success rate and safety of totally implantable access ports placed by the cephalic vein cutdown technique in oncological patients - a single-center study

INTRODUCTION

Totally implantable access ports (TIAPs) are commonly used in oncologic patients undergoing ongoing chemotherapy. The methods of choice for implantation are the subclavian vein puncture approach and the cephalic vein cutdown technique, followed by internal jugular vein access and external jugular vein access.

Bacterial Biofilm Formation on Biomaterials and Approaches to Its Treatment and Prevention

Bacterial biofilms can cause widespread infection. In addition to causing urinary tract infections and pulmonary infections in patients with cystic fibrosis, biofilms can help microorganisms adhere to the surfaces of various medical devices, causing biofilm-associated infections on the surfaces of biomaterials such as venous ducts, joint prostheses, mechanical heart valves, and catheters. Biofilms provide a protective barrier for bacteria and provide resistance to antimicrobial agents, which increases the morbidity and mortality of patients. This review summarizes biofilm formation processes and resistance mechanisms, as well as the main features of clinically persistent infections caused by biofilms. Considering the various infections caused by clinical medical devices, we introduce two main methods to prevent and treat biomaterial-related biofilm infection: antibacterial coatings and the surface modification of biomaterials. Antibacterial coatings depend on the covalent immobilization of antimicrobial agents on the coating surface and drug release to prevent and combat infection, while the surface modification of biomaterials affects the adhesion behavior of cells on the surfaces of implants and the subsequent biofilm formation process by altering the physical and chemical properties of the implant material surface. The advantages of each strategy in terms of their antibacterial effect, biocompatibility, limitations, and application prospects are analyzed, providing ideas and research directions for the development of novel biofilm infection strategies related to therapeutic materials.

Randomized Clinical Trial of the Need for Antibiotic Treatment for Low-Risk Catheter-Related Bloodstream Infection Caused by Coagulase-Negative Staphylococci

According to clinical guidelines, the management of catheter-related bloodstream infections (CRBSI) due to coagulase-negative staphylococci (CoNS) includes catheter removal and antibiotic treatment for 5 to 7 days. However, in low-risk episodes, it remains uncertain whether antibiotic therapy is necessary. This randomized clinical trial aims to determine whether the non-administration of antibiotic therapy is as safe and effective as the recommended strategy in low-risk episodes of CRBSI caused by CoNS. With this purpose, a randomized, open-label, multicenter, non-inferiority clinical trial was conducted in 14 Spanish hospitals from 1 July 2019 to 31 January 2022. Patients with low-risk CRBSI caused by CoNS were randomized 1:1 after catheter withdrawal to receive/not receive parenteral antibiotics with activity against the isolated strain. The primary endpoint was the presence of any complication related to bacteremia or to antibiotic therapy within 90 days of follow-up. The secondary endpoints were persistent bacteremia, septic embolism, time until microbiological cure, and time until the disappearance of a fever. EudraCT: 2017-003612-39 INF-BACT-2017. A total of 741 patients were assessed for eligibility. Of these, 27 were included in the study; 15 (55.6%) were randomized to the intervention arm (non-antibiotic administration) and 12 (44.4%) to the control arm (antibiotic therapy as per standard practice). The primary endpoint occurred in one of the 15 patients in the intervention group (septic thrombophlebitis) and in no patients in the control group. The median time until microbiological cure was 3 days (IQR 1-3) in the intervention arm and 1.25 days (IQR 0.5-2.62) in the control arm, while the median time until fever resolution was zero days in both arms. The study was stopped due to the insufficient number of recruited patients. These results seem to indicate that low-risk CRBSI caused by CoNS can be managed without antibiotic therapy after catheter removal; efficacy and safety are not affected.

Surgical Experience Affects the Outcome of Central Venous Access Catheter Implantation in Children: A Retrospective Cohort Study

INTRODUCTION

Surgical complications occur in up to third of children, limiting the benefits of tunneled central venous catheters (tCVCs) in children. We aimed to identify risk factors for complications related to catheter implantation.

METHODS

All children and adolescents undergoing tCVC implantation at a single center over a period of 9 years were analyzed. Infection, thrombosis, dislocation, and catheter dysfunction were defined as complications. Both patient-related (ie, age, sex, vessel characteristics, revision surgery) and surgical factors (ie, sex of surgeon, surgical experience) were analyzed for their association with complications.

RESULTS

A total of 1024 catheters were inserted, 887 ports and 137 broviac catheters. In terms of patient-related factors, Broviac catheters, and nononcological patients had a higher complication rate. The use of the internal jugular vein and revision surgery was associated with significantly increased complications in patients with port catheters. Experience of the surgeon correlated with various outcome parameters. Implantation performed by an attending were associated with lower complication rates in comparison to those performed by residents. Within the resident group, insertions performed by experienced residents had more complications compared with those performed by residents during their first years.

CONCLUSION

The study suggests that the outcome of tCVCs insertion is affected by the type of catheter used, the utilized vessel and above all by surgical experience. Residents had significantly increased complication rates in comparison to board-certified surgeons and amongst resident's outcome got worse with increasing experience of the residents. The presence of an experienced attending did not compensate for this effect. To improve the outcome of tCVCs, strategies like direct feedback after every procedure to achieve proficiency should be implanted in residency programs.

Radionuclide Imaging of Infective Endocarditis

Infective endocarditis (IE) is associated with high morbidity and mortality. Early diagnosis is crucial for adequate patient management. Due to difficulties in the diagnosis, a multidisciplinary discussion in addition to the integration of clinical signs, microbiology data, and imaging data is used. Imaging, including echocardiography, molecular imaging techniques, and coronary CT angiography (CTA) is central to detect infections involving heart valves and implanted cardiovascular devices, also allowing for early detection of septic emboli and metastatic. This article describes the main clinical application of white blood cell SPECT/CT and [¹⁸F]FDG-PET/CT and CTA in IE and infections associated with cardiovascular implantable electronic devices.

Clinical Characteristics and Outcomes of Persistent Staphylococcal Bacteremia in a Tertiary Care Hospital

Clinical outcomes of persistent staphylococcal bacteremia vary depending on the causative organism. This secondary data analysis study compared the clinical characteristics of persistent Staphylococcus aureus (S. aureus)- and coagulase-negative staphylococci (CoNS)-caused bacteremia, focusing on the methicillin-resistant status. This study used data collected from patients who underwent blood cultures between January 2012 and December 2021 at Tohoku University Hospital, Japan. Patients with persistent staphylococcal bacteremia were divided into groups based on the pathogen and methicillin-resistant status, and their characteristics were analyzed. The primary outcomes were early (30-day), late (30–90 days), and 90-day mortality rates. The early, late, and 90-day mortality rates were similar between the persistent CoNS and S. aureus bacteremia groups. Patients with persistent methicillin-resistant S. aureus (MRSA) bacteremia tended to have higher early, late, and 90-day mortality rates than those with persistent methicillin-susceptible S. aureus bacteremia (not statistically significant). No differences were observed between the methicillin-resistant and-susceptible CoNS groups. In patients with persistent CoNS bacteremia, mortality tended to increase, especially in debilitated or immunocompromised patients with distant metastases, underscoring the importance of infection source control. Mortality tended to be high in patients with persistent MRSA bacteremia, especially when persistent bacteremia clearance was not confirmed, illustrating the need for careful therapeutic management.

TIVAP-related infection due to Gram-negative aerobic bacilli: should TIVAP stay or should it go?

We aimed to describe the outcome of totally implantable venous-access port (TIVAP)-related infections due to Gram-negative aerobic bacilli (Pseudomonas aeruginosa and other Pseudomonas spp., Acinetobacter spp., and Stenotrophomonas maltophilia), or GNAB, and assess the safety of conservative treatment. We conducted a retrospective study in a French teaching hospital, from January 2016 to December 2020, including adult patients treated for TIVAP-related infection due to GNAB. Success of conservative treatment was defined as a functional TIVAP 3 months after infection with no recurrence. We performed a bivariate analysis and analyzed causes for treatment failure. We included 68 patients (53 TIVAP-related bloodstream infections, 11 TIVAP-related infections, and 4 probable TIVAP-related infections) due to GNAB, mostly P. aeruginosa (50/68, 74%). TIVAP removal was initially decided for 49/68 patients (72%). Among the 19/68 (28%) patients with conservative treatment (all for infections caused by P. aeruginosa), 5/19 (26%) had successful treatment, 7/19 (37%) experienced failure (without sepsis or septic shock), 6/19 (32%) died within 3 months without TIVAP removal and no signs of infection recurrence, and 1 patient had TIVAP removal as it was no longer required. TIVAP-related infections caused by GNAB frequently require TIVAP removal. Conservative treatment can be performed in selected patients with a non-complicated infection caused by P. aeruginosa, who can benefit from the continuation of antineoplastic chemotherapy or palliative care. Treatment failures were not associated with sepsis or septic shock.

Impact of central venous port implantation method and access choice on outcomes

BACKGROUND

Although the number of patients who need central venous ports for permanent vascular access is increasing, there is still no "gold standard" for the implantation technique.

AIM

To identify the implantation technique that should be favored.

METHODS

Two hundred central venous port-implanted patients in a tertiary hospital were retrospectively evaluated. Patients were assigned into two groups according to the access method. The first group comprised patients whose jugular veins were used, and the second group comprised patients whose subclavian veins were used. Groups were evaluated regarding age, sex, application side, primary diagnosis, active follow-up period in the hospital, chemotherapy agents administered, number of complications, and the Clavien-Dindo severity score. The distribution of the variables was tested with the Kolmogorov-Smirnov test and the Mann-Whitney U test. The χ 2 test was used to analyze the variables.

RESULTS

There was no statistically significant difference between the groups regarding age, sex, side, number of chemotherapy drugs, and duration of port usage (P > 0.05). Only 2 patients in group 1 had complications, whereas in group 2 we observed 19 patients with complications (P < 0.05). No port occlusion was found in group 1, but the catheters of 4 patients were occluded in group 2. One port was infected in group 1 compared to three infected ports in group 2. Two port ruptures, two pneumothorax, one revision due to a mechanical problem, one tachyarrhythmia during implantation, and four suture line problems were also recorded in group 2 patients. We also showed that it would be sufficient to evaluate and wash ports once every 2 mo.

CONCLUSION

Our results robustly confirm that the jugular vein route is safer than the subclavian vein approach for central venous port implantation.

Phyto-assisted synthesis of zinc oxide nanoparticles for developing antibiofilm surface coatings on central venous catheters

Medical devices such as Central Venous Catheters (CVCs), are routinely used in intensive and critical care settings. In the present scenario, incidences of Catheter-Related Blood Stream Infections (CRBSIs) pose a serious challenge. Despite considerable advancements in the antimicrobial therapy and material design of CVCs, clinicians continue to struggle with infection-related complications. These complications are often due colonization of bacteria on the surface of the medical devices, termed as biofilms, leading to infections. Biofilm formation is recognized as a critical virulence trait rendering infections chronic and difficult to treat even with 1,000x, the minimum inhibitory concentration (MIC) of antibiotics. Therefore, non-antibiotic-based solutions that prevent bacterial adhesion on medical devices are warranted. In our study, we report a novel and simple method to synthesize zinc oxide (ZnO) nanoparticles using ethanolic plant extracts of Eupatorium odoratum. We investigated its physio-chemical characteristics using Field Emission- Scanning Electron Microscopy and Energy dispersive X-Ray analysis, X-Ray Diffraction (XRD), Photoluminescence Spectroscopy, UV-Visible and Diffuse Reflectance spectroscopy, and Dynamic Light Scattering characterization methods. Hexagonal phase with wurtzite structure was confirmed using XRD with particle size of ∼50 nm. ZnO nanoparticles showed a band gap 3.25 eV. Photoluminescence spectra showed prominent peak corresponding to defects formed in the synthesized ZnO nanoparticles. Clinically relevant bacterial strains, viz., Proteus aeruginosa PAO1, Escherichia coli MTCC 119 and Staphylococcus aureus MTCC 7443 were treated with different concentrations of ZnO NPs. A concentration dependent increase in killing efficacy was observed with 99.99% killing at 500 μg/mL. Further, we coated the commercial CVCs using green synthesized ZnO NPs and evaluated it is in vitro antibiofilm efficacy using previously optimized in situ continuous flow model. The hydrophilic functionalized interface of CVC prevents biofilm formation by P. aeruginosa, E. coli and S. aureus. Based on our findings, we propose ZnO nanoparticles as a promising non-antibiotic-based preventive solutions to reduce the risk of central venous catheter-associated infections.

Biofilm formation and antibiotic resistance among Coagulase Negative Staphylococcus species isolated from central venous catheters of intensive care unit patients

PURPOSE

This study was conducted to determine the biofilm formation of coagulase negative Staphylococcus species (CoNS) isolated from patients with catheter related blood stream infection (CRBSI) and colonized central venous catheters (CVC) and their antibiotic susceptibility patterns and in situ biofilm formation of CVC tips.

METHODS

Eighty-two CoNS isolated from intensive care unit (ICU) patients with CRBSI (n ​= ​8) or colonized CVC (n ​= ​74) were included. Species identification and antibiotic susceptibility test were done. All isolates were screened for biofilm formation using crystal violet and 3-(4,5-dimethylthiazole-2-yl)-2-5-diphenyl-2H-tetrazolium bromide (MTT) assays and categorized as strong or moderate biofilm formers. CVC tips were subjected to crystal violet stain and scanning electron microscopy (SEM) to detect in-situ biofilm formation.

RESULTS

Staphylococcus haemolyticus (n ​= ​34; 41%) was the commonest to cause both CRBSI and CVC colonization. All 82 CoNS produced biofilms. Among them 77 (93.90%) were strong biofilm formers including all from CRBSI patients and 05 (6.10%) were moderate biofilm formers as detected by both methods. SEM showed bacteria adhered to surfaces of CVC tips with microbial-aggregates embedded in extracellular matrix. Mean crystal violet absorbance of CVC from CRBSI patients (0.6628) was significantly higher than colonized CVC (mean value 0.5592) (p ​= ​0.030). S. haemolyticus showed higher resistance to cloxacillin compared to other CoNS (p ​= ​0.039).

CONCLUSION

Majority of CoNS isolated were strong biofilm formers. In-situ biofilm formation on CVC tips were significantly evident in CRBSI patients compared to CVC colonized patients. S. haemolyticus is the commonest to cause both CRBSI and CVC colonization and shows significantly higher cloxacillin resistance rate.

Ultrasound-guided totally implantable venous access ports placement via right brachiocephalic vein in pediatric population: A clinical debut

BACKGROUND AND OBJECTIVES

To investigate the feasibility and safety of ultrasound-guided totally implantable venous access ports (TIVAPs) via the right brachiocephalic vein (BCV) in pediatric patients.

METHODS

A single-institute retrospective review was performed on 35 pediatric patients with predominantly hematological malignancies (88.6%) who underwent TIVAP implantation via ultrasound-guided right BCV approach from July 2018 to June 2021. The catheter tip was adjusted to be positioned at the cavoatrial junction under pulsed fluoroscopic guidance. Technical success rate, procedural information, and TIVAP-related complications were evaluated.

RESULTS

All the pediatric TIVAP devices were successfully implanted via right BCV access. Venous access was successful by first attempt in 32 children (91%), two cases (5.7%) required a second attempt, and one patient (2.9%) required a third attempt. The mean procedural time was 44.6 ± 6.4 minutes (range: 34-62 minutes). No intraoperative complications occurred. The average TIVAP indwelling time was 564 ± 208 days (range: 193-1014 days), with a cumulative 19,723 catheter-days. Overall, three patients (8.6%) experienced four postoperative complications (two cases of local hematoma and two catheter dysfunctions) at a rate of 0.2 per 1000 catheter-days. No other complications such as wound dehiscence, delayed incision healing, catheter-related thrombosis (CRT), catheter malposition/fracture, surgical site infection, catheter-related bloodstream infection (CRBSI), pinch-off syndrome, and drug extravasation were observed during follow-up.

CONCLUSIONS

Ultrasound-guided right BCV access for TIVAP placement in pediatric patients appears to be technically feasible, safe, and effective. Further large-sample, prospective studies are warranted.

Risk Factors of Catheter-Related Infection in Unplanned Extubation of Totally Implantable Venous-Accessportsin Tumor Patients

Background

Totally implantable intravenous ports (TIVAPs) are mostly used for long-term intravenous infusion therapy in cancer patients and can be left in the body for long periods of time for easy management, making them a simple and safe infusion device. Although the risks associated with long-term retention of fully implantable IV ports are less than those associated with other intravenous catheters, various complications may still occur at the time of implantation or during long-term use.

Purpose

To provide a scientific basis for clinical reduction of implantable intravenous port-associated infection complications by studying the risk factors for catheter-associated infection complications in patients applying implantable intravenous ports.

Methods

A retrospective study was conducted on oncology patients treated with TIVAP at our hospital between January 2017 and November 2021, with a review of patients who were unplanned for extubation. Their demographic data, underlying disease status, and surgery-related data were counted to summarize and analyze the complications and related influencing factors of implantation and postimplantation.

Results

A total of 70 individuals with a mean age of 56.49 ± 12.19 years were included in the study. Among them, 39 were male and 64 had the highest percentage of epithelial tumors, followed by tumors of the lymphopoiesis system and mesenchymal tumors with 4 and 2 cases, respectively. Forty-eight of these patients did not have their ports removed as planned due to the occurrence of catheter-related hematogenous infections. In univariate analysis, BMI and neutropenia were risk factors for catheter-associated infections. In the multivariate analysis, BMI (OR = 1.38, 95% CI: 1.07–1.78, p=0.013) was an independent risk factor for catheter-associated infections.

Conclusions

The overall complication rate of fully implanted intravenous ports was high, but most complications improved with symptomatic management, and no deaths due to port complications were identified. Infection was the most common complication, with catheter-associated bloodstream infection being the most common cause of unplanned port extraction. Patients with a higher BMI were at high risk of developing implantable IV port-associated infections, which may be an independent risk factor for implantable IV port-associated infections.

Incidence and Risk Factors for Totally Implantable Venous Access Device Infections in Pediatric Patients With Cancer: A Study of 25,954 Device-Days

BACKGROUND

Totally implantable venous access devices (TIVADs) are frequently used in pediatric patients with cancer owing to their multiple benefits. Despite occasional infections with TIVADs, knowledge of the incidence and risk factors is limited.

METHODS

This retrospective study included pediatric patients with cancer who received TIVAD at Chungbuk National University Hospital from 2001 to 2021. We collected data on demographics, diagnosis, duration of TIVAD use, pathogens, and other risk factors.

RESULTS

During the study period, 55 TIVADs with 25,954 device-days were applied in 49 patients. There were 15 TIVAD infections (15/55, 27.3%), with an infection rate of 0.21 infections per TIVAD per year (0.58 cases/1,000 device-days). TIVAD infections occurred at a median of 5 months (range, 8 days-30 months) after insertion. The most common causative microorganisms were methicillin-resistant coagulase-negative staphylococci (n = 8, 53.3%) followed by Escherichia coli (n = 3, 20.0%). Infection-free TIVAD survival was higher in the group with normal platelet count at insertion (platelet counts ≥ 150,000/μL) than in the group with thrombocytopenia at insertion (platelet counts < 150,000/μL) (81.3% vs. 32.1%, P = 0.004). Device removal was the mainstay of treatment (11/15, 73.3%).

CONCLUSION

TIVAD infection may be related to thrombocytopenia at the time of device insertion. Further studies are needed to identify preventive factors against TIVAD infections in children with cancer.

Burden of bacterial bloodstream infections and recent advances for diagnosis

Bloodstream infections (BSIs) and subsequent organ dysfunction (sepsis and septic shock) are conditions that rank among the top reasons for human mortality and have a great impact on healthcare systems. Their treatment mainly relies on the administration of broad-spectrum antimicrobials since the standard blood culture-based diagnostic methods remain time-consuming for the pathogen's identification. Consequently, the routine use of these antibiotics may lead to downstream antimicrobial resistance and failure in treatment outcomes. Recently, significant advances have been made in improving several methodologies for the identification of pathogens directly in whole blood especially regarding specificity and time to detection. Nevertheless, for the widespread implementation of these novel methods in healthcare facilities, further improvements are still needed concerning the sensitivity and cost-effectiveness to allow a faster and more appropriate antimicrobial therapy. This review is focused on the problem of BSIs and sepsis addressing several aspects like their origin, challenges, and causative agents. Also, it highlights current and emerging diagnostics technologies, discussing their strengths and weaknesses.

Retrospective analysis: 5509 cases of "totally implantable venous access port systems implantation (TIVAPS) depth" assisted by digital radiography

PURPOSE

Modern oncological treatment in breast cancer patients requires the precise delivery of chemotherapy infusion into the central venous systems without toxicity. TIVAPS is the significant method of chemotherapy delivery although certain internal or external complications associated with their placement. However, the long-term use of TIVAPS is still a concern to minimize the complications such as venous thrombosis syndrome (VTS) and cardiac defects. The aim of this study is to investigate the potential disadvantages that may be avoided by digital radiography (DR)-assisted measurement of catheter depth pertinent to TIVAPS implanted system.

METHODS

Retrospective analysis related to 5509 TIVAPS recipients of 99% female breast cancer patients and 1% male blood disorder patients registered from April 2013 to November 2017 were included in the study. Patients with TIVAPS catheter tip depth into superior vena cava into upper (group A), middle (group B), and lower (group C) parts were stratified for evaluation during implantation; DR-assisted measurement of TIVAPS was performed to decipher "tip depth of catheter" and determined the relevance of tip depth to complications such as VTS and cardiac defects.

RESULTS

Incidence of VTS complications were significantly higher in TIVAPS recipients of group A (82.7%) than group B (16%) and group C (0.12%) in which the "tip depth of TIVAPS was deeper" (P < 0.01). Defects in heart function are higher in group C (59.6%) than group A (15.8%) and group B (24.6%) in which the "tip depth of TIVAPS was deeper" (P < 0.01).

CONCLUSION

DR-assisted measurement can more accurately determine the depth of TIVAPS catheter implantation, and avoid the incidence of related complications, and provide a better method for surgeons.

Smart implanted access port catheter for therapy intervention with pH and lactate biosensors

Totally implanted access ports (TIAP) are widely used with oncology patients requiring long term central venous access for the delivery of chemotherapeutic agents, infusions, transfusions, blood sample collection and parenteral nutrition. Such devices offer a significant improvement to the quality of life for patients and reduced complication rates, particularly infection, in contrast to the classical central venous catheters. Nevertheless, infections do occur, with biofilm formation bringing difficulties to the treatment of infection-related complications that can ultimately lead to the explantation of the device. A smart TIAP device that is sensor-enabled to detect infection prior to extensive biofilm formation would reduce the cases for potential device explantation, whereas biomarkers detection within body fluids such as pH or lactate would provide vital information regarding metabolic processes occurring inside the body. In this paper, we propose a novel batteryless and wireless device suitable for the interrogation of such markers in an embodiment model of an TIAP, with miniature biochemical sensing needles. Device readings can be carried out by a smartphone equipped with Near Field Communication (NFC) interface at relative short distances off-body, while providing radiofrequency energy harvesting capability to the TIAP, useful for assessing patient's health and potential port infection on demand.

An Alternative to Transvenous Lead Extraction in Selected Patients with CIED Infections—A Retrospective Outcome Study

Cardiac implantable electronic device (CIED) implants are rising in an older, more co-morbid population. The prevalence of CIED infection ranges from 1–4%. Whilst complete extraction of all transvenous hardware is recommended for infected, eroded, or pre-eroding CIEDs, this approach is not without risk and may be unacceptable to some patients. Long-term data on a more conservative strategy is lacking. We report on our experience of conservative management with pocket revision as a primary strategy in carefully selected patients. Method: A retrospective review of all CIED revision procedures was undertaken at a large tertiary center, over a 7-year period, with a mean follow-up timeframe of 39 months. Results: A total of 86 patients underwent 96 revision procedures; 7 patients required further revisions and 13 went on to undergo CIED extraction by the end of the follow-up period. The overall rate of mortality at 12 months was 8.1%, increasing to 24.4% at the end of the follow-up period. Conclusion: Our data provide important outcome information on an alternative strategy to lead extraction in carefully selected patients where the risk of extraction is perceived to be unacceptable. The absence of systemic infection appears to predict better outcomes than previously reported, and over two-thirds of patients remained complication-free at 12 months.

Standardized procedure prevents perioperative and early complications in totally implantable venous-access ports-a complication analysis of more than 1000 TIVAP implantations

PURPOSE

Since their invention 40 years ago, totally implantable venous-access ports (TIVAPs) have become indispensable in cancer treatment. The aim of our study was to analyze complications under standardized operative and perioperative procedures and to identify risk factors for premature port catheter explantation.

METHODS

A total of 1008 consecutive TIVAP implantations were studied for success rate, perioperative, early, and late complications. Surgical, clinical, and demographic factors were analyzed as potential risk factors for emergency port catheter explantation.

RESULTS

Successful surgical TIVAP implantation was achieved in 1005/1008 (99.7%) cases. No intraoperative or perioperative complications occurred. A total of 32 early complications and 88 late complications were observed leading to explantation in 11/32 (34.4%) and 34/88 (38.6%) cases, respectively. The most common complications were infections in 4.7% followed by thrombosis in 3.6%. Parameters that correlated with unplanned TIVAP explantation were gender (port in situ: female 95% vs. male 91%, p = 0.01), underlying disease (breast cancer 97% vs. gastrointestinal 89%, p = 0.004), indication (chemotherapy 95% vs. combination of chemotherapy and parenteral nutrition 64%, p < 0.0001), and type of complication (infection 13.4% vs. TIVAP-related complication 54% and thrombosis 95%, p < 0.0001).

CONCLUSION

Standardized operative and perioperative TIVAP implantation procedures provide excellent results and low explantation rate.

Gut biofilms: Bacteroides as model symbionts to study biofilm formation by intestinal anaerobes

Bacterial biofilms are communities of adhering bacteria that express distinct properties compared to their free-living counterparts, including increased antibiotic tolerance and original metabolic capabilities. Despite the potential impact of the biofilm lifestyle on the stability and function of the dense community of micro-organisms constituting the mammalian gut microbiota, the overwhelming majority of studies performed on biofilm formation by gut bacteria focused either on minor and often aerobic members of the community or on pathogenic bacteria. In this review, we discuss the reported evidence for biofilm-like structures formed by gut bacteria, the importance of considering the anaerobic nature of gut biofilms and we present the most recent advances on biofilm formation by Bacteroides, one of the most abundant genera of the human gut microbiota. Bacteroides species can be found attached to food particles and colonizing the mucus layer and we propose that Bacteroides symbionts are relevant models to probe the physiology of gut microbiota biofilms.

Phyto-fabricated Nanoparticles and Their Anti-biofilm Activity: Progress and Current Status

Biofilm is the self-synthesized, mucus-like extracellular polymeric matrix that acts as a key virulence factor in various pathogenic microorganisms, thereby posing a serious threat to human health. It has been estimated that around 80% of hospital-acquired infections are associated with biofilms which are found to be present on both biotic and abiotic surfaces. Antibiotics, the current mainstream treatment strategy for biofilms are often found to be futile in the eradication of these complex structures, and to date, there is no effective therapeutic strategy established against biofilm infections. In this regard, nanotechnology can provide a potential platform for the alleviation of this problem owing to its unique size-dependent properties. Accordingly, various novel strategies are being developed for the synthesis of different types of nanoparticles. Bio-nanotechnology is a division of nanotechnology which is gaining significant attention due to its ability to synthesize nanoparticles of various compositions and sizes using biotic sources. It utilizes the rich biodiversity of various biological components which are biocompatible for the synthesis of nanoparticles. Additionally, the biogenic nanoparticles are eco-friendly, cost-effective, and relatively less toxic when compared to chemically or physically synthesized alternatives. Biogenic synthesis of nanoparticles is a bottom-top methodology in which the nanoparticles are formed due to the presence of biological components (plant extract and microbial enzymes) which act as stabilizing and reducing agents. These biosynthesized nanoparticles exhibit anti-biofilm activity via various mechanisms such as ROS production, inhibiting quorum sensing, inhibiting EPS production, etc. This review will provide an insight into the application of various biogenic sources for nanoparticle synthesis. Furthermore, we have highlighted the potential of phytosynthesized nanoparticles as a promising antibiofilm agent as well as elucidated their antibacterial and antibiofilm mechanism.

Incidence and risk factor for infection of totally implantable venous access port

BACKGROUND

Totally implantable venous access ports (TIVAP) have been widely used in cancer patients for many years. The early infection (within 30 days after TIVAP implantation) rate of TIVAP accounts for about one-third of all TIVAP infections, and early infection often causes port removal and affects subsequent cancer treatment. This study investigated the incidence and risk factors for early and late infection after TIVAP implantation.

METHODS

From January 2013 to December 2018, all adult cancer patients who received TIVAP implantation in Taipei Medical University Shuang-Ho Hospital were reviewed. We evaluated the incidence of TIVAP-related infection, patient characteristics, and bacteriologic data. Univariable analysis and multiple logistic regression analysis were used to evaluate the risk factors of TIVAP-related infection.

RESULTS

A total of 3001 TIVAPs were implanted in 2897 patients, and the median follow-up time was 424 days (range: 1-2492 days), achieving a combined total of 1,648,731 catheter days. Thirty-one patients (1.0%) had early infection and 167 (5.6%) patients had late infection. In multivariate analysis, TIVAP combined with other surgeries (p = 0.03) and inpatient setting (p < 0.001) was the risk factor of early infection, and TIVAP combined with other surgeries (p = 0.007), hematological cancer (p = 0.03), and inpatient setting (p < 0.001) was the risk factor of late infection.

CONCLUSION

Inpatient TIVAP implantation and TIVAP implantation combined with other surgeries are associated with high rates of TIVAP-related early and late infections.

Cardiovascular implantable electronic devices and native arteriovenous fistula in hemodialysis patients: novel perspectives

The benefits from cardiovascular implantable electronic devices (CIED) implantation in hemodialysis (HD) patients are still far to be thoroughly defined, especially on primary prevention. In addition, CIED placement is not a risk-free procedure, because it could be followed by a not negligible burden of complications that could compromise the health and the vascular access of HD patients. In fact, the arteriovenous fistula (AVF) dysfunction following CIED implantation is usually due to a hemodynamically significant alteration of blood flow. This condition could lead to a potential decrease of dialysis efficacy and a raised risk of thrombosis of both the central vein and the efferent vein of the AVF.The pathological pathway that leads to AVF dysfunction after CIED implantation may involve the irritating actions of the CIED and their leads to the vascular wall in HD patients that are more prone to show previous vascular diseases.The aim of this review is to focus the physiopathology of the CIED-induced AVF dysfunction, the current treatment strategies and the novel perspectives that could be taken into consideration and offered to the HD population to preserve both their AVF and their quality of life.

How to perform appropriate flushing after lipid emulsion administration using totally implantable venous access devices in long-term total parenteral nutrition and home parenteral nutrition

BACKGROUND & AIMS

There has been no clear evidence regarding the appropriate method of flushing catheters and totally implantable venous access devices (TIVADs) after lipid emulsion (LE) administration. Therefore, the aim of the study was to identify appropriate methods of flushing to minimize residual LE when using TIVADs to ensure the safety of long-term total parenteral nutrition (TPN) and home parenteral nutrition (HPN).

METHODS

A soybean oil LE containing indocyanine green (ICG) was administered from the injection site of the primary infusion set for flowing TPN, and LE dynamics were evaluated by a fluorescence imaging system. TIVADs were connected to the end of the infusion sets. After LE administration, the tubes and chambers were flushed from the injection site using saline at various speeds (20, 40, 60 mL/min), with and without pulsation. The washout effect of TPN solution after LE administration followed by flushing was examined, as was the washout effect of size differences in the infusion sets.

RESULTS

When the LE was flushed with 20 mL of saline immediately after administering the LE using a standard infusion set (inner diameter 2.5 mm), the LE still remained in the tubes and chambers under any flushing condition. Flushing the LE from the injection site with 10 mL of saline and then flowing >240 mL of TPN solution were effective for minimizing residual LE inside the tubes and chambers. When using an infusion set with a small inner diameter (1.0 mm), the LE inside the tubes and chambers was almost discharged with ≥20 mL of saline immediately after administering the LE. In all settings, flushing with/without pulsation did not affect LE washout efficacy.

CONCLUSIONS

Flushing immediately with saline ≥10 mL and then flowing >240 mL of primary PN solution after soybean oil LE administration using the standard infusion set or flushing with 20 mL saline immediately after administering the soybean oil LE using the infusion set with a small inner diameter are effective for minimizing the residual LE in the catheter and TIVAD, ensuring the safety of long-term TPN and HPN.

Combining Miconazole and Domiphen Bromide Results in Excess of Reactive Oxygen Species and Killing of Biofilm Cells

Fungal biofilm-related infections are increasingly occurring. We previously identified a fungicidal antibiofilm combination, consisting of miconazole (MCZ) and the quaternary ammonium compound domiphen bromide (DB). DB eliminates tolerance rather than altering the susceptibility to MCZ of various Candida spp. Here we studied the mode of action of the MCZ-DB combination in more detail. We found that DB's action increases the permeability of the plasma membrane as well as that of the vacuolar membrane of Candida spp. Furthermore, the addition of DB affects the intracellular azole distribution. MCZ is a fungicidal azole that, apart from its well-known inhibition of ergosterol biosynthesis, also induces accumulation of reactive oxygen species (ROS). Interestingly, the MCZ-DB combination induced significantly more ROS in C. albicans biofilms as compared to single compound treatment. Co-administration of the antioxidant ascorbic acid resulted in abolishment of the ROS generated by MCZ-DB combination as well as its fungicidal action. In conclusion, increased intracellular MCZ availability due to DB's action results in excess of ROS and enhanced fungal cell killing.

Controlling Experimental Parameters to Improve Characterization of Biomaterial Fouling

Uncontrolled protein adsorption and cell binding to biomaterial surfaces may lead to degradation, implant failure, infection, and deleterious inflammatory and immune responses. The accurate characterization of biofouling is therefore crucial for the optimization of biomaterials and devices that interface with complex biological environments composed of macromolecules, fluids, and cells. Currently, a diverse array of experimental conditions and characterization techniques are utilized, making it difficult to compare reported fouling values between similar or different biomaterials. This review aims to help scientists and engineers appreciate current limitations and conduct fouling experiments to facilitate the comparison of reported values and expedite the development of low-fouling materials. Recent advancements in the understanding of protein-interface interactions and fouling variability due to experiment conditions will be highlighted to discuss protein adsorption and cell adhesion and activation on biomaterial surfaces.

Combination Therapy to Treat Fungal Biofilm-Based Infections

An increasing number of people is affected by fungal biofilm-based infections, which are resistant to the majority of currently-used antifungal drugs. Such infections are often caused by species from the genera Candida, Aspergillus or Cryptococcus. Only a few antifungal drugs, including echinocandins and liposomal formulations of amphotericin B, are available to treat such biofilm-based fungal infections. This review discusses combination therapy as a novel antibiofilm strategy. More specifically, in vitro methods to discover new antibiofilm combinations will be discussed. Furthermore, an overview of the main modes of action of promising antibiofilm combination treatments will be provided as this knowledge may facilitate the optimization of existing antibiofilm combinations or the development of new ones with a similar mode of action.

Evaluation of a Monte Carlo-based algorithm for the influence of totally implantable venous access ports in external radiation therapy

PURPOSE

This study aimed to assess whether a Monte Carlo (MC)-based algorithm reflects the influence of totally implantable venous access ports (TIVAPs) in external radiation therapy.

MATERIALS AND METHODS

The present study comprised two steps: experimental measurements of depth doses and surface doses with and without TIVAPs and calculation with an MC-based algorithm.

RESULTS

The TIVAP-associated maximum dose reduction compared with the dose at the same depths without TIVAPs was 7.8% at 4 MV, 6.9% at 6 MV, and 5.7% at 10 MV in measurement, and 7.4% at 4 MV, 6.6% at 6 MV, and 5.5% at 10 MV in calculation. Relative surface doses were higher with TIVAPs made of titanium, due to a higher fluence of backscattered electrons from the TIVAPs, than with plastic TIVAPs. There were no significant differences in the relative differences between the measured and calculated doses of the titanium TIVAP group and the plastic TIVAP group at 4 MV (p = 0.99), 6 MV (p = 0.67), and 10 MV (p = 0.54).

CONCLUSION

TIVAPs caused target dose reductions and dose increase near the TIVAP, especially when made of titanium. The influences are reflected in the MC-based algorithm.

Arm mobilization provokes deformity of long-term indwelling ports implanted via the jugular vein

BACKGROUND

The incidence of totally implantable catheter fracture ranges from 0.48% to 5.00%, and these fractures represent a potentially fatal complication. The fracture mechanism of catheters implanted via the jugular vein is unclear, and whether extreme arm movements represent an additional risk factor for repetitive stress of the material remains unknown. The aim of this study was to demonstrate and classify catheter deformations caused by extreme arm mobilization and associations with changes in catheter function and displacement.

METHODS

We analyzed the fluoroscopy images of 60 consecutive patients undergoing long-term indwelling port implantation via the jugular vein. Three images were taken: arm in maximal abduction, maximal frontal elevation, and maximal adduction. The images were compared with an image of the remainder of the arm. We analyzed three catheter regions to classify the deformity: A, connection between catheter and reservoir; B, the catheter's subcutaneous tunnel; and C, the catheter's entrance in the jugular vein. The deformations were classified in comparative manner as follows: 0 (no changes), 1 (minor changes, new slightly curvatures with an angle of >90°), and 2 (major changes, new severe curvatures with angles of ≤90°). In each position, catheter function (injection and aspiration) and displacement of the reservoir and tip were analyzed.

RESULTS

Only 15% of patients did not show a deformity; 33.3% had a deformity in only one position, 47.7% in two positions, and 10% in three positions. Minor deformities were observed in 70% of patients and major deformities in 40%. Moreover, 25% of patients presented both major and minor deformities. Major deformities were observed in 25.0% of patients on maximal frontal elevation, in 23.3% on maximal adduction and in none on maximal abduction. Region B was the most affected, with 57.8% of all minor deformities and 78.1% of all major deformities. No change in function was noted in 91.7% of the catheters. Maximal arm adduction resulted in greater vertical and horizontal displacement of the catheter tip and horizontal displacement of the reservoir. Higher body mass index values were associated with major deformities.

CONCLUSIONS

Maximal frontal elevation and maximal adduction were associated with major catheter deformities, and the subcutaneous tunnel region was the most deformed catheter region. An association between major catheter deformity and high body mass index was noted; in contrast, no association between the severity of catheter deformity, tip or reservoir displacement, or worsened functioning was observed.

Comparison of methods for the microbiological diagnosis of totally implantable venous access port-related infections

Introduction. Totally implanted venous access ports (TIVAPs) are widely used in patients receiving long-term chemotherapy but may lead to serious complications such as catheter-related bloodstream infections (CRBSIs). Diagnosis of CRBSI requires catheter culture, but there is no consensus on microbiological culture methods to be adopted.Aim. To compare three different procedures to recover bacterial cells from colonized catheters and to determine which section of the TIVAP (i.e. tip, septum, reservoir) is the probable source of infection. To investigate the correlation between blood culture results and TIVAP culture in order to get further evidence about the utility of differential time to positivity (DTP) as a diagnostic tool before TIVAP removal.Hypothesis/Gap statement. Comparisons of different diagnostic procedures for catheter culture have been rarely reported for TIVAPs. We hypothesized that the optimization of methods to recover micro-organisms from different parts of TIVAPs may help to decrease the number of false-negative results in the diagnosis of TIVAP-related bloodstream infections.Methodology. A total of 53 TIVAPs removed because of suspected infection (n=36) or end of use (n=17) were evaluated. The reservoir, the septum and the catheter tip were separated and subjected to different treatments for the recovery of adherent micro-organisms: (a) flushing of the catheter lumen, (b) sonication and flushing, (c) treatment with dithiothreitol and flushing. The three methods were also evaluated in an in vitro catheter infection model with Staphylococcus epidermidis. Culture results were compared to those obtained from paired blood cultures drawn from TIVAP and peripheral vein and to the relative DTP.Results. The results obtained demonstrated that vigorous flushing/vortexing of the catheter lumen/septum, allows the recovery of a number of micro-organisms comparable to that of more complex procedures such as sonication or chemical treatment. Among 24 positive TIVAP-cultures, nine were tip-culture negative, whereas the corresponding reservoirs and septa were culture positive. A good correlation was observed between DTP and TIVAP cultures (P<0.001).Conclusions. The results support the evidence that sending the port reservoir in addition to the catheter tip to the microbiology laboratory may increase the sensitivity and the accuracy of CRBSI diagnosis. Moreover, when a TIVAP-related infection is suspected, DTP is a useful diagnostic tool to decide between device removal or a more conservative approach.

Chemoport-associated Complications and Its Management

Chemoport is being routinely used to administer chemotherapy, blood, blood products, total parenteral nutrition, and also to draw blood for investigations. We started using chemoport in our institute. We use it exclusively to administer chemotherapy. We analyzed our results of chemoport usage and confirm that the rate of complications associated with chemoport usage is at par with the available literature. We also conclude that with regular use, the intra-op and post-op complications will reduce further.