Central venous catheter infections in patients with acute leukemia

Febrile Neutropenia in Acute Leukemia. Epidemiology, Etiology, Pathophysiology and Treatment

Acute leukemias are a group of aggressive malignant diseases associated with a high degree of morbidity and mortality. An important cause of both the latter is infectious complications. Patients with acute leukemia are highly susceptible to infectious diseases due to factors related to the disease itself, factors attributed to treatment, and specific individual risk factors in each patient. Patients with chemotherapy-induced neutropenia are at particularly high risk, and microbiological agents include viral, bacterial, and fungal agents. The etiology is often unknown in infectious complications, although adequate patient evaluation and sampling have diagnostic, prognostic and treatment-related consequences. Bacterial infections include a wide range of potential microbes, both Gram-negative and Gram-positive species, while fungal infections include both mold and yeast. A recurring problem is increasing resistance to antimicrobial agents, and in particular, this applies to extended-spectrum beta-lactamase resistance (ESBL), Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and even carbapenemase-producing Enterobacteriaceae (CPE). International guidelines for the treatment of sepsis in leukemia patients include the use of broad-spectrum Pseudomonas-acting antibiotics. However, one should implant the knowledge of local microbiological epidemiology and resistance conditions in treatment decisions. In this review, we discuss infectious diseases in acute leukemia with a major focus on febrile neutropenia and sepsis, and we problematize the diagnostic, prognostic, and therapeutic aspects of infectious complications in this patient group. Meticulously and thorough clinical and radiological examination combined with adequate microbiology samples are cornerstones of the examination. Diagnostic and prognostic evaluation includes patient review according to the multinational association for supportive care in cancer (MASCC) and sequential organ failure assessment (SOFA) scoring system. Antimicrobial treatments for important etiological agents are presented. The main challenge for reducing the spread of resistant microbes is to avoid unnecessary antibiotic treatment, but without giving to narrow treatment to the febrile neutropenic patient that reduce the prognosis.

Incidence of Sepsis in Central Venous Catheter-Bearing Patients with Hematologic Malignancies: Preliminary Results

Background

Indwelling central venous catheters (CVCs) are essential devices in the management of patients with hematological disorders treated with chemotherapy. However, their nature predisposes patients to unwanted complications.

Methods

CVC-related complications were retrospectively analyzed in 227 hematologic patients who were consecutively admitted to our hematology department between May 2002 and April 2004. Patients’ diagnoses comprised acute myeloid leukemia (36.8%), acute lymphoid leukemia (7.3%), lymphoproliferative disorders (28.3%), multiple myeloma (19.5%), myeloproliferative syndromes (5%) and others (3.1%). The CVCs used were polyurethane three lumen 7-Fr (111 patients) for chemotherapy and 12-Fr (114 patients) for chemotherapy and peripheral blood stem cell apheresis, plus two tunneled catheters.

Results

The pathological events were: bacteriaemias (n=46); occlusions (n=10); exit tunnel infections (n=8); thrombosis (n=6); lung emboli (n=2). Among febrile patients the bacteriemia frequency was 20%, of which 13.6% were CVC-related (with a higher incidence in leukemia patients (p=0.027). Among the isolates, gram-positive bacteria were found in 29 cases (23 CVC-related cases), and gram-negative bacteria in 16 cases (8 CVC-related cases). Only one patient had Candida albicans sepsis. At univariate and multivariate analysis significant risk factors for infection (p<0.0001) were only the number of days/catheters and neutropenia duration.

Conclusions

In our hematologic patients, the CVC complications were mainly septic, with only 10.1% of CVC-related bacteriemias, despite prolonged catheterization duration. Acute leukemia patients were at major risk for sepsis, probably due to a more severe neutropenia and prolonged catheterization duration.

Varicella in pediatric oncology patients in the post-vaccine era-Analysis of routine hospital data from Bavaria (Germany), 2005-2011

Varicella in oncology patients can result in serious complications. We analyzed trends in hospitalization rates and characteristics of pediatric oncology and non-oncology patients hospitalized with varicella during the first 7 years after introduction of routine varicella vaccination. Our data included children <17 years of age with an International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) main or secondary discharge diagnosis of varicella identified by annual database queries in 22-29 pediatric hospitals in Bavaria (Germany) in 2005-2011. Of a total of 1,245 varicella-associated hospitalizations, 42 children (median age 4 years, interquartile range 3-5) had an underlying malignancy (67% with acute lymphoblastic leukemia). Overall, additional diagnoses potentially associated with varicella were reported less often in oncology than in non-oncology varicella patients (62% vs. 77%, p = 0.041), suggesting earlier hospitalization of high-risk patients. Acute hematological diagnoses (29% vs. 3%, p < 0.001) and coinfections (invasive 12% vs. 2%, p = 0.001; noninvasive 19% vs. 8%, p = 0.019) were more frequent, whereas neurological (5% vs. 19%, p = 0.023) and upper respiratory tract diagnoses (2% vs. 16%, p = 0.014) were less frequent in oncology compared to non-oncology varicella patients. Oncology varicella patients showed a longer hospital stay (median 5 vs. 3 days, p < 0.001). Hospitalization rates in non-oncology varicella patients declined constantly since 2006, from 114.8 (2006) to 30.5 (2011) per 1,000 pediatric beds. The rates of varicella-associated hospitalizations in oncology patients indicated an overall decreasing trend (3.8, 1.9, 4.6, 3.5, 0.4, 2.1 and 0.6 cases per 1,000 pediatric beds in 2005-2011). Thus, pediatric oncology patients potentially profit from herd protection effects, resulting from increasing vaccine coverage in the general population.

Implementing a central venous catheter self-management education program for patients with cancer

PURPOSE

To evaluate the effects of the central venous catheter self-management education program (CVC S-MEP) in improving knowledge, attitude, and behavior regarding CVC and in decreasing CVC-related complications in patients with cancer during homecare service.

METHODS

A quasi-experimental, sequential cohort design study of patients with cancer and who have CVCs was performed to compare the effect of CVC S-MEP with usual care.

RESULTS

The study group consisted of 45 participants (26 male and 19 female), and the mean age was 46.1 (SD, 10.5) years. The subjects of the CVC S-MEP had significantly high mean levels of self-management knowledge (p = 0.007), attitude (p < 0.001), and behavior (p = 0.002). Also, the participants in the CVC S-MEP had significantly lower frequency of catheter-related complications (p = 0.030).

CONCLUSIONS

The CVC S-MEP helped improve patients' ability to resolve problems and adequately respond to CVC-related emergency situations by fostering greater self-care ability. Additionally, providing practical information for CVC self-management in a gradual and repetitive manner had a notable positive effect on patients.

Clinical analysis of combination therapy for febrile neutropenic patients in childhood cancer

BACKGROUND

The objective of this study was to evaluate the efficacy and safety of our combination therapy in febrile neutropenic children with cancer.

METHODS

A total of 109 patients with 251 episodes of febrile neutropenia received antibiotic therapy between January 2003 and December 2008 at a single institution.

RESULTS

Blood cultures were positive in 35 episodes (14%). Gram-positive organisms predominated (23/38 organisms isolated). There were 15 gram-negative isolates and no fungal isolates. The recommended empirical first-line antibiotics (cefepime or cefozopran + piperacillin + amikacin) were used in 206 (82%), second-line antibiotics (piperacillin-tazobactam + carbapenem + amikacin + micafungin) in 73 (29%), and third-line antibiotics (meropenem + glycopeptides + micafungin) in 24 (10%) episodes. The overall response rates were 71.4%, 50.7%, and 62.5% for the first-, second-, and third-line antibiotic therapies, respectively. Granulocyte transfusion was performed in seven patients, and the response rate was 57%. Four deaths were recorded.

CONCLUSIONS

Although a significant improvement of mortality was not observed, our regimen of empirical antibiotic therapies led to a significant and clinically relevant decrease in glycopeptide use, and it is safe and well tolerated by pediatric neutropenic patients.

Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections

Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices.Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria.The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use of suitable antiseptics in combination with medical devices may further support reduction and prevention of such infections. In addition to reducing the adverse clinical outcomes related with these infections, such reduction may substantially decrease the economic burden caused by device-related infection for health care systems.

Severe neutropenia at time of port insertion is not a risk factor for catheter-associated infections in children with acute lymphoblastic leukemia

BACKGROUND

The objective of this study was to determine whether severe neutropenia on the day of port-a-catheter (PORT) insertion was a risk factor for catheter-associated infection (CAI) in children with acute lymphoblastic leukemia (ALL).

METHODS

This was a retrospective study of children with ALL who had a PORT insertion between January 2005 and August 2008. Early (≤ 30 days) and late (>30 days) postprocedure complications were reviewed. The length of follow-up ranged between 7 months and 42 months.

RESULTS

In total, 192 PORTs were inserted in 179 children. There were 43 CAIs (22%), and the infection rate was 0.35 per 1000 catheter-days. The CAI rate (15%) in children who had severe neutropenia on the day of the procedure did not differ statistically from the CAI rate (24%) in children who did not have severe neutropenia (P = .137). Conversely, patients with severe neutropenia who had a CAI were more likely to have their PORT removed (P = .019). The most common organisms to cause catheter removal were coagulase-negative Staphylococcus and Staphylococcus aureus. Patients with high-risk ALL had a statistically significant higher incidence of late CAI than patients with standard-risk ALL (P = .012). Age (P = .272), positive blood culture preprocedure (P = 1.0), and dexamethasone use (P = .201) were not risk factors for CAI. Patients who had an early CAI did not have a greater chance of having a late CAI. The catheter infection-free survival rate at 1 year was 88.6%.

CONCLUSIONS

The current results indicated that severe neutropenia on the day of PORT insertion does not increase the risk of CAI in children with ALL.

Congenital thrombophilia and central venous catheter-related thrombosis in patients with cancer

Central venous catheter (CVC)-related thrombosis is a frequently occurring complication and may cause significant morbidity in patients with cancer. The aim of this review is to discuss the main studies that examined whether a state of thrombophilia increases the risk of CVC-related thrombosis in patients with cancer. The studies were retrieved by an extensive Medline search. Patients with cancer with a CVC and a factor V Leiden mutation have a higher risk of developing CVC-related thrombosis than patients with cancer having a CVC without the mutation. The scarce information available suggests hyperhomocysteinemia to be a risk factor for CVC-related thrombosis. For other congenital thrombophilia factors, the available data are too limited to allow for any definitive conclusions to be made. Because the clinical implications of all these findings remain to be clarified, routine screening of patients with cancer having a CVC for thrombophilia cannot yet be recommended on the basis of the studies discussed.

Evaluating pulmonary complications in childhood acute leukemias

We evaluated the frequency, etiologic factors, outcome, and the comorbid conditions affecting the morbidity and mortality of pulmonary complications in acute childhood leukemia. Sixty-six (40.4%) out of 163 patients developed 79 pulmonary complications. Infectious etiology was the leading cause (92.4%). The most identified infectious agents were Gram (-) bacteria, followed by fungi. Acute respiratory distress syndrome, leukostasis, lymphomatoid granulomatosis, pulmonary edema, and pneumothorax were among the noninfectious causes. The pulmonary complications in the induction and consolidation phase of leukemia therapy were more severe and the mortality rate was higher. Tachypnea, shock, oxygen and mechanical ventilation requirement, disseminated intravascular coagulation, involvement of other organs or systems, cytopenias, requirement of modification in antimicrobial drugs were found to be related with increased mortality risk. The mortality rate of pulmonary complications was 8.9%. Pulmonary infections in the maintenance phase of the therapy were frequently treated with oral antibiotics, and they were generally rapidly taken under control. In conclusion, pulmonary complications are frequent in children with acute leukemia, and early diagnosis and appropriate management are important to avoid mortality owing to pulmonary complications, especially in neutropenic patients receiving induction or consolidation phase of chemotherapy.

Patients' perceptions of having a central venous catheter or a totally implantable subcutaneous port system-results from a randomised study in acute leukaemia

GOALS OF WORK

The selection process of type of central venous access device (CVAD) in patients with acute leukaemia (AL) is generally based on appropriate catheter capacity/function and risk of complications in relation to the planned length of therapy. Advantages and disadvantages of the CVAD from the patient's perspective should also be important parts in the selection of type of device. Perceptions on having a CVAD were thus analysed in a series of adult patients with AL included in a prospective randomised study evaluating the use of a double lumen totally implantable subcutaneous port system (PORT) or a double lumen central venous catheter (CVC) regarding survival time and complication rate.

MATERIALS AND METHODS

Perceptions were registered in 32 patients (median age 68 years, range 24-83 years) on three occasions (T1; the day after placement, T2; 3 weeks after placement and T3 after 12 weeks and/or when the CVAD was removed) with the use of two study specific questionnaires.

MAIN RESULTS

Overall, many patients reported minor catheter related discomfort, feelings of anxiety and restrictions. Half of the patients (6/11) who experienced a local bleeding after CVAD insertion described the placement procedure as unpleasant. More patients in the CVC group compared with the PORT group stated that they thought of having a CVAD (T3; p = 0.02) and that the CVAD interfered when dressing themselves (T2; p = 0.02 and T3; 0.04) or taking a shower (T3; p = 0.009).

CONCLUSION

Our findings support the view that the PORT is less restrictive in daily life than the CVC.

The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies

OBJECTIVE

To better understand the absolute and relative risks of bloodstream Infection (BSI) associated with the various types of intravascular devices (IVDs), we analyzed 200 published studies of adults In which every device in the study population was prospectively evaluated for evidence of associated infection and microbiologically based criteria were used to define IVD-related BSI.

METHODS

English-language reports of prospective studies of adults published between January 1, 1966, and July 1, 2005, were identified by MEDLINE search using the following general search strategy: bacteremla [Medical Subject Heading, MeSH] OR septicemia [MeSH] OR bloodstream Infection AND the specific type of intravascular device (e.g., central venous port). Mean rates of IVD-related BSI were calculated from pooled data for each type of device and expressed as BSIs per 100 IVDs (%) and per 1000 IVD days.

RESULTS

Point incidence rates of IVD-related BSI were lowest with peripheral Intravenous catheters (0.1%, 0.5 per 1000 IVD-days) and midline catheters (0.4%, 0.2 per 1000 catheter-days). Far higher rates were seen with short-term noncuffed and nonmedicated central venous catheters (CVCs) (4.4%, 2.7 per 1000 catheter-days). Arterial catheters used for hemodynamic monitoring (0.8%, 1.7 per 1000 catheter-days) and peripherally inserted central catheters used in hospitalized patients (2.4%, 2.1 per 1000 catheter-days) posed risks approaching those seen with short-term conventional CVCs used in the Intensive care unit. Surgically implanted long-term central venous devices--cuffed and tunneled catheters (22.5%, 1.6 per 1000 IVD-days) and central venous ports (3.6%, 0.1 per 1000 IVD-days)--appear to have high rates of Infection when risk Is expressed as BSIs per 100 IVDs but actually pose much lower risk when rates are expressed per 1000 IVD-days. The use of cuffed and tunneled dual lumen CVCs rather than noncuffed, nontunneled catheters for temporary hemodlalysis and novel preventive technologies, such as CVCs with anti-infective surfaces, was associated with considerably lower rates of catheter-related BSI.

CONCLUSIONS

Expressing risk of IVD-related BSI per 1000 IVD-days rather than BSIs per 100 IVDs allows for more meaningful estimates of risk. These data, based on prospective studies In which every IVD in the study cohort was analyzed for evidence of infection by microbiologically based criteria, show that all types of IVDs pose a risk of IVD-related BSI and can be used for benchmarking rates of infection caused by the various types of IVDs In use at the present time. Since almost all the national effort and progress to date to reduce the risk of IVD-related Infection have focused on short-term noncuffed CVCs used in Intensive care units, Infection control programs must now strive to consistently apply essential control measures and preventive technologies with all types of IVDs.

Infections in a pediatric patient cohort with acute lymphoblastic leukemia during the entire course of treatment

GOALS

To assess the type, frequency, severity, and outcome of all infectious episodes in a pediatric patient cohort with acute lymphoblastic leukemia (ALL) from a single institution during the entire length of leukemia treatment.

PATIENTS AND METHODS

Eighty-six patients were treated according to a modified ALL Berlin-Frankfurt-Munster protocol. Retrospective analysis of all types of infections according to the treatment phase and the degree of neutropenia is presented.

RESULTS

A total of 610 infectious episodes were recorded. Most infections were documented during maintenance (57%), followed by the induction phase (20.3%). During maintenance, 347 episodes were encountered, with nonspecific viral upper respiratory tract infections (URIs) being the commonest diagnosis (40.0%). Additionally, 38 of 58 total specific viral infections occurred during maintenance: 16 herpes simplex, 7 varicella, 10 herpes zoster infections [varicella-zoster virus (VZV), 45%]. The majority of bacteremia and fever of unknown origin occurred during induction (20%). The number of Gram-negative bacteremia was 50% of the total (26 of 52). The majority of the infections (59.5%) occurred without neutropenia [absolute neutrophil count (ANC) >1,000 microl(-1)]. Fewer infections (9.3%) were recorded with concurrent very severe neutropenia (ANC <100 microl(-1)), although 38.5% of positive blood cultures were documented with severe neutropenia. No infection-related fatality occurred.

CONCLUSIONS

Most of the severe infections occurred during induction. Gram-positive bacteremia and Gram-negative bacteremia were almost equal. URIs were the commonest infections during the entire treatment and during maintenance. Specific viral infections represented a smaller percentage of the total (VZV was the commonest pathogen). Infectious complications represented a significant morbidity factor, but notably, mortality was negligible.

Treatment of pediatric febrile neutropenia in the era of vancomycin-resistant microbes

PURPOSE

The increasing frequency of Gm(+) infections in febrile neutropenic (FN) patients has resulted in increased use of vancomycin (VN). Likely as a result, VN-resistant Enterococcus (VRE) has become a significant concern in FN patients. We sought to understand how the emergence of VN resistant microbes has changed the antibiotic management of pediatric FN.

METHODS

A questionnaire was distributed by e-mail to responsible investigators of the Children's Oncology Group.

RESULTS

One hundred and thirty responses were analyzed. Forty-four percent initially used monotherapy, with 82% of those using ceftazidime. Twenty-seven used VN with another agent, generally ceftazidime. After the emergence of VRE and VN-resistant staphylococcus (VRS), monotherapy increased to 58%. Ceftazidime continued to be most frequently used. There was a 57% reduction in the use of VN with 88% of centers not currently using VN in their initial treatment of FN. Forty-seven percent of the centers that continue to use VN have VRE, while 90% that have discontinued its use have VRE/VRS.

CONCLUSIONS

Ours is the first study to survey current practices in the treatment of pediatric FN and to document changes in practice patterns due to emerging antibiotic resistance patterns. We demonstrate increased use of monotherapy for FN, and a 57% decrease in the use of VN. Local considerations influence antibiotic choices with a significant difference in VRE prevalence between those centers that continue to use VN as compared to those that have discontinued it.