Incidence of hospital-acquired pneumonia, bacteraemia and urinary tract infections in patients with haematological malignancies, 2004-2010: a surveillance-based study

Patient-reported outcomes with subcutaneous immunoglobulin in secondary immunodeficiency

Subcutaneous (SCIG) and intravenous immunoglobulin (IVIG) replacement are both used to prevent infections in patients with secondary immunodeficiency (SID). Compared with IVIG, SCIG has fewer systemic side effects and, additionally, facilitates home-based treatment. Shared decision-making practice should include discussion of aspects such as patient preference as well as the associated risks and benefits of treatment. We review the available evidence for the use of SCIG treatment in patients with SID, focusing on patient-reported outcomes (PROs). In most studies, there were improvements to health-related quality of life with SCIG treatment, compared with before initiating SCIG without prior IVIG treatment, or after switching to SCIG from IVIG treatment, or a no-SCIG/IVIG cohort. Treatment satisfaction with SCIG was similar between patients with SID and primary immunodeficiency disease. Patient preference and perception assessments highlighted the benefits of SCIG compared with IVIG, such as ease of use and administration, convenience, and time-effectiveness. In addition, many patients self-administered SCIG at home. Such aspects may be of specific benefit to patients with SID and hematological malignancy by reducing the risk of infection exposure in clinical settings. PRO data may be useful during shared decision-making discussions with patients with SID.

Failure mode and effects analysis-based strategies for controlling multidrug-resistant organism infections in cancer patients

In the context of advancing medical procedures, postoperative infections in cancer patients, particularly those involving multidrug-resistant organisms, have become a significant clinical concern. This study aims to comprehensively and systematically evaluate the effectiveness of infection prevention and control for multidrug-resistant organisms (MDROs) in postoperative cancer patients using Failure Mode and Effects Analysis (FMEA). This study was conducted in a tertiary A-level cancer specialty hospital in China, employing Failure Mode and Effects Analysis (FMEA) to assess the risks of hospital infections. Intervention measures were implemented for high-risk and medium-high-risk factors. Through the hospital's infection information system, data on patients who underwent surgical treatment from 2017 to 2022 were extracted. Data from 2017 to 2019 served as the control group, and data from 2020 to 2022 as the intervention group, to compare the changes in hospital infection incidence and MDRO infection incidence before and after the intervention. Categorical data were described in terms of frequency and percentage. The chi-square test was utilized for statistical inference to assess the differences in infection rates before and after the intervention. Prior to the intervention (2017-2019), the incidence rate of hospital infections was 1.66%, which decreased to 1.22% after the intervention (2020-2022), showing a statistically significant difference (χ2 = 48.83, P < 0.001). The incidence rate of MDRO infections also decreased from 1.808‰ before the intervention to 1.136‰ after the intervention, with a statistically significant difference (χ2 = 11.417, P = 0.001). This study confirms the effectiveness of the FMEA method in preventing and controlling MDRO infections in postoperative cancer patients. It highlights the practicality and value of widespread adoption of this method, particularly in the context of the COVID-19 pandemic.

Hospital-acquired bloodstream infections in patients with cancer: current knowledge and future directions

Patients with cancer experience higher rates of preventable harm from hospital-acquired bloodstream infections (haBSIs) and central-line-associated bloodstream infections (CLABSIs) compared with the general hospital population. The prevention of haBSIs and CLABSIs in patients with cancer is an urgent priority, and requires standardized surveillance and reporting efforts. The application of haBSI and CLABSI definitions, classification systems and surveillance strategies for patients with cancer is complex, and there is wide variation in clinical practice. Existing systems were not designed explicitly for patients with cancer, and have different strengths and weaknesses in the cancer setting. For these reasons, epidemiological estimates of haBSIs and CLABSIs in patients with cancer also require careful interpretation. This complexity can be a barrier to identifying appropriate targets for intervention and reducing preventable harm. This review provides an overview of key concepts and challenges in haBSI surveillance and prevention specific to patients with cancer. In addition, this review summarizes the strengths and weaknesses of commonly used surveillance definitions and denominators in the setting of cancer care; existing surveillance practice; epidemiology of haBSIs and CLABSIs; prevention strategies; and current knowledge gaps. A global collaborative effort to harmonize the surveillance of hospital-acquired infections in patients with cancer would be invaluable to improve the accuracy and utility of existing data, advance efforts to prevent hospital-acquired infections, and improve patient safety.

Evaluation of antibiotic resistance, toxin-antitoxin systems, virulence factors, biofilm-forming strength and genetic linkage of Escherichia coli strains isolated from bloodstream infections of leukemia patients

BACKGROUND

One of the most common complications in patients with febrile neutropenia, lymphoma, leukemia, and multiple myeloma is a bloodstream infection (BSI).

OBJECTIVE

This study aimed to evaluate the antibiotic resistance patterns, virulence factors, biofilm-forming strength, and genetic linkage of Escherichia coli strains isolated from bloodstream infections (BSIs) of leukemia patients.

METHODS

The study conducted in Iran from June 2021 to December 2022, isolated 67 E. coli strains from leukemia patients' bloodstream infections in hospitals in two different areas. Several techniques including disk diffusion and broth microdilution were used to identify patterns of antibiotic resistance, microtiter plate assay to measure biofilm formation, and PCR to evaluate the prevalence of different genes such as virulence factors, toxin-antitoxin systems, resistance to β-lactams and fluoroquinolone antibiotics of E. coli strains. Additionally, the genetic linkage of the isolates was analyzed using the Enterobacterial Repeat Intergenic Consensus Polymerase Chain Reaction (ERIC-PCR) method.

RESULTS

The results showed that higher frequency of BSI caused by E. coli in man than female patients, and patients with acute leukemia had a higher frequency of BSI. Ampicillin and Amoxicillin-clavulanic acid showed the highest resistance, while Imipenem was identified as a suitable antibiotic for treating BSIs by E. coli. Multidrug-resistant (MDR) phenotypes were present in 22% of the isolates, while 53% of the isolates were ESBL-producing with the blaCTX-M gene as the most frequent β-lactamase gene. The fluoroquinolone resistance genes qnrB and qnrS were present in 50% and 28% of the isolates, respectively. More than 80% of the isolates showed the ability to form biofilms. The traT gene was more frequent than other virulence genes. The toxin-antitoxin system genes (mazF, ccdAB, and relB) showed a comparable frequency. The genetic diversity was detected in E. coli isolates.

CONCLUSION

Our results demonstrate that highly diverse, resistant and pathogenic E. coli clones are circulating among leukemia patients in Iranian hospitals. More attention should be paid to the treatment and management of E. coli bloodstream infections in patients with leukemia.

A New Scoring System for Predicting Mortality in Hematological Malignancies with Sepsis: A Derivation and Validation Study

Objective

This study aimed to derive and validate a prognostic scoring system to identify patients with hematological malignancies (HMs) and sepsis who have a high mortality rate.

Methods

Cohorts for derivation and validation were created from all data. Using univariate and multivariate analysis, the independent variables connected to 28-day mortality in the derivation cohort were found. A receiver operating characteristic (ROC) curve was used to compare the predictive power and determine their cutoff points. These risk variables were given a score weighted by risk prediction function, and a new scoring system was also developed. The area under the ROC curve (AUROC) and sensitivity and specificity for mortality of the risk category of the new scoring system were compared with Sequential Organ Failure Assessment (SOFA) score.

Results

90 (45.22%) of the 199 patients passed away within 28 days. Ninety-nine patients made up the derivation cohort, with 47 (47.47%) fatalities. Ages in the non-survival group were higher (61.47 ± 14.53 vs 55.13 ± 15.66) than in the survival group. As independent predictors of death, multivariable analysis identified SOFA score (OR 1.442, 95% CI 1.035, 2.009), age (OR 1.242, 95% CI 1.026, 1.503), and prothrombin time (PT) (OR 1.213, 95% CI 1.030, 1.430). The AUROC with 95% CI of the new scoring system and its sensitivity and specificity to mortality were virtually all superior to SOFA score in both derivation and validation cohorts: AUROC (0.757 vs 0.716), Sensitivity (75 vs 67.3%), and Specificity (68.1% vs 63.8%) are the Derivation cohort; Validation cohort: Sensitivity (91.2% vs 84.2%), AUROC (0.792 vs 0.733), and Specificity (58.1% vs 58.1%). The model was correctly calibrated, according to the Hosmer-Lemeshow test.

Conclusion

The new scoring system was more accurate in predicting 28-day mortality among patients with HMs and sepsis than the SOFA score.

Incidence of Invasive Infections Among Hemato-Oncology Patients with Significant Burden of Candida in Stool

Candidemia is a serious infection associated with increased mortality. It is unclear whether a high concentration of Candida in stool in patients with hematologic malignancies is associated with a higher risk for developing candidemia. In this observational historical study in patients hospitalized in hemato-oncology departments, we describe the association between gastrointestinal Candida colonization and the risk for candidemia and other severe outcomes. Data from 166 patients with heavy burden of Candida in stool were collected and compared to a control group of 309 patients with minimal or no Candida in stool, from 2005 to 2020. Severe immunosuppression and recent use of antibiotics were more common in heavily colonized patients. Outcomes of heavily colonized patients were worse as compared to the control group with statistical significance in 1-year mortality (53% vs. 37.5%, p = 0.001) and borderline statistical significance in candidemia rate (12.6% vs. 7.1%, p = 0.07). Risk factors for 1-year mortality were significant colonization of Candida in stool, older age and recent use of antibiotics. In conclusion, significant stool burden of Candida among hospitalized hemato-oncology patients may pose a risk for 1-year mortality and increased candidemia rate.

Impact of Nosocomial Infection on in-Hospital Mortality Rate in Adult Patients Under Venoarterial Extracorporeal Membrane Oxygenation After Cardiac Surgery

Objective

There was no consensus on the impact of nosocomial infection on In-hospital mortality rate in patients receiving ECMO. This study aimed to investigate the impact of nosocomial infection (NI) on In-hospital mortality rate in adult patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) after cardiac surgery.

Materials and Methods

This retrospective study included 503 adult patients who underwent VA-ECMO after cardiac surgery. The impact of time-dependent NIs on In-hospital mortality rate within 28 days of ECMO initiation was investigated using a Cox regression model. The cumulative incidence function for death was compared between patients with NIs and those without NIs using a competing risk model.

Results

Within 28 days after ECMO initiation, 206 (41.0%) patients developed NIs, and 220 (43.7%) patients died. The prevalence rates of NIs were 27.8% and 20.3% during and after ECMO therapy, respectively. The incidence rates of NIs during and after ECMO therapy were 49‰ and 25‰, respectively. Time-dependent NI was an independent risk factor for predicting death (hazard ratio = 1.05, 95% confidence interval = 1.00-1.11). The cumulative incidence of death in patients with NI was significantly higher than that in patients without NI at each time point within 28 days of ECMO initiation. (Z = 5.816, P = 0.0159).

Conclusion

NI was a common complication in adult patients who received VA-ECMO after cardiac surgery, and time-dependent NI was an independent risk factor for predicting mortality in these patients. Using a competing risk model, we confirmed that NIs increased the risk of In-hospital mortality rate in these patients.

Extended-spectrum beta-lactamase-producing Enterobacteriaceae related urinary tract infection in adult cancer patients: a multicenter retrospective study, 2015-2019

BACKGROUND

The aim of this study was to investigate the prevalence and risk factors of extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae related urinary tract infections (UTI) in adult cancer patients.

METHODS

We conducted a retrospective study of three cancer hospitals centered on Cancer Hospital of Chinese Academy of Medical Sciences from 2015 to 2019. The clinical characters, risk factors and antimicrobial susceptibility of ESBL-producing Enterobacteriaceae UTI in adult cancer patients were described and analyzed.

RESULTS

A total of 4967 specimens of UTI were evaluated, of which 909 were positive. After excluding multiple infection bacteria, non-conforming strains, inconsistent pathological information, no drug sensitivity test or medical records, 358 episodes remained. Among them, 160 episodes belonged to ESBL-producing Enterobacteriaceae, while 198 were classified into non-ESBL group. The prevalence of ESBL UTI circled around 39.73 to 53.03% for 5 years. Subgroup analysis by tumor type revealed that 62.5% of isolates from patients with urological tumors were ESBL positive. Multivariate analysis showed that tumor metastasis (OR 3.41, 95%CI 1.84-6.30), urological cancer (OR 2.96, 95%CI 1.34-6.53), indwelling catheter (OR 2.08, 95%CI 1.22-3.55) and surgery or invasive manipulation (OR 1.98, 95%CI 1.13-3.50) were the independent risk factors. According to antimicrobial sensitivity, meropenem, imipenem and piperacillin/tazobactam were the most commonly used antibiotics for ESBL-producing Enterobacteriaceae UTI.

CONCLUSIONS

In view of the high prevalence, clinicians should be alert to the occurrence of ESBL UTI, especially for patients with urological cancer or metastatic tumors. Regular replacement of urinary catheters, reduction of unnecessary invasive operations and selection of appropriate antibiotics are the necessary conditions to deal with the occurrence of ESBL UTI in adult cancer patients.

Risk factors for ICU mortality in patients with hematological malignancies: a singlecenter, retrospective cohort study from Turkey

BACKGROUND

Patients with hematological malignancies (HM) often require admission to the intensive care unit (ICU) due to organ failure, disease progression or treatment-related complications, and they generally have a poor prognosis. Therefore, understanding the factors affecting ICU mortality in HM patients is important. In this study, we aimed to identify the risk factors for ICU mortality in our critically ill HM patients.

METHODS

We retrospectively reviewed the medical records of HM patients who were hospitalized in our medical ICU between January 1, 2010 and December 31, 2018. We recorded some parameters of these patients and compared these parameters by statistically between survivors and nonsurvivors to determine the risk factors for ICU mortality.

RESULTS

The study included 368 critically ill HM patients who were admitted to our medical ICU during a 9-year period. The median age was 58 (49-67) years and 63.3% of the patients were male. Most of the patients (43.2%) had acute leukemia. Hematopoietic stem cell transplantation (HSCT) was performed in 153 (41.6%) patients. The ICU mortality rate was 51.4%. According to univariable analyses, a lot of parameters (e.g., admission APACHE II and SOFA scores, length of ICU stay, some laboratory parameters at the ICU admission, the reason for ICU admission, comorbidities, type of HM, type of HSCT, infections on ICU admission and during ICU stay, etc.) were significantly different between survivors and nonsurvivors. However, only high SOFA scores at ICU admission (OR:1.281, p = 0.004), presence of septic shock (OR:17.123, p = 0.0001), acute kidney injury (OR:48.284, p = 0.0001), and requirement of invasive mechanical ventilation support during ICU stay (OR:23.118, p = 0.0001) were independent risk factors for ICU mortality.

DISCUSSION

In our cohort, critically ill HM patients had high ICU mortality. We found four independent predictors for ICU mortality. Yet, there is still a need for further research to better understand poor outcome predictors in critically ill HM patients.

Healthcare-associated blood stream infections in hematological patients in Finland during the years 2006-2016

OBJECTIVES

The aim was to identify the clinical characteristics, outcome, and antimicrobial susceptibility of healthcare-associated bloodstream infections (BSIs) in hematological patients.

METHODS

This retrospectively collected laboratory-based surveillance data include 3404 healthcare-associated BSIs in 2296 patients with a hematological malignancy in hospitals participating in the Finnish Hospital Infection Program from January 1, 2006, to December 31, 2016.

RESULTS

The most common underlying diseases were acute myelogenous leukemia (35%) and non-Hodgkin lymphoma (22%). Gram-positive organisms accounted for 60%-46% and gram-negative organisms for 24%-36% of BSIs in 2006-2016. The most common causative organism was coagulase-negative staphylococci (CoNS) (n = 731). The 7- and 28-day case fatality rates were 5.2% and 11.4%, respectively, and was highest in BSIs caused by Candida species (10.8% and 30.8%). The median age of patients increased from 59 years in 2006-2008 to 62 years in 2015-2016 (P < .01). Five percent of S aureus isolates were resistant to methicillin and five percent of Pseudomonas aeruginosa isolates were multidrug-resistant. Four percent of Klebsiella and seven percent of E coli isolates were resistant to ceftazidime.

CONCLUSIONS

The proportion of gram-positive bacteria decreased and gram-negative bacteria increased over time. The case fatality rate was low and the median age of patients increased during the study.

Chlorhexidine Bathing to Prevent Central Line-Associated Bloodstream Infections in Hematology Units: A Prospective, Controlled Cohort Study

BACKGROUND

Chlorhexidine (CHG) bathing decreases the incidence of bloodstream infections in intensive care units, but its effect has been understudied in patients with hematological malignancies in noncritical care units.

METHODS

Adults with hematological malignancies hospitalized for cytotoxic chemotherapy in noncritical care units were offered daily 2% CHG bathing. We compared outcomes of patients who chose CHG bathing (CHG group) with outcomes of those who did not choose CHG bathing (usual-care group). The primary outcome was gram-positive cocci-related, skin flora-related, or central line-associated bloodstream infection. The negative control outcome was gut-origin bacteremia.

RESULTS

The CHG group (n = 485) had a crude incidence rate of the primary outcome that was 60% lower than the rate for the usual-care group (n = 408; 3.4 vs 8.4 per 1000 patient-days, P = .02) but had a similar crude incidence rate of the negative control outcome (4.5 vs 3.2 per 1000 patient-days; P = .10). In multivariable analyses, CHG bathing was associated with a 60% decrease in the primary outcome (adjusted hazard ratio [HR], 0.4; P < .001). In contrast, CHG bathing had no effect on the negative control outcome (adjusted HR, 1.1; P = .781). CHG bathing was well tolerated by participants in the CHG group.

CONCLUSIONS

CHG bathing could be a highly effective approach for preventing gram-positive cocci-related, skin flora-related, or central line-associated bacteremia in patients with hematological malignancies who are hospitalized for cytotoxic chemotherapy in noncritical care units.

The current scope of healthcare-associated infection surveillance activities in hospitalized immunocompromised patients: a systematic review

BACKGROUND

Immunocompromised patients are at increased risk of acquiring healthcare-associated infections (HAIs) and often require specialized models of care. Surveillance of HAIs is essential for effective infection-prevention programmes. However, little is known regarding standardized or specific surveillance methods currently employed for high-risk hospitalized patients.

METHODS

A systematic review adopting a narrative synthesis approach of published material between 1 January 2000 and 31 March 2018 was conducted. Publications describing the application of traditional and/or electronic surveillance of HAIs in immunocompromised patient settings were identified from the Ovid MEDLINE®, Ovid Embase® and Elsevier Scopus® search engines [PROSPERO international prospective register of systematic reviews (registration ID: CRD42018093651)].

RESULTS

In total, 2708 studies were screened, of whom 17 fulfilled inclusion criteria. Inpatients diagnosed with haematological malignancies were the most-represented immunosuppressed population. The majority of studies described manual HAI surveillance utilizing internationally accepted definitions for infection. Chart review of diagnostic and pathology reports was most commonly employed for case ascertainment. Data linkage of disparate datasets was performed in two studies. The most frequently monitored infections were bloodstream infections and invasive fungal disease. No surveillance programmes applied risk adjustment for reporting surveillance outcomes.

CONCLUSIONS

Targeted, tailored monitoring of HAIs in high-risk immunocompromised settings is infrequently reported in current hospital surveillance programmes. Standardized surveillance frameworks, including risk adjustment and timely data dissemination, are required to adequately support infection-prevention programmes in these populations.

Prevalence of Asymptomatic Bacteriuria and Antibiotic Susceptibility Patterns of Bacterial Isolates among Cancer Patients and Healthy Blood Donors at the University of Gondar Specialized Hospital

Background

Urinary tract infections are the common types of infections in the community and health care settings. Despite the widespread availability of antibiotics, urinary tract infection remains a worldwide therapeutic problem. It is a continuous and significant problem in cancer patients.

Methods

A hospital-based comparative cross-sectional study was conducted on 240 study participants from January to June 2019. Sociodemographic data were collected by a predesigned questionnaire and midstream urine samples collected using simple random sampling technique by using clean, sterile plastic cups and then inoculated onto CLED agar plates and incubated at 37°C for 24 hours. Urine culture was considered significant bacteriuria when colony forming units ≥10⁵/mL of voided urine and a single pure colony suspended in nutrient broth and then subcultured onto a blood agar plate and MacConkey agar plate, incubated at 37°C for 24 hours for identification. Identification was done by using standard microbiological methods. Modified Kirby–Bauer disk diffusion technique was applied for antimicrobial susceptibility testing in accordance with CLSI 2018 criteria. Data were entered, cleared, and checked using Epi Info version 7 and exported to SPSS version 20 for analysis. The results were displayed using tables and figures. p value <0.05 at 95% CI was considered as statistically significant.

Results

The overall prevalence of asymptomatic bacteriuria in cancer patients was 23.3% while 6.7% in apparently healthy blood donors. E. coli (32.1%) was the commonest isolated uropathogenic bacteria followed by Klebsiella species (25.0%), S. aureus (21.4%), Enterococcus species (10.7%), Serratia species (7.1%), and Enterobacter aerogenes (3.6%) in cancer patients. In apparently healthy blood donors, E. coli, Klebsiella species, and S. aureus were isolated from 75%, 12.5%, and 12.5%, respectively. Most Gram-negative bacteria were more sensitive to ceftazidime, cefoxitin, nalidixic acid, nitrofurantoin, norfloxacin, ciprofloxacin, and tobramycin, whereas highly resistant to ampicillin, penicillin, tetracycline, and ceftazidime. S. aureus isolates were 100% susceptible to nitrofurantoin.

Conclusions

This study showed a high prevalence of asymptomatic bacteriuria among cancer patients (23.3%) compared to apparently healthy blood donors (6.7%). E. coli was isolated predominately. Nitrofurantoin and ciprofloxacin should be used to treat asymptomatic bacteriuria in the study area.

Bloodstream infections in neutropenic patients with haematological malignancies

BACKGROUND

Patients with haematological malignancies have higher risk of acquiring bloodstream infection (BSI). Neutropenia resulting from cytotoxic chemotherapy is the most common risk factor. Infections can progress rapidly with poor outcomes. Understanding the epidemiology may enable prevention and effective management. We investigated and compared the incidence of BSI amongst patients with haematological malignancies and neutropenia and examined the changing spectrum of organisms, and their antimicrobial profiles.

METHODS

BSI data between July 1st 2009 and June 30th 2015 was reviewed.

RESULTS

Three hundred and fifty five BSI were identified in 255 neutropenic patients. Acute myeloid leukaemia (AML) accounted for 40%, Non-Hodgkin's lymphoma for 22% and Acute lymphocytic leukaemia (ALL) for 11.8%. A neutrophil count of <500 cells/μL was present in 93.2%. The overall incidence was 5.40 BSI per 1000 Haematology Occupied Bed days (OBD). Viridans streptococci and Enterococcus species were the most predominant Gram-positives. Vancomycin resistant Enterococcus faecium (VRE) emerged as the predominant Enterococcus species during the study period. Escherichia coli was the most predominant Gram-negative and Extended-spectrum beta-lactamases (ESBL) were detected in 7.1% of isolates. Amongst the Enterobacteriaceae and Pseudomonas aeruginosa dual resistance to Piperacillin-tazobactam and Gentamicin was detected in 5.4%.

CONCLUSION

Our incidence of BSI was 5.40 per 1000 OBD, however variability in reporting of rates in neutropenic patients with haematological malignancies makes comparison between studies difficult, highlighting the need for rate reporting standardization. The epidemiology of organisms causing BSI has changed over time. There is a trend towards an increasing incidence of VRE and multidrug resistant Gram-negatives.

Risk of subsequent health care-associated infection among patients with a bloodstream infection present on hospital admission

BACKGROUND

The risks and outcomes of acquiring a health care-associated infection (HAI) among patients with a bloodstream infection present on hospital admission (BSI-POA) have not been well described. The objective of this study was to examine the incidence of and risk factors for developing a subsequent HAI and to compare length of stay and mortality between patients with a BSI-POA who develop an HAI and those who do not.

METHODS

This was a retrospective cohort study of patients aged ≥18 years discharged with a BSI-POA from 3 hospitals in New York City between 2006 and 2014.

RESULTS

There were 761 HAIs among the 11,436 patients with a BSI-POA. Incidence rates were: catheter-associated urinary tract infections, 5.03 infections per 1,000 catheter days; pneumonia, 2.7% among BSI-POA patients; surgical site infections, 9.2% among BSI-POA patients. Length of stay was longer among patients who developed an HAI (mean ± SD, 35.0 ± 29.8 vs 12.4 ± 11.9, P < .001). Mortality was higher in patients who developed an HAI (23.9% vs 11.6%, P < .001).

CONCLUSIONS

Risk factors for those who developed an HAI differed by infection type. Overall, HAI was associated with longer hospitalization, and pneumonia was associated with increased mortality.

Outcomes for haematological cancer patients admitted to an intensive care unit in a university hospital

BACKGROUND

Haematological cancer (HC) patients are increasingly requiring intensive care (ICUs). The aim of this study was to investigate the outcome of HC patients in our ICU and evaluate 5 days-full support as a breakpoint for patients' re-assessment for support.

METHODS

Retrospective study enrolling 112 consecutive HC adults, requiring ICU in January-December 2015. Patients' data were collected from medical records and Infection Control Committee surveillance reports. Logistic regression analysis was performed to identify independent risk factors for ICU mortality.

RESULTS

Sixty-one were neutropenic, and 99 (88%) had infection at ICU admission. Acute myeloid leukaemia was diagnosed in 43%. Thirty-five (31%) were hematopoietic stem cell transplant recipients. Only 17 (15%) were in remission. Eighty-nine underwent mechanical ventilation on admission. Fifty-three patients acquired ICU-infection (35 bacteremia) being gram negative bacteria (Klebsiella pneumoniae and non-fermenters) the top pathogens. However, ICU-acquired infection had no impact on mortality. The overall ICU and 1-year survival rate was 27% (30 patients) and 7% (8 patients), respectively. Moreover, only 2/62 patients survived with APACHE II score ≥25. The median time for death was 4 days. APACHE II score ≥25 [OR:35.20], septic shock [OR:8.71] and respiratory failure on admission [OR:10.55] were independent risk factors for mortality in multivariate analysis. APACHE II score ≥25 was a strong indicator for poor outcome (ROC under curve 0.889).

CONCLUSIONS

APACHE II score ≥25 and septic shock were criteria of ICU futility. Our findings support the full support of patients for 5 days and the need to implement a therapeutic limitations protocol.

Chlorhexidine-containing dressings in the prevention of central venous catheter-related bloodstream infections: A cost and resource utilization analysis

BACKGROUND

A recent study reported a reduction in probable/definite central venous catheter (CVC)-related bloodstream infections (CRBSIs) in neutropenic high-risk patients using CVC dressings with a chlorhexidine-containing gel pad.

METHODS

Based on published data, a health-economic analysis was performed to analyze the economic effect of using CVC dressings with a chlorhexidine-containing gel pad compared to non-chlorhexidine control dressings. A micro-costing approach was used to determine CRBSI-related direct treatment cost factors.

RESULTS

Between February 2012 and September 2014, 356 patients (178 patients in both groups) were analyzed. Distribution of probable and definite CRBSI in the chlorhexidine group and control group were 12 (7%) vs 18 (10%) and 9 (5%) vs 21 (12%), respectively (P = .011). Median overall length of stay (25 vs 27.5 days; P = .630) and days on treatment with antibacterials (10 vs 12 days; P = .140) were similar between the chlorhexidine and control groups. The most important cost driver in both groups was treatment on general ward (€4275 [US$ 5173], interquartile range [IQR]: €592 - €6504 [US$ 716 - US$ 7871] vs €4560 [US$ 5518], IQR: €1227 - €8567 [US$ 1485 - US$ 10,367]; P = .120), resulting in median overall direct treatment costs of €13,881 (US$ 16,798) [IQR: €10,922 - €25,457 (US$ 13,217 - US$ 30,807) vs €13,929 [US$ 16,856] [IQR: €11,295 - €23,561 (US$ 13,669 - US$ 28,512); P = .640]).

CONCLUSION

Our study shows similar results in overall direct treatment costs, meaning that higher acquisition costs of chlorhexidine-containing dressings did not translate into higher costs. Expenses were primarily outweighed by a lower rate of probable/definite CRBSI and reduced associated costs.

Epidemiologische Grundlagen nosokomialer Infektionen

Viele Faktoren tragen zu erhöhten nosokomialen Infektionsraten bei. Der Anteil alter Patienten mit chronischen Krankheiten und Immunsupprimierter steigt. Fortschritte in Diagnostik und Therapie resultieren immer häufiger in invasiven Eingriffen. Antibiotikaresistenzen und Folgen nosokomialer Infektionen erfordern daher eine verlässliche Epidemiologie. Konsequenzen nosokomialer Infektionen betreffen einerseits Patienten (Morbidität und Letalität), aber auch das Gesundheitswesen, dem zusätzliche, teilweise vermeidbare finanzielle Belastungen entstehen.

[Incidence of blood stream infections of 1265 patients with hematopoietic stem cell transplantation and analysis of pathogenic bacteria]

Objective: To analyze the incidence and microbiological features of blood stream infections (BSI) of patients with hematopoietic stem cell transplantation (HSCT) and to provide laboratory data for empirical use of antibiotic for the HSCT patients with BSI. Methods: The incidence of bloodstream infection, the positive rate of blood culture, bacterial spectrum and drug resistance were analyzed in 1 265 HSCT recipients during 2013 and 2015 were retrospectively studied. Results: Of 1265 patients undergoing HSCT, 1 422 cases of suspected BSI occurred in 784 patients (61.98%) , and 464 patients (59.2%) were in the stage of agranulocytosis (ANC<0.5×10(9)/L) . The detection rate of pathogens in 2013-2015 was about 20% and increase year after year. Of the 401 strains detected, 221 were Gram-negative (G(-)) bacteria (55.1%) , 165 Gram-positive (G(+)) bacteria (41.2%) and 15 fungi (3.7%) . Escherichia coli (16.0%) , Staphylococcus epidermidis (15.5%) and Klebsiella pneumoniae (11.2%) were listed the top three. The proportion of multidrug resistant Acinetobacter Bauman and Stenotrophomonas maltophilia was 64.70% and 63.64% respectively, and methicillin resistant Staphylococcus aureus (MRSA) was more than half (57.14%) . The ratio of vancomycin resistant Enterococci (VRE) and carbapenem resistant Enterobacteriaceae (CRE) was 14.29% and 6.78% respectively. More than 40% Enterobacteriaceae bacteria were resistant to three or four generation cephalosporin antibiotics, and less were resistant to the carbapenems (6.4%) . However, many non-fermentating bacteria were highly resistant to these antibiotics and showed diversity among different strains, with a rate of 47.8% resistance to carbapenems. All the Staphylococcus were sensitive to vancomycin, teicoplanin and linezolid. Conclusions: The incidence of BSI in patients with HSCT was high, and the pathogens were mainly G(-) bacteria. In addition to Enterobacteriaceae, the proportion of non-fermentative bacteria was quite high. No Staphylococcus detected were resistant to vancomycin, teicoplanin and linezolid.

Influence of high body mass index on mortality and infectious outcomes in patients who underwent open gastrointestinal surgery: A meta-analysis

BACKGROUND

The influence of high body mass index (BMI) on mortality and infectious outcomes of patients following open gastrointestinal surgery was unclear. This meta-analysis aimed to resolve this controversy.

METHODS

PubMed and EMBASE were searched by 2 researchers. High and normal BMIs were defined as ≥25 and 18.5-24.99, respectively. Odds ratios (ORs) were calculated to compare the pooled effect sizes. The primary outcome was mortality. The secondary outcome was infectious outcomes, including surgical site, pulmonary infections, and urinary tract infections.

RESULTS

Eleven eligible articles with 51,307 patients total were included. Compared with normal BMIs, high BMIs did not increase the risk of mortality (OR, 0.78; 95% confidence interval [CI], 0.58-1.06; P = .12). The secondary outcome indicated a significantly higher risk of infectious outcomes in high-BMI patients (OR, 1.34; 95% CI; 1.13-1.58; P = .0007). Among high-BMI patients, the risks of surgical site infections (OR, 1.75; 95% CI, 1.33-2.3; P < .0001) and pulmonary infections (OR, 1.2; 95% CI, 1.02-1.40; P = .03) increased significantly; urinary tract infections (OR, 1.10; 95% CI, 0.92-1.31; P = .30) did not show statistical difference.

CONCLUSIONS

High BMI was associated with higher risks of infectious outcomes, including surgical site infections and pulmonary infections after open gastrointestinal surgery, but no association was observed between high BMI and urinary tract infections.

Association of proton pump inhibitors with the occurrence of gut-derived bacteraemia in patients with haematological malignancy after chemotherapy

BACKGROUND

Gut-derived bacteraemia is a major complication in patients with haematological malignancy after chemotherapy.

OBJECTIVE

Our study aimed to investigate the role of proton pump inhibitors (PPIs) in the occurrence of gut-derived bacteraemia.

METHODS

We compared data from 92 hospitalized haematological malignancy patients after chemotherapy with gut-derived bacteraemia, collected from January 2009 to July 2015, with those of 92 contemporaneous, hospitalized haematological malignancy patients without bacteraemia. We evaluated PPIs use and analysed the effects of covariates.

RESULTS

Patients with gut-derived bacteraemia had a significantly higher incidence of PPIs use (69.6%) than that of controls (47.8%). Of the patients with gut-derived bacteraemia, only 44.6% had a documented indication for PPIs therapy. The antibacterial prophylaxis rate was 38.0% in the bacteraemia group and 58.7% in the non-antibacterial group. Based on multivariable logistic regression analysis, only PPIs use (P = 0.00, odds ratio (OR) = 0.546) was found to be associated with the risk of bacteraemia whereas antibacterial prophylaxis (P = 0.00, OR = 0.652) was protective. There were no significant differences in demographics, malignancy status, length of neutropenia, complications, or steroid use between the gut-derived bacteraemia and control group.

CONCLUSIONS

This study suggests a potential association between PPIs use and development of gut-derived bacteraemia in haematological malignancy patients after chemotherapy.

Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial

Long‐lasting neutropenia associated with acute myeloid leukemia (AML) and its treatment gives rise to a high risk of pneumonia. The use of broad‐spectrum antibiotic prophylaxis during outpatient management has not completely protected patients against admission due to infections and neutropenic fever, emphasizing the need to approach infection protection with complementary efforts. In a randomized controlled design, we examined the applicability of patient‐performed daily spirometry [forced expiratory volume in one second (FEV1)] as an early warning tool and explored the effectiveness of positive expiratory pressure (PEP) in preventing pneumonia among 80 AML patients. Twenty‐five incidences of pneumonia were detected among 23 patients (6 interventions, 17 controls), giving a prevalence of 28.75% during 5420 days of observation. We found a significant difference in incidence between intervention versus control group (2.17 per 1000 days vs. 6.52 per 1000 days, P = 0.021, respectively). A cross point at 80‐76% of the personal FEV1 reference value showed high sensitivity and specificity on pneumonia development. Our data demonstrate the feasibility of educating AML patients in their continuous daily measurement of FEV1 and use of PEP. Daily measures of FEV1 may be an important early warning tool for assessment of pulmonary deterioration during critical phases of neutropenia. We suggest that strategic patient education in the use of spirometry and PEP should be part of standard of care for AML patients undergoing induction chemotherapy. Am. J. Hematol. 91:271–276, 2016. © 2015 The Authors. American Journal of Hematology Published by Wiley Periodicals, Inc.

Evaluation of New bioMérieux Chromogenic CPS Media for Detection of Urinary Tract Pathogens

Four chromogenic media were compared for their ability to detect urinary tract pathogens in 299 urine specimens, of which 175 were found positive, allowing the growth of 279 microorganisms. After 18 to 24 h of incubation, the CPS ID4, CPSE, CPSO (bioMérieux), and UriSelect4 (Bio-Rad) media showed sensitivities of 97.1%, 99.3%, 99.6%, and 99.6%, respectively.

Incidence rates of hospital-acquired urinary tract and bloodstream infections generated by automated compilation of electronically available healthcare data

BACKGROUND

Monitoring of hospital-acquired infection (HAI) by automated compilation of registry data may address the disadvantages of laborious, costly and potentially subjective and often random sampling of data by manual surveillance.

AIM

To evaluate a system for automated monitoring of hospital-acquired urinary tract (HA-UTI) and bloodstream infections (HA-BSI) and to report incidence rates over a five-year period in a Danish hospital trust.

METHODS

Based primarily on electronically available data relating to microbiology results and antibiotic prescriptions, the automated monitoring of HA-UTIs and HA-BSIs was validated against data from six previous point-prevalence surveys (PPS) from 2010 to 2013 and data from a manual assessment (HA-UTI only) of one department of internal medicine from January 2010. Incidence rates (infections per 1000 bed-days) from 2010 to 2014 were calculated.

FINDINGS

Compared with the PPSs, the automated monitoring showed a sensitivity of 88% in detecting UTI in general, 78% in detecting HA-UTI, and 100% in detecting BSI in general. The monthly incidence rates varied between 4.14 and 6.61 per 1000 bed-days for HA-UTI and between 0.09 and 1.25 per 1000 bed-days for HA-BSI.

CONCLUSION

Replacing PPSs with automated monitoring of HAIs may provide better and more objective data and constitute a promising foundation for individual patient risk analyses and epidemiological studies. Automated monitoring may be universally applicable in hospitals with electronic databases comprising microbiological findings, admission data, and antibiotic prescriptions.

Species determination within Staphylococcus genus by extended PCR-restriction fragment length polymorphism of saoC gene

Genetic methods based on PCR-restriction fragment length polymorphism (RFLP) are widely used for microbial species determination. In this study, we present the application of saoC gene as an effective tool for species determination and within-species diversity analysis for Staphylococcus genus. The unique sequence diversity of saoC allows us to apply four restriction enzymes to obtain RFLP patterns, which appear highly distinctive even among closely related species as well as atypical isolates of environmental origin. Such patterns were successfully obtained for 26 species belonging to Staphylococcus genus. What is more, tracing polymorphisms detected by different restriction enzymes allowed for basic phylogeny analysis for Staphylococcus aureus, which is potentially applicable for other staphylococcal species.

Nosocomial infection in adult admissions with hematological malignancies originating from different lineages: a prospective observational study

Background

Nosocomial infection (NI) causes prolonged hospital stays, increased healthcare costs, and higher mortality among patients with hematological malignancies (HM). However, few studies have compared the incidence of NI according to the HM lineage.

Objective

To compare the incidence of NI according to the type of HM lineage, and identify the risk factors for NI.

Methods

This prospective observational study monitored adult patients with HM admitted for >48 hours to the General Hospital of the People's Liberation Army during 2010–2013. Attack rates and incidences of NI were compared, and multivariable logistic regression was used to control for confounding effects.

Results

This study included 6,613 admissions from 1,922 patients. During these admissions, 1,023 acquired 1,136 NI episodes, with an attack rate of 15.47% and incidence of 9.6‰ (95% CI: 9.1–10.2). Higher rates and densities of NIs were observed among myeloid neoplasm (MN) admissions, compared to lymphoid neoplasm (LN) admissions (28.42% vs. 11.00%, P<0.001 and 11.4% vs. 8.4‰, P<0.001). NI attack rates in acute myeloid leukemia (AML) and myelodysplastic/myeloproliferative neoplasm (MDS/MPN) were higher than those in MDS (30.69% vs. 20.19%, P<0.001; 38.89% vs. 20.19%, P = 0.003). Attack rates in T/NK-cell neoplasm and B-cell neoplasm were higher than those in Hodgkin lymphoma (15.04% vs. 3.65%; 10.94% vs. 3.65%, P<0.001). Multivariable regression analysis indicated prolonged hospitalization, presence of central venous catheterization, neutropenia, current stem cell transplant, infection on admission, and old age were independently associated with higher NI incidence. After adjusting for these factors, MN admissions still had a higher risk of infection (odds ratio 1.34, 95% CI: 1.13–1.59, P<0.001).

Conclusion

Different NI attack rates were observed for HM from different lineages, with MN lineages having a higher attack rate and incidence than LN lineages. Special attention should be paid to MN admissions, especially AML and MDS/MPN admissions, to control NI incidence.