Jan Umphrey

The duration of placement as a predictor of peripheral and pulmonary arterial catheter infections

To determine the appropriate time for removal or replacement of peripheral and pulmonary arterial catheters in critically ill cancer patients, we prospectively studied 71 peripheral arterial catheters and 71 pulmonary artery (Swan-Ganz) catheters from 110 consecutive cancer patients. All catheters were cultured semiquantitatively, by the roll-plate culture technique. Of the 71 peripheral arterial catheters, 11 (15%) produced local infections (> or = 15 colonies) and four (5.5%) produced catheter-related septicaemia. Ten of the 11 local infections and all four septicaemias occurred after 4 days of catheter placement (P < 0.05). Likewise, of the 71 Swan-Ganz catheters, 12 (17%) produced local infection and four (5.6%) led to septicaemia. Swan-Ganz catheter-related septicaemia occurred at rates of 2% and 16%, before and after 7 days of catheter placement, respectively (P = 0.056). Duration of placement was a risk factor for the development of catheter infections, independent of the patients neutropenic status, administration of antibiotics such as vancomycin during catheterization, and the presence of concurrent central venous catheters. Life-table analysis showed that the cumulative risks of developing a catheter infection increased from 7% to 17% after 6 days of peripheral arterial catheter placement and from 9% to 18% after 4 days of placement of the Swan-Ganz catheter. We conclude that in the critically ill cancer patient in our unit, peripheral arterial catheters should be changed to a new site every 4-6 days and pulmonary artery catheters every 4-7 days.

Optimal frequency of changing intravenous administration sets: is it safe to prolong use beyond 72 hours?

OBJECTIVE To determine the safety and cost-effectiveness of replacing the intravenous (IV) tubing sets in hospitalized patients at 4- to 7-day intervals instead of every 72 hours. DESIGN Prospective, randomized study of infusion-related contamination associated with changing IV tubing sets within 3 days versus within 4 to 7 days of placement. SETTING A tertiary university cancer center. PATIENTS AND METHODS Cancer patients requiring IV infusion therapy were randomized to have the IV tubing sets replaced within 3 days (280 patients) or within 4 to 7 days of placement (232 patients). Demographic, microbiological, and infusion-related data were collected for all participants. The main outcome measures were infusion- or catheter-related contamination or colonization of IV tubing, determined by quantitative cultures of the infusate, and infusion- or catheter-related bloodstream infection (BSI), determined by quantitative culture of the infusate in association with blood cultures in febrile patients. RESULTS The two groups were comparable in terms of patient and catheter characteristics and the agents given through the IV tubing. Intent-to-treat analysis demonstrated a higher level of tubing colonization in the 4- to 7-day group versus the 3-day group (median, 145 vs 50 colony-forming units; P=.02). In addition, there were three episodes of possible infusion-related BSIs, all of which occurred in the 4- to 7-day group (P=.09). However, when the 84 patients who received total parenteral nutrition, blood transfusions, or interleukin-2 through the IV tubing were excluded, the two groups had a comparable rate of colonization (0.4% vs 0.5%), with no catheter- or infusion-related BSIs in either group. CONCLUSION In patients at low risk for infection from infusion- or catheter-related infection who are not receiving total parenteral nutrition, blood transfusions, or interleukin-2, delaying the replacement of IV tubing up to 7 days may be safe, as well as cost-effective

Nosocomial respiratory syncytial virus infections: Prevention and control in bone marrow transplant patients

OBJECTIVE To assess the effectiveness of a multifaceted infection control strategy in limiting the nosocomial transmission of respiratory syncytial virus (RSV) infection to patients in a bone marrow transplant (BMT) unit. DESIGN Before/after trial. SETTING University-affiliated tertiary cancer center. PATIENTS Adult BMT recipients hospitalized during two consecutive wintertime community outbreaks of RSV infection. INTERVENTIONS An infection control strategy against nosocomial RSV infection was implemented in the BMT unit in February 1993. The strategy involved prompt identification, isolation, and cohorting of RSV-infected patients; prompt therapy with aerosolized ribavirin; use of masks and gloves by anyone entering an infected BMT patients room; screening visitors for respiratory symptoms; restricting visitation by all children under 12 years of age and all family members and other visitors with RSV symptoms; and restricting symptomatic hospital staff from working in the BMT unit. RESULTS After implementation of the multifaceted infection-control strategy, there were four cases of nosocomial RSV infection in 3,870 patient days (incidence density, 1.0 case/1,000 patient days) compared with 14 cases of nosocomial RSV infection in 3,152 patient days (incidence density, 4.4 cases/1,000 patient days) during the 1992-1993 RSV season (rate ratio, 4.4; 95% confidence interval [CI95]. 1.4-17.9: P < .01). This decrease in incidence occurred despite a comparable prevalence of community-acquired RSV cases between the two seasons (2.2% vs 3.2% in 1992-1993 and 1993-1994, respectively; prevalence ratio, 0.7; CI95, 0.2-2.1; P = 0.5). CONCLUSION Institution of a multifaceted infection control strategy significantly reduced the frequency of nosocomial RSV infection in a high-risk group of adult BMT recipients.

Masking of neutropenic patients on transport from hospital rooms is associated with a decrease in nosocomial aspergillosis during construction

To prevent nosocomial pulmonary aspergillosis during hospital construction, neutropenic patients with hematologic malignancy were required to wear high-efficiency masks when leaving their rooms. The rate of nosocomial aspergillosis decreased from 0.73 per 1,000 hospital patient-days during fiscal years 1993 to 1996 to 0.24 per 1,000 hospital patient-days during fiscal years 1996 to 1999 (P < .001). High-efficiency masks reduced nosocomial aspergillosis during hospital construction.

Infusion therapy team and dressing changes of central venous catheters.

OBJECTIVE To determine whether central venous catheter (CVC) dressing changes could be performed by ward nurses rather than by the infusion therapy team (ITT) nurses without increasing the risk of catheter-related infection. DESIGN Retrospective cohort study using prospectively collected data. The study extended from January 1995 to June 1996. SETTING The University of Texas M.D. Anderson Cancer Center, a referral cancer center. PATIENTS The study group was a random sample of 483 patients who received CVC dressing changes by ward nurses during the study period. A random sample of 483 patients who received CVC dressing changes by the ITT constituted the control group. RESULTS The risks of catheter-related septicemia were 1.7% among cases and 1.4% among controls (risk ratio, 1.14; 95% confidence interval [CI95], 0.26-6.42; P=.70). There also were no significant differences between the two groups in the risks of catheter-related site infection (risk ratio, 0.50; CI95, 0.02-4.12; P=.25) or any catheter-related infection (risk ratio=1.00; CI95, 0.27-3.64; P=.59). CONCLUSIONS Provided that aseptic techniques (including maximal barrier precautions during insertion) are maintained, the responsibility of CVC dressing changes could be delegated to the ward nurses without increasing the low risk of CVC-related infection, resulting in an estimated cost saving in excess of

Management of an outbreak of vancomycin-resistant enterococci in the medical intensive care unit of a cancer center

90,000 per year.

Control of nosocomial Clostridium difficile transmission in bone marrow transplant patients

Between November 1996 and February 1997, 17 episodes of vancomycin-resistant enterococci (VRE) infection or colonization (9 infections, 8 colonizations), all with the same or a similar genomic DNA pattern, were identified in the medical intensive care unit (MICU) of a tertiary-care cancer hospital. The cases were genotypically traced to a patient who was admitted to the hospital in September 1996 and who, by December 1996, had four different admissions to the MICU. Multifaceted infection control measures, including decontamination of the environment and of nondisposable equipment, halted the nosocomial transmission of VRE in the MICU.

The Risk of Infection Associated With Intra-arterial Catheters for Cancer Chemotherapy

This is a report of six cases of Clostridium difficile-associated diarrhea (CDAD) that occurred among cancer patients undergoing bone marrow transplantation in a tertiary-care cancer hospital. Specific infection control measures that were taken to minimize the nosocomial spread of CDAD also are discussed.

Low Infection Rate and Long Durability of Nontunneled Silastic Catheters: A Safe and Cost-effective Alternative for Long-term Venous Access

OBJECTIVE To determine the frequency of, and risk factors for, infections associated with intra-arterial catheters used for cancer chemotherapy. METHODS Between September 1992 and September 1995, we conducted a surveillance study of all 807 intra-arterial catheters placed for chemotherapy at our center. The insertion site was disinfected with povidone iodine and alcohol, and the arterial catheter was placed using maximal sterile barrier precautions. Upon removal, all intravascular segments were submitted for semi-quantitative culture. RESULTS No episodes of catheter-related bloodstream infection (95% confidence interval [CI95], 0%-1.6%) were observed. However, the risk of colonization (>15 colony-forming units) of arterial catheters was 15% (CI95, 12%-17%). Retrospective risk-factor analysis conducted on 224 intra-arterial catheters placed for chemotherapy in 1993 showed that colonization was associated significantly with duration of catheterization (median of 1 day for culture-negative catheters vs median of 4 days for culture-positive catheters, P<.001). Age, gender, prior radiotherapy, underlying cancer, neutropenia, and hypoalbuminemia were not associated with catheter colonization. CONCLUSION Intra-arterial catheters for cancer chemotherapy placed under maximal sterile barrier precautions for a short period of time are associated with a very low risk of bloodstream infection.