Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis. (Singh)

O’Horo JC, Maki DG, Krupp AE, Safdar N. Arterial catheters as a source of
bloodstream infection: a systematic review and meta-analysis*. Crit Care Med.
2014 Jun;42(6):1334-9.

OBJECTIVE: Catheter-related bloodstream infections are associated with significant costs and adverse consequences. Arterial catheters are commonly used in the critical care setting and are among the most heavily manipulated vascular access devices. We sought to evaluate the prevalence of arterial catheter-related bloodstream infection.

DATA SOURCES: PubMed, CinAHL, EMBASE, and Web of Science.

STUDY SELECTION: Included studies reported prevalence rate of catheter-related bloodstream infection for arterial catheters used for critical illness or postoperative monitoring. For the purposes of this study, catheter-related bloodstream infection was defined as positive blood culture collected from an arterial catheter and from the periphery with the same organism in a patient demonstrating systemic signs of sepsis.

DATA EXTRACTION: The study population, site of insertion, antiseptic preparation, catheter days, and prevalence of catheter-related bloodstream infection were abstracted. When data were not available, authors were contacted for further information.

DATA SYNTHESIS: Forty-nine studies met criteria including 222 cases of arterial catheter-related bloodstream infection in 30,841 catheters. Pooled incidence was 3.40/1,000 catheters or 0.96/1,000 catheter days. Prevalence was considerably higher in the subgroup of studies that cultured all catheters (1.26/1,000 catheter days) compared with those studies that cultured only when the arterial catheter was suspected as the source for the catheter-related bloodstream infection (0.70/1,000 catheter days). Pooled data also found a significantly increased risk of infection for femoral site of insertion compared with radial artery for arterial catheter placement (relative risk, 1.93; 95% CI, 1.32-2.84; p = 0.001)

CONCLUSIONS:: Arterial catheters are an underrecognized cause of catheter-related bloodstream infection. Pooled incidence when catheters were systematically cultured and correlated to blood culture results indicated a substantial burden of arterial catheter-related bloodstream infection. Selection of a radial site over a femoral site will help reduce the risk of arterial catheter-related bloodstream infection. Future studies should evaluate technologies applied to preventing central venous catheter-related bloodstream infection to arterial catheters as well.

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Use of time from fever onset improves the diagnostic accuracy of C-reactive protein in identifying bacterial infections. (Kamat)

Segal I, Ehrlichman M, Urbach J, Bar-Meir M. Use of time from fever onset
improves the diagnostic accuracy of C-reactive protein in identifying bacterial
infections. Arch Dis Child. 2014 May 15.

OBJECTIVE: To determine whether the input of time from fever onset will change the accuracy of C-reactive protein (CRP) in diagnosing bacterial infections in febrile children.

STUDY DESIGN: We performed a prospective observational study on febrile children presenting to the emergency department. The diagnostic performance of CRP at different time points from fever onset was compared using a receiver operating characteristic (ROC) curve.

RESULTS: Among 373 patients included, 103 (28%) had bacterial infection. The optimal cut-off for CRP suggesting bacterial infection changed with time from fever onset: 6 mg/dL for >12-24 h of fever; 10.7 and 12.6 mg/dL at >24-48 and >48 h of fever, respectively. The input of time from fever onset improved the area under the ROC curve from 0.83 (95% CI 0.78 to 0.88) for CRP overall to 0.87 (95% CI 0.77 to 0.96) and 0.90 (95% CI 0.84 to 0.97) at >24-48 and >48 h of fever, respectively. Duration of fever mostly affected the ability of CRP to correctly rule out bacterial infections. CRP level of 2 mg/dL obtained at ≤24 h of fever corresponds with a post-test probability for bacterial infection of 10%, whereas the same value obtained >24 h of fever reduces the risk to 2%.

CONCLUSIONS: Clinicians should apply different CRP cut-off values depending on whether they are trying to rule in or rule out bacterial infection, but also depending on fever duration at the time of CRP testing.

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Blood cultures in the evaluation of uncomplicated skin and soft tissue infections. (Vats)

Malone JR, Durica SR, Thompson DM, et al. Blood cultures in the evaluation of uncomplicated skin and soft tissue infections. Pediatrics. 2013 Sep;132(3):454-9.

BACKGROUND: Blood cultures are often obtained in children hospitalized with skin and soft tissue infections (SSTIs). Because little evidence exists to validate this practice, we examined the yield of blood cultures in the evaluation of immunocompetent children with SSTIs.

METHODS: Medical records were reviewed for all children admitted between January 1, 2007 and December 31, 2009 after emergency department evaluation and diagnosis of cellulitis or abscess. We compared patients with SSTIs (n = 482) with those with complicated SSTIs (cSSTIs; n = 98). A cSSTI was defined as surgical or traumatic wound infection, need for surgical intervention, or infected ulcers or burns. The SSTI group included patients without complicating factors.

RESULTS: None of the patients in the SSTI group had a positive blood culture. In the cSSTI group, 12.5% of blood cultures were positive. The mean length of hospital stay (LOHS) of children with SSTIs was shorter than that of those with cSSTIs (P < .001). In the SSTI group, obtaining a blood culture was associated with a higher mean LOHS (P = .044).

CONCLUSIONS: Blood cultures are not useful in evaluating immunocompetent children who are admitted to the hospital with uncomplicated SSTIs, and they are associated with a nearly 1-day increase in mean LOHS.

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Targeted versus universal decolonization to prevent ICU infection. (Kamat)

N Engl J Med. 2013 Jun 13;368(24):2255-65. PMID: 23718152

BACKGROUND: Both targeted decolonization and universal decolonization of patients in intensive care units (ICUs) are candidate strategies to prevent health care-associated infections, particularly those caused by methicillin-resistant Staphylococcus aureus (MRSA).

METHODS: We conducted a pragmatic, cluster-randomized trial. Hospitals were randomly assigned to one of three strategies, with all adult ICUs in a given hospital assigned to the same strategy. Group 1 implemented MRSA screening and isolation; group 2, targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers); and group 3, universal decolonization (i.e., no screening, and decolonization of all patients). Proportional-hazards models were used to assess differences in infection reductions across the study groups, with clustering according to hospital.

RESULTS: A total of 43 hospitals (including 74 ICUs and 74,256 patients during the intervention period) underwent randomization. In the intervention period versus the baseline period, modeled hazard ratios for MRSA clinical isolates were 0.92 for screening and isolation (crude rate, 3.2 vs. 3.4 isolates per 1000 days), 0.75 for targeted decolonization (3.2 vs. 4.3 isolates per 1000 days), and 0.63 for universal decolonization(2.1 vs. 3.4 isolates per 1000 days) (P=0.01 for test of all groups being equal). In the intervention versus baseline periods, hazard ratios for bloodstream infection with any pathogen in the three groups were 0.99 (crude rate, 4.1 vs. 4.2 infections per 1000 days), 0.78 (3.7 vs. 4.8 infections per 1000 days), and 0.56 (3.6 vs. 6.1 infections per 1000 days), respectively (P<0.001 for test of all groups being equal). Universal decolonization resulted in a significantly greater reduction in the rate of all bloodstream infections than either targeted decolonization or screening and isolation. One bloodstream infection was prevented per 54 patients who underwent decolonization. The reductions in rates of MRSA bloodstream infection were similar to those of all bloodstream infections, but the difference was not significant. Adverse events, which occurred in 7 patients, were mild and related to chlorhexidine.

CONCLUSIONS: In routine ICU practice, universal decolonization was more effective than targeted decolonization or screening and isolation in reducing rates of MRSA clinical isolates and bloodstream infection from any pathogen. (Funded by the Agency for Healthcare Research and the Centers for Disease Control and Prevention; REDUCE MRSA ClinicalTrials.gov number, NCT00980980).

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