Hostname: page-component-6898cfcb55-zkb6p Total loading time: 0 Render date: 2026-11-11T18:28:06.842Z Has data issue: false hasContentIssue false
  • English
  • Français

Changing Epidemiology of Catheter-Related Bloodstream Infections in Cancer Patients

Published online by Cambridge University Press:  17 May 2018

Anne Marie Chaftari,
Ray Hachem,
Ying Jiang,
Pankil Shah,
Alawami Hussain,
Zainab Al Hamal,
Ammar Yousif,
Mary Jordan,
Majd Michael and
Issam Raad
Anne Marie Chaftari*
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Ray Hachem
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Ying Jiang
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Pankil Shah
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Alawami Hussain
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Zainab Al Hamal
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Ammar Yousif
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Mary Jordan
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Majd Michael
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
Issam Raad
Affiliation:
Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston Texas
*
Address correspondence to Anne Marie Chaftari, MD, Department of Infectious Diseases, Infection Control and Employee Health, Unit 1460, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030 (achaftar@mdanderson.org).
Rights & Permissions [Opens in a new window]

Abstract

We compared the etiologic organisms of bloodstream infections (BSIs) in cancer patients with central venous catheters (CVCs) between 2 cohorts separated by more than a decade.

Gram-negative organisms have become the predominant etiologic organisms of BSIs (52%); they now contribute to 41% of catheter-related BSIs (CRBSIs).

Infect Control Hosp Epidemiol 2018;39:727–729

Information

Type
Concise Communications
Information
Infection Control & Hospital Epidemiology , Volume 39 , Issue 6 , June 2018, pp. 727 - 729
Copyright
© 2018 by The Society for Healthcare Epidemiology of America. All rights reserved 

With the rapid evolution in cancer treatment, central venous catheters (CVC) became indispensable devices for the care of cancer patients. However, they are a leading source of bloodstream infections (BSIs).Reference Raad and Chaftari 1 When present, the CVC is considered the source of the BSI when no other source is identified and when the BSI meets the Infectious Diseases Society of America (IDSA) criteria for the diagnosis of catheter-related bloodstream infection (CRBSI).Reference Mermel, Allon and Bouza 2 In this study, we reviewed the current epidemiology of BSI and CRBSI and compared it to the previous era to investigate whether prevention and management guidelines need to be reassessed in this patient population.

MATERIALS AND METHODS

We searched the infection control database at our institution from January 2013 to March 2014 to identify all cancer patients who had simultaneous blood cultures (BCs) drawn from the central line and peripheral site that were positive for the same organism or who had a percutaneous BC and a catheter tip culture growing the same organism. A previous cohort (cohort 1) of similar cancer patients with BSIs at the same institution between September 1999 and November 2000 was compared to our current cohort (cohort 2).Reference Raad, Hachem and Hanna 3 We restricted our analysis to patients with CVC.

For the current cohort, data were extracted from the institution’s electronic medical records.

We compared patients from cohort 2 to patients from cohort 1 (previously publishedReference Raad, Hachem and Hanna 3 ) and patients with CRBSIs to those with non-CRBSIs.

We defined CRBSI according to the IDSA definition as a bloodstream infection that meets 1 of these 3 criteria: (1) paired quantitative BCs (QBCs) drawn simultaneously through the CVC and peripheral vein reveals a 3-fold greater number of colonies of the same organism from the CVC than the peripherally drawn QBC; or (2) the catheter-drawn BC turns positive for the same organisms at least 2 hours earlier than the peripherally drawn BC; or (3) the same organism is cultured from a percutaneous BC and from a catheter tip.Reference Mermel, Allon and Bouza 2

Statistical Analysis

We used the χ2 or Fisher exact test to compare categorical variables, as appropriate. We used Wilcoxon rank-sum tests to compare continuous variables because of the deviation of the data from normal distribution.

RESULTS

Of the 283 cancer patients identified with BSIs in cohort 2, 25% met the criteria for CRBSI. Compared to cohort 1, where 56% of all BSIs were CRBSIs, this is a significant decrease in the rate of CRBSI (P<.0001). Patient characteristics are presented in Table 1.

TABLE 1

Comparison of Patients With and Without Catheter-Related Bloodstream Infection (CRBSI) in Cohort 2

NOTE. CNS, coagulase-negative staphylococci; CVC, central venous catheter.

Although most BSIs occurred in patients with hematological malignancies in both cohorts, BSIs were more often observed in patients with hematological malignancies in cohort 2 compared to cohort 1 (72% vs 60%, respectively; P=.013). Also, BSIs were less frequently observed in patients with solid tumors in cohort 2 compared to cohort 1 (28% vs 40%) (Table 2).

TABLE 2

Comparing Patients With Bloodstream Infections in Both Cohorts

NOTE. BSI, bloodstream infections; CRBSI, catheter-related bloodstream infections.

a One patient had no cancer. This patient was excluded when analysis was stratified by type of cancer.

When comparing the 2 cohorts, we observed that the frequency of gram-negative organisms as etiologic agents of BSI significantly increased from 24% in cohort 1 to 52% in cohort 2 (P<.0001), while gram-positive organisms causing BSI decreased from 71% in cohort 1 to 44% in cohort 2 (P<.0001). When stratified by underlying disease, BSIs caused by gram-negative organisms significantly increased from cohort 1 to cohort 2 in both hematologic malignancy and solid-tumor patients, while BSIs caused by gram-positive organisms significantly decreased from cohort 1 to cohort 2 (Table 2). However, in patients with solid tumor, the changes were not significant.

Similarly, when considering CRBSIs, gram-negative organisms were the etiologic organisms of 17% of CRBSIs in cohort 1, and they contributed to 41% of CRBSIs in cohort 2 (P=.0005). Inversely, gram-positive organisms causing CRBSI decreased from 77% in cohort 1 to 56% in cohort 2 (P=.005) (Table 2).

Candida was the etiologic organism of 4% of all BSIs, 4% of non-CRBSIs and 3% of CRBSIs. While coagulase-negative Staphylococcus spp followed by Staphylococcus aureus were the most common etiological organisms causing CRBSI (26% and 19%, respectively), Escherichia coli is the most common gram-negative organism, causing BSI (22%) and CRBSI (9%) in cohort 2.

The rate of neutropenia was similar in both BSI cohorts (53% in cohort 1 vs 60% in cohort 2; P=.14).

In cohort 2, CRBSIs occurred at a median of 58 days after CVC insertion for all organisms; gram-positive CRBSIs and Candida CRBSIs occurred after a median of 30 days, whereas gram-negative CRBSIs occurred after a much longer median duration of 74 days (P=.06). (Table 1).

DISCUSSION

Our data show a major change in the epidemiology and microbial etiology of BSI and CRBSI in cancer patients occurring over the last 20 years. In the 1999–2000 cohort (ie, cohort 1), most BSIs were CRBSIs and were caused by gram-positive bacteria.Reference Raad, Hachem and Hanna 3 However, in the 2013–2014 cohort (ie, cohort 2), CBRSIs contributed to only 25% of all BSIs, with a significant increase in the rate of gram-negative bacteria CRBSI. Furthermore, this study is the first to demonstrate that gram-negative CRBSIs in cancer patients occurred much later after CVC insertion than did gram-positive CRBSIs.

Many studies conducted in the late 20th century showed that the catheter was the leading source of the BSI, including in those with underlying cancer.Reference Raad, Hachem and Hanna 3 , Reference Wisplinghoff, Seifert, Wenzel and Edmond 4 Furthermore, Planes et alReference Planes, Calleja and Bernet 5 showed that 56% of all BSIs were confirmed catheter related, compared to 34% in 2012.Reference Planes, Calleja and Bernet 5 This finding is similar to that of our study, in which the percentage of catheter-related BSIs dropped from 56% to 25% in a similar period. This decrease in the contribution of the catheter as the source of BSI could be related to the wide implementation of preventive interventions over the last 20 years, including the BSI bundle and the use of antimicrobial catheters at our institution and worldwide.Reference Raad and Chaftari 1 , Reference Furuya, Dick, Herzig, Pogorzelska-Maziarz, Larson and Stone 6 , Reference Chong, Lai, Apisarnthanarak and Chaiyakunapruk 7

Similarly, decreasing rates of gram-positive infections causing CRBSI were noted and occurred relatively early. Concurrently, we noted an increase in the rates of gram-negative BSI and CRBSI that occurred at a later point after CVC insertion. At our institution, this finding could be attributed to the wide use of antimicrobial CVCs (which mainly cover gram-positive organisms) with an antimicrobial durability that lasts for 30–40 days.Reference Furuya, Dick, Herzig, Pogorzelska-Maziarz, Larson and Stone 6 , Reference Darouiche, Berger and Khardori 8 The antimicrobial CVCs were introduced between the 2 periods and are mainly used in high-risk patients (eg, critically ill and recipients of hematopoietic stem-cell transplant). In addition, several components of the CVC insertion bundles were implemented including maximal sterile barrier precautions and introduction of chlorhexidine for insertion site cleaning. Furthermore, the use of cefpodoxime as antimicrobial prophylaxis in high-risk neutropenic cancer patients has increased, which may have contributed to the increase in enteric gram-negative organisms. Despite the numerous infection control precautions in current use that may have impacted the change in the predominant organisms, there is a need for improved preventive strategies (eg, antimicrobial lock and CVC) that broadly cover gram-negative organisms for months after insertion.

In conclusion, over the last 20 years, an epidemiologic shift has occurred among BSIs and CRBSIs in cancer patients. Overall, CVCs have become less of a source of BSI, and the microbial causes of BSI and CBSIs have shifted toward a more gram-negative etiology with a delayed occurrence after CVC insertion. These findings should be considered with the development of interventions that will prevent gram-negative CRBSI several months after CVC insertion.Reference Jamal, Rosenblatt and Hachem 9 , Reference Chaftari, Hachem and Szvalb 10

ACKNOWLEDGMENTS

Financial support: No financial support was provided relevant to this article.

Potential conflicts of interest: All authors report no conflicts of interest relevant to this article.

References

REFERENCES

1. Raad, I, Chaftari, AM. Advances in prevention and management of central line-associated bloodstream infections in patients with cancer. Clin Infect Dis 2014;59(Suppl 5):S340–S343.Google Scholar
2. Mermel, LA, Allon, M, Bouza, E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis 2009;49:1–45.Google Scholar
3. Raad, I, Hachem, R, Hanna, H, et al. Sources and outcome of bloodstream infections in cancer patients: the role of central venous catheters. Eur J Clin Microbiol Infect Dis 2007;26:549–556.CrossRefGoogle Scholar
4. Wisplinghoff, H, Seifert, H, Wenzel, RP, Edmond, MB. Current trends in the epidemiology of nosocomial bloodstream infections in patients with hematological malignancies and solid neoplasms in hospitals in the United States. Clin Infect Dis 2003;36:1103–1110.Google Scholar
5. Planes, AM, Calleja, R, Bernet, A, et al. Evaluation of the usefulness of a quantitative blood culture in the diagnosis of catheter-related bloodstream infection: comparative analysis of two periods (2002 and 2012). Enferm Infecc Microbiol Clin 2016;34:484–489.CrossRefGoogle ScholarPubMed
6. Furuya, EY, Dick, AW, Herzig, CT, Pogorzelska-Maziarz, M, Larson, EL, Stone, PW. Central-line–associated bloodstream infection reduction and bundle compliance in intensive care units: a national study. Infect Control Hosp Epidemiol 2016;37:805–810.CrossRefGoogle ScholarPubMed
7. Chong, HY, Lai, NM, Apisarnthanarak, A, Chaiyakunapruk, N. Comparative efficacy of antimicrobial central venous catheters in reducing catheter-related bloodstream infections in adults: abridged cochrane systematic review and network meta-analysis. Clin Infect Dis 2017;64:S131–S140.CrossRefGoogle ScholarPubMed
8. Darouiche, RO, Berger, DH, Khardori, N, et al. Comparison of antimicrobial impregnation with tunneling of long-term central venous catheters: a randomized controlled trial. Ann Surg 2005;242:193–200.Google Scholar
9. Jamal, MA, Rosenblatt, JS, Hachem, RY, et al. Prevention of biofilm colonization by gram-negative bacteria on minocycline-rifampin-impregnated catheters sequentially coated with chlorhexidine. Antimicrob Agents Chemother 2014;58:1179–1182.CrossRefGoogle ScholarPubMed
10. Chaftari, AM, Hachem, R, Szvalb, A, et al. Correction for Chaftari et al, “A Novel Nonantibiotic Nitroglycerin-Based Catheter Lock Solution for Prevention of Intraluminal Central Venous Catheter Infections in Cancer Patients.” Antimicrob Agent Chemother 2017:61.Google Scholar
Figure 0

TABLE 1Comparison of Patients With and Without Catheter-Related Bloodstream Infection (CRBSI) in Cohort 2

Figure 1

TABLE 2Comparing Patients With Bloodstream Infections in Both Cohorts