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Published on: February 9, 2011
Catheter-related polymicrobial bloodstream infections among pediatric bone marrow transplant outpatients--Atlanta,
Petra Wiersma1, Sarah Schillie, Harry Keyserling
1Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. petra.wiersma@gmail.com
Insights
Polymicrobial bloodstream infections (BSIs) in pediatric bone marrow transplant (BMT) outpatients were linked to catheter use and saline flushing practices. Predrawing saline from single-dose vials increased BSI risk, highlighting infection control challenges in new clinics.
Area of Science:
- Healthcare-associated infections
- Pediatric bone marrow transplantation
- Infection prevention and control
Background:
- Pediatric bone marrow transplant (BMT) outpatients are vulnerable to infections.
- Newly constructed clinics may present unique infection control challenges.
- Polymicrobial bloodstream infections (BSIs) pose a significant threat to immunocompromised patients.
Purpose of the Study:
- To identify risk factors for polymicrobial bloodstream infections (BSIs) in pediatric bone marrow transplant (BMT) outpatients.
- To investigate infection prevention practices in a newly established BMT clinic.
- To determine associations between clinical practices and BSI development.
Main Methods:
- A cohort study of 30 pediatric BMT outpatients was conducted.
- Data collection involved interviews, medical records review, and environmental/patient isolate cultures.
- Exact conditional logistic regression was used for data analysis.
Main Results:
- Thirteen patients developed BSIs caused by gram-negative organisms.
- Independent risk factors for BSI included tunneled catheter presence, catheter access, and saline flushing with predrawn saline.
- Each additional injection of predrawn saline significantly increased BSI odds.
Conclusions:
- Infection prevention challenges and improper medication handling (predrawing saline) likely facilitated healthcare-associated pathogen transmission.
- Recommendations include single-use saline syringes and avoiding multiple punctures of preservative-free vials.
- Hospitals should conduct mock patient flow exercises to identify infection control issues before opening new facilities.
Objective:
To identify risk factors for polymicrobial bloodstream infections (BSIs) in pediatric bone marrow transplant (BMT) outpatients attending a newly constructed clinic affiliated with a children's hospital.
Methods:
All 30 outpatients treated at a new BMT clinic during September 10-21, 2007, were enrolled in a cohort study. The investigation included interviews, medical records review, observations, and bacterial culture and molecular typing of patient and environmental isolates. Data were analyzed using exact conditional logistic regression.
Results:
Thirteen patients experienced BSIs caused by 16 different, predominantly gram-negative organisms. Presence of a tunneled catheter (odds ratio [OR], 19.9 [95% confidence interval {CI}, 2.4-infinity), catheter access (OR, 13.7 [95% CI, 1.8-infinity]), and flushing of a catheter with predrawn saline (OR, 12.9 [95% CI, 1.0-766.0]) were independently associated with BSI. The odds of experiencing a BSI increased by a factor of 16.8 with each additional injection of predrawn saline (95% CI, 1.8-827.0). Although no environmental source of pathogens was identified, interviews revealed breaches in recommended infection prevention practice and medication handling. Saline flush solutions were predrawn, and multiple doses were obtained from single-dose preservative-free vials to avoid delays in patient care.
Conclusion:
We speculate that infection prevention challenges in the new clinic, combined with successive needle punctures of vials, facilitated extrinsic contamination and transmission of healthcare-associated pathogens. We recommend that preservative-free single-use vials not be punctured more than once. Use of single-use prefilled saline syringes might prevent multiuse of single-use saline vials. Storage of saline outside a medication supply system might be advisable. Before opening new clinic facilities, hospitals should consider conducting a mock patient flow exercise to identify infection control challenges.
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