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Xu J, Zare H, Chiu HC, Castillo RC. Evaluating the Cost-Effectiveness of Chlorhexidine-Coated vs. Standard Peripheral Insertion Central Catheters in Patients with Hematologic Disease: A Health Economic Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2025; 22:373. [PMID: 40238404 PMCID: PMC11942587 DOI: 10.3390/ijerph22030373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2025] [Revised: 02/25/2025] [Accepted: 02/27/2025] [Indexed: 04/18/2025]
Abstract
BACKGROUND/OBJECTIVES This study was conducted to assess the cost-effectiveness of chlorhexidine-coated (AGBA) peripheral insertion central catheters (PICCs) versus standard PICCs for managing catheter-related complications among patients with hematologic disease. METHODS A decision tree health economic model was developed, incorporating quality-adjusted life years (QALYs) derived from the literature, as well as complication rates and per-patient costs from a randomized controlled trial. The base case incremental cost-effectiveness ratio (ICER) was assessed against established willingness to pay (WTP) thresholds. One-way sensitivity analyses were conducted to address assumptions and uncertainties. RESULTS The mean healthcare cost per patient of standard PICCs was RMB 21,987.32 (USD 3242.82, at an average exchange rate of RMB 678.03 = USD 100), affecting 0.68 QALYs in 90 days. The mean healthcare cost per patient of AGBA PICCs was RMB 19,696.23 (USD 2904.92), affecting 0.73 QALYs in 90 days, thus resulting in a saving of RMB 2291.10 (USD 428.44). After the model simulation, standard PICCs resulted in a reduction of 0.05 QALYs. The ICER for AGBA PICCs compared with standard PICCs was consistently centered at RMB 4271.31 (USD 629.96). CONCLUSIONS one-way sensitivity analyses of cost-effectiveness versus WTP confirmed the robustness of the model across various parameter changes, indicating that AGBA PICCs could provide significant healthcare savings over a 1-year period when adopted in routine chemotherapy treatment for patients with hematologic disease.
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Affiliation(s)
- Jia Xu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21202, USA; (H.Z.); (R.C.C.)
| | - Hossein Zare
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21202, USA; (H.Z.); (R.C.C.)
| | - Herng-Chia Chiu
- Institute for Hospital Management, Tsinghua Shenzhen International Graduate School, Shenzhen 518055, China;
| | - Renan C. Castillo
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21202, USA; (H.Z.); (R.C.C.)
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Bibire T, Dănilă R, Yilmaz CN, Verestiuc L, Nacu I, Ursu RG, Ghiciuc CM. In Vitro Biological Evaluation of an Alginate-Based Hydrogel Loaded with Rifampicin for Wound Care. Pharmaceuticals (Basel) 2024; 17:943. [PMID: 39065793 PMCID: PMC11280071 DOI: 10.3390/ph17070943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/10/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
We report a biocompatible hydrogel dressing based on sodium alginate-grafted poly(N-vinylcaprolactam) prepared by encapsulation of Rifampicin as an antimicrobial drug and stabilizing the matrix through the repeated freeze-thawing method. The hydrogel structure and polymer-drug compatibility were confirmed by FTIR, and a series of hydrogen-bond-based interactions between alginate and Rifampicin were identified. A concentration of 0.69% Rifampicin was found in the polymeric matrix using HPLC analysis and spectrophotometric UV-Vis methods. The hydrogel's morphology was evaluated by scanning electron microscopy, and various sizes and shapes of pores, ranging from almost spherical geometries to irregular ones, with a smooth surface of the pore walls and high interconnectivity in the presence of the drug, were identified. The hydrogels are bioadhesive, and the adhesion strength increased after Rifampicin was encapsulated into the polymeric matrix, which suggests that these compositions are suitable for wound dressings. Antimicrobial activity against S. aureus and MRSA, with an increased effect in the presence of the drug, was also found in the newly prepared hydrogels. In vitro biological evaluation demonstrated the cytocompatibility of the hydrogels and their ability to stimulate cell multiplication and mutual cell communication. The in vitro scratch assay demonstrated the drug-loaded alginate-grafted poly(N-vinylcaprolactam) hydrogel's ability to stimulate cell migration and wound closure. All of these results suggest that the prepared hydrogels can be used as antimicrobial materials for wound healing and care applications.
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Affiliation(s)
- Tudor Bibire
- Doctoral School, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700116 Iasi, Romania;
- St. Spiridon County Clinical Emergency Hospital, 1 Independentei Blvd., 700111 Iasi, Romania;
| | - Radu Dănilă
- St. Spiridon County Clinical Emergency Hospital, 1 Independentei Blvd., 700111 Iasi, Romania;
- Department of Surgery, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700116 Iasi, Romania
| | - Cătălina Natalia Yilmaz
- Biochemistry Division, Department of Chemistry, Faculty of Science, Dokuz Eylül University, Kültür Mah. Cumhuriyet Bulv. No:144 Alsancak, 35210 Izmir, Turkey
| | - Liliana Verestiuc
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700116 Iasi, Romania;
| | - Isabella Nacu
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700116 Iasi, Romania;
- Petru Poni Institute of Macromolecular Chemistry, 41-A Grigore Ghica Voda Alley, 700487 Iasi, Romania
| | - Ramona Gabriela Ursu
- Department of Microbiology, Faculty of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700116 Iasi, Romania;
| | - Cristina Mihaela Ghiciuc
- Department of Pharmacology, Faculty of Medicine, Clinical Pharmacology and Algeziology, Grigore T. Popa University of Medicine and Pharmacy, 16 Universitatii Street, 700116 Iasi, Romania;
- St. Maria Clinical Emergency Hospital for Children, 62 Vasile Lupu Street, 700309 Iasi, Romania
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Affiliation(s)
- Naomi P O'Grady
- From the National Institutes of Health Clinical Center, Bethesda, MD
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Itoh K, Tsutani H, Mitsuke Y, Iwasaki H. Potential additional effects of iron chelators on antimicrobial- impregnated central venous catheters. Front Microbiol 2023; 14:1210747. [PMID: 37608951 PMCID: PMC10442153 DOI: 10.3389/fmicb.2023.1210747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 07/27/2023] [Indexed: 08/24/2023] Open
Affiliation(s)
- Kazuhiro Itoh
- Department of Internal Medicine, National Hospital Organization Awara Hospital, Awara, Japan
- Division of Infection Control and Prevention, University of Fukui Hospital, Fukui, Japan
| | - Hiroshi Tsutani
- Department of Internal Medicine, National Hospital Organization Awara Hospital, Awara, Japan
| | - Yasuhiko Mitsuke
- Department of Internal Medicine, National Hospital Organization Awara Hospital, Awara, Japan
| | - Hiromichi Iwasaki
- Division of Infection Control and Prevention, University of Fukui Hospital, Fukui, Japan
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Viola GM, Szvalb AD, Malek AE, Chaftari AM, Hachem R, Raad II. Prevention of device-related infections in patients with cancer: Current practice and future horizons. CA Cancer J Clin 2023; 73:147-163. [PMID: 36149820 PMCID: PMC9992006 DOI: 10.3322/caac.21756] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 11/18/2022] Open
Abstract
Over the past several years, multifaceted advances in the management of cancer have led to a significant improvement in survival rates. Throughout patients' oncological journeys, they will likely receive one or more implantable devices for the administration of fluids and medications as well as management of various comorbidities and complications related to cancer therapy. Infections associated with these devices are frequent and complex, often necessitating device removal, increasing health care costs, negatively affecting quality of life, and complicating oncological care, usually leading to delays in further life-saving cancer therapy. Herein, the authors comprehensively review multiple evidence-based recommendations along with best practices, expert opinions, and novel approaches for the prevention of diverse device-related infections. The authors present many general principles for the prevention of these infections followed by specific device-related recommendations in a systematic manner. The continuous involvement and meaningful cooperation between regulatory entities, industry, specialty medical societies, hospitals, and infection control-targeted interventions, along with primary care and consulting health care providers, are all vital for the sustained reduction in the incidence of these preventable infections.
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Affiliation(s)
- George M Viola
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ariel D Szvalb
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Alexandre E Malek
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Anne-Marie Chaftari
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ray Hachem
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Malhotra A, Chauhan SR, Rahaman M, Tripathi R, Khanuja M, Chauhan A. Phyto-assisted synthesis of zinc oxide nanoparticles for developing antibiofilm surface coatings on central venous catheters. Front Chem 2023; 11:1138333. [PMID: 37035110 PMCID: PMC10076889 DOI: 10.3389/fchem.2023.1138333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 03/02/2023] [Indexed: 04/11/2023] Open
Abstract
Medical devices such as Central Venous Catheters (CVCs), are routinely used in intensive and critical care settings. In the present scenario, incidences of Catheter-Related Blood Stream Infections (CRBSIs) pose a serious challenge. Despite considerable advancements in the antimicrobial therapy and material design of CVCs, clinicians continue to struggle with infection-related complications. These complications are often due colonization of bacteria on the surface of the medical devices, termed as biofilms, leading to infections. Biofilm formation is recognized as a critical virulence trait rendering infections chronic and difficult to treat even with 1,000x, the minimum inhibitory concentration (MIC) of antibiotics. Therefore, non-antibiotic-based solutions that prevent bacterial adhesion on medical devices are warranted. In our study, we report a novel and simple method to synthesize zinc oxide (ZnO) nanoparticles using ethanolic plant extracts of Eupatorium odoratum. We investigated its physio-chemical characteristics using Field Emission- Scanning Electron Microscopy and Energy dispersive X-Ray analysis, X-Ray Diffraction (XRD), Photoluminescence Spectroscopy, UV-Visible and Diffuse Reflectance spectroscopy, and Dynamic Light Scattering characterization methods. Hexagonal phase with wurtzite structure was confirmed using XRD with particle size of ∼50 nm. ZnO nanoparticles showed a band gap 3.25 eV. Photoluminescence spectra showed prominent peak corresponding to defects formed in the synthesized ZnO nanoparticles. Clinically relevant bacterial strains, viz., Proteus aeruginosa PAO1, Escherichia coli MTCC 119 and Staphylococcus aureus MTCC 7443 were treated with different concentrations of ZnO NPs. A concentration dependent increase in killing efficacy was observed with 99.99% killing at 500 μg/mL. Further, we coated the commercial CVCs using green synthesized ZnO NPs and evaluated it is in vitro antibiofilm efficacy using previously optimized in situ continuous flow model. The hydrophilic functionalized interface of CVC prevents biofilm formation by P. aeruginosa, E. coli and S. aureus. Based on our findings, we propose ZnO nanoparticles as a promising non-antibiotic-based preventive solutions to reduce the risk of central venous catheter-associated infections.
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Affiliation(s)
- Akshit Malhotra
- Department of Microbiology, Tripura University, Suryamaninagar, Tripura, India
- Invisiobiome, New Delhi, India
| | - Suchitra Rajput Chauhan
- Centre for Advanced Materials and Devices (CAMD), School of Engineering and Technology, BML Munjal University, Gurgaon, Haryana, India
| | - Mispaur Rahaman
- Central Instrumentation Centre, Tripura University, Suryamaninagar, Tripura, India
| | - Ritika Tripathi
- Centre for Advanced Materials and Devices (CAMD), School of Engineering and Technology, BML Munjal University, Gurgaon, Haryana, India
| | - Manika Khanuja
- Centre for Nanoscience and Nanotechnology, Jamia Millia Islamia, New Delhi, India
| | - Ashwini Chauhan
- Department of Microbiology, Tripura University, Suryamaninagar, Tripura, India
- *Correspondence: Ashwini Chauhan,
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Comas M, Domingo L, Jansana A, Lafuente E, Civit A, García-Pérez L, Lasso de la Vega C, Cots F, Sala M, Castells X. Cost-effectiveness Analysis of Peripherally Inserted Central Catheters Versus Central Venous Catheters for in-Hospital Parenteral Nutrition. J Patient Saf 2022; 18:e1109-e1115. [PMID: 35587883 DOI: 10.1097/pts.0000000000001028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Our objective was to evaluate the cost-effectiveness of the use of peripherally inserted central venous catheters (PICCs) by a vascular access team (VAT) versus central venous catheters (CVCs) for in-hospital total parenteral nutrition (TPN). METHODS The study used a cost-effectiveness analysis based on observational data retrospectively obtained from electronic medical records from 2018 to 2019 in a teaching hospital. We included all interventional procedures requiring PICCs or CVCs with the indication of TPN. We recorded the costs of insertion, maintenance, removal, and complications. The main outcome measure was the incidence rate of catheter-associated bacteremia per 1000 catheter days. Cost-effectiveness analysis was performed from the hospital perspective within the context of the publicly funded Spanish health system. Confidence intervals for costs and effectiveness differences were calculated using bootstrap methods. RESULTS We analyzed 233 CVCs and 292 PICCs from patients receiving TPN. Average duration was longer for PICC (13 versus 9.4 days, P < 0.001). The main reason for complications in both groups was suspected infection (9.77% CVC versus 5.18% PICC). Complication rates due to bacteremia were 2.44% for CVC and 1.15% for PICC. The difference in the incidence of bacteremia per 1000 catheter days was 1.29 (95% confidence interval, -0.89 to 3.90). Overall, costs were lower for PICCs than for CVCs: the difference in mean overall costs was -€559.9 (95% confidence interval, -€919.9 to -€225.4). Uncertainty analysis showed 86.37% of results with lower costs and higher effectiveness for PICC versus CVC. CONCLUSIONS Placement of PICC by VAT compared with CVC for TPN reduces costs and may decrease the rate of bacteremia.
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Affiliation(s)
| | | | | | - Elisabeth Lafuente
- Infusion and Vascular Access Nurse, Nursing Care Research, Hospital del Mar Research Institute (IMIM), Barcelona
| | - Anna Civit
- Infusion and Vascular Access Nurse, Nursing Care Research, Hospital del Mar Research Institute (IMIM), Barcelona
| | | | - Carmen Lasso de la Vega
- Infusion and Vascular Access Nurse, Nursing Care Research, Hospital del Mar Research Institute (IMIM), Barcelona
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Blood compatibility of widely used central venous catheters; an experimental study. Sci Rep 2022; 12:8600. [PMID: 35597879 PMCID: PMC9124179 DOI: 10.1038/s41598-022-12564-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 05/12/2022] [Indexed: 12/16/2022] Open
Abstract
An inserted central venous catheter (CVC) is considered foreign material by the inert host defence systems and induce inflammation and thrombus formation. The objective of this study was to evaluate blood compatibility of six commonly used CVCs. Three coated and three uncoated CVC materials were tested in a modified Chandler loop model. Each catheter material circulated in blood from ten different healthy volunteers for 1 h. Blood cell counts and measurements of the inert host defence systems were performed on blood samples from the loop. All the tested catheters demonstrated impact on blood cells, contact coagulation, the complement system, or inflammatory markers, although the impact varied significantly. Of the catheters we evaluated, the most unfavourable blood compatibility profile was found for the polyurethane CVC coated with chlorohexidine and silver sulfadiazine. The greatest variation in blood compatibility between test runs was noted for the silicone dialysis catheter. Poor blood compatibility should be taken seriously but given the experimental design of the current study the clinical significance remains to be evaluated.
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9
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Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2022; 43:553-569. [PMID: 35437133 PMCID: PMC9096710 DOI: 10.1017/ice.2022.87] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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van den Bosch C, van Woensel J, van de Wetering MD. Prophylactic antibiotics for preventing gram-positive infections associated with long-term central venous catheters in adults and children receiving treatment for cancer. Cochrane Database Syst Rev 2021; 10:CD003295. [PMID: 34617602 PMCID: PMC8495768 DOI: 10.1002/14651858.cd003295.pub4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND This is an updated version of a Cochrane Review last published in 2013. Long-term central venous catheters (CVCs), including tunnelled CVCs (TCVCs) and totally implanted devices or ports (TIDs), are increasingly used when treating people with cancer. Despite international guidelines on sterile insertion and appropriate CVC maintenance and use, infections remain a common complication. These infections are mainly caused by gram-positive bacteria. Antimicrobial prevention strategies aimed at these micro-organisms could potentially decrease the majority of CVC-related infections. The aim of this review was to evaluate the efficacy of prophylactic antibiotics for the prevention of gram-positive infections in people with cancer who have long-term CVCs. OBJECTIVES To assess the effects of administering antibiotics prior to the insertion of long-term CVCs or as a flush/lock solution, or both during long-term CVC access to prevent gram-positive CVC-related infections in adults and children receiving treatment for cancer. SEARCH METHODS The search for this updated review was conducted on 19 November 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE via Ovid and Embase via Ovid. We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform portal for additional articles. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared either the administration of prophylactic antibiotics prior to long-term CVC insertion versus no administration of antibiotics, or the use of an antibiotic versus a non-antibiotic flush/lock solution in long-term CVCs, in adults and children receiving treatment for cancer. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two authors independently selected studies, classified them and extracted data onto a predesigned data collection form. The outcomes of interest were gram-positive catheter-related infection events and total number of CVCs and CVC days. We pooled the data using a random-effects model for meta-analyses. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS: For this update, we identified 310 potentially relevant studies and screened them for eligibility. We included one additional RCT with 404 participants. The original review included 11 RCTs with a total of 840 people with cancer (adults and children). In total this review included 12 RCTs with 1244 participants. Antibiotics prior to insertion of the CVC Six trials compared the use of antibiotics (vancomycin, teicoplanin, ceftazidime or cefazolin) versus no antibiotics given before the insertion of a long-term CVC. One study did not observe any CVC-related infection events in either group was not included in the quantitative analysis as it was not possible to calculate a risk ratio. Administering an antibiotic prior to insertion of the CVC may not reduce gram-positive CVC-related infections (pooled risk ratio 0.67, confidence interval (CI) 95% 0.32 to 1.43; control versus intervention group risk 10.4% versus 7.3% of the participants; 5 studies, 648 participants; moderate-certainty evidence). We sought adverse event data, but these were not described by the authors. The overall risk of bias was deemed low. Antibiotics as a flushing or locking solution Six trials compared a combined antibiotic (vancomycin, amikacin or taurolidine) and heparin solution with a heparin-only solution for flushing or locking the long-term CVC after use. One study did not observe any CRS events and was not include this study in the quantitative analysis as it was not possible to calculate a risk ratio. Flushing and locking long-term CVCs with a combined antibiotic and heparin solution likely reduced the risk of gram-positive CVC-related infections compared to a heparin-only solution (pooled rate ratio 0.47, CI 95% 0.26 to 0.85; control versus intervention group rate ratio 0.66 versus 0.27 per 1000 CVC-days; 5 studies, 443 participants; moderate-certainty evidence). One trial reported a higher incidence of occlusions and participants in one trial reported an unpleasant taste after flushing associated with a combined antibiotic and heparin solution. The overall risk of bias was deemed low. AUTHORS' CONCLUSIONS: Since the last version of this review, we included one additional study. There was no observed benefit of administering antibiotics before the insertion of long-term CVCs to prevent gram-positive CVC-related infections. Flushing or locking long-term CVCs with an antibiotic solution likely reduces gram-positive CVC-related infections experienced in people at risk of neutropenia through chemotherapy or disease. However, a limitation of this review is heterogeneity between the studies for both outcomes. Insufficient data were available to evaluate if the conclusions apply equally for different CVC types and for adults versus children. It must be noted that the use of an antibiotic flush/lock solution may increase microbial antibiotic resistance, therefore it should be reserved for high-risk people or if the baseline CVC-related infection rates are high. Further research is needed to identify high-risk groups most likely to benefit from these antibiotic flush/lock solutions.
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Affiliation(s)
- Ceder van den Bosch
- Department of Pediatric Surgery, Princess Máxima Center for Pediatric Oncology, Utrecht, Netherlands
| | - Job van Woensel
- Pediatrics, Emma Children's Hospital / Academic Medical Centre, Amsterdam, Netherlands
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Lam M, Migonney V, Falentin-Daudre C. Review of silicone surface modification techniques and coatings for antibacterial/antimicrobial applications to improve breast implant surfaces. Acta Biomater 2021; 121:68-88. [PMID: 33212233 DOI: 10.1016/j.actbio.2020.11.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/12/2020] [Accepted: 11/12/2020] [Indexed: 12/19/2022]
Abstract
Silicone implants are widely used in the medical field for plastic or reconstructive surgeries for the purpose of soft tissue issues. However, as with any implanted object, healthcare-associated infections are not completely avoidable. The material suffers from a lack of biocompatibility and is often subject to bacterial/microbial infections characterized by biofilm growth. Numerous strategies have been developed to either prevent, reduce, or fight bacterial adhesion by providing an antibacterial property. The present review summarizes the diverse approaches to deal with bacterial infections on silicone surfaces along with the different methods to activate/oxidize the surface before any surface modifications. It includes antibacterial coatings with antibiotics or nanoparticles, covalent attachment of active bacterial molecules like peptides or polymers. Regarding silicone surfaces, the activation step is essential to render the surface reactive for any further modifications using energy sources (plasma, UV, ozone) or chemicals (acid solutions, sol-gel strategies, chemical vapor deposition). Meanwhile, corresponding work on breast silicone prosthesis is discussed. The latter is currently in the line of sight for causing severe capsular contractures. Specifically, to that end, besides chemical modifications, the antibacterial effect can also be achieved by physical surface modifications by adjusting the surface roughness and topography for instance.
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12
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Böll B, Schalk E, Buchheidt D, Hasenkamp J, Kiehl M, Kiderlen TR, Kochanek M, Koldehoff M, Kostrewa P, Claßen AY, Mellinghoff SC, Metzner B, Penack O, Ruhnke M, Vehreschild MJGT, Weissinger F, Wolf HH, Karthaus M, Hentrich M. Central venous catheter-related infections in hematology and oncology: 2020 updated guidelines on diagnosis, management, and prevention by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO). Ann Hematol 2021; 100:239-259. [PMID: 32997191 PMCID: PMC7782365 DOI: 10.1007/s00277-020-04286-x] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/23/2020] [Indexed: 12/31/2022]
Abstract
Cancer patients frequently require central venous catheters for therapy and parenteral nutrition and are at high risk of central venous catheter-related infections (CRIs). Moreover, CRIs prolong hospitalization, cause an excess in resource utilization and treatment cost, often delay anti-cancer treatment, and are associated with a significant increase in mortality in cancer patients. We therefore summoned a panel of experts by the Infectious Diseases Working Party (AGIHO) of the German Society of Hematology and Medical Oncology (DGHO) and updated our previous guideline on CRIs in cancer patients. After conducting systematic literature searches on PubMed, Medline, and Cochrane databases, video- and meeting-based consensus discussions were held. In the presented guideline, we summarize recommendations on definition, diagnosis, management, and prevention of CRIs in cancer patients including the grading of strength of recommendations and the respective levels of evidence. This guideline supports clinicians and researchers alike in the evidence-based decision-making in the management of CRIs in cancer patients.
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Affiliation(s)
- Boris Böll
- Department I of Internal Medicine, Hematology and Oncology, Intensive Care Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany.
| | - Enrico Schalk
- Department of Hematology and Oncology, Otto-von-Guericke University Magdeburg, Medical Center, Magdeburg, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, Mannheim University Hospital, Heidelberg University, Mannheim, Germany
| | - Justin Hasenkamp
- Clinic for Hematology and Oncology, University Medicine Göttingen, Georg-August-University, Göttingen, Germany
| | - Michael Kiehl
- Department of Internal Medicine, Frankfurt (Oder) General Hospital, Frankfurt/Oder, Germany
| | - Til Ramon Kiderlen
- Department of Hematology, Oncology and Palliative Care, Vivantes Clinic Neukoelln, Berlin, Germany
| | - Matthias Kochanek
- Department I of Internal Medicine, Hematology and Oncology, Intensive Care Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Michael Koldehoff
- Department of Bone Marrow Transplantation, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Philippe Kostrewa
- Department of Hematology and Oncology, Campus Fulda, Philipps-University Marburg, Fulda, Germany
| | - Annika Y Claßen
- Department I of Internal Medicine, Hematology and Oncology, Intensive Care Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Sibylle C Mellinghoff
- Department I of Internal Medicine, Hematology and Oncology, Intensive Care Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, University of Cologne, Kerpener Strasse 62, 50937, Cologne, Germany
| | - Bernd Metzner
- Department of Hematology and Oncology, University Hospital Oldenburg, Oldenburg, Germany
| | - Olaf Penack
- Department of Hematology, Oncology, and Tumor Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Markus Ruhnke
- Department of Hematology and Oncology, Helios Klinikum Aue, Aue, Germany
| | - Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Florian Weissinger
- Department of Hematology, Oncology and Palliative Care, Department of Internal Medicine, Evangelisches Klinikum Bethel, Bielefeld, Germany
| | - Hans-Heinrich Wolf
- Department III of Internal Medicine, Hematology, Oncology and Hemostaseology, Südharzklinikum, Nordhausen, Germany
| | - Meinolf Karthaus
- Department of Hematology, Oncology & Palliative Care, Klinikum Neuperlach, Munich, Germany
| | - Marcus Hentrich
- Department of Hematology and Oncology, Red Cross Hospital Munich, Munich, Germany
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13
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Gilbert R, Brown M, Faria R, Fraser C, Donohue C, Rainford N, Grosso A, Sinha AK, Dorling J, Gray J, Muller-Pebody B, Harron K, Moitt T, McGuire W, Bojke L, Gamble C, Oddie SJ. Antimicrobial-impregnated central venous catheters for preventing neonatal bloodstream infection: the PREVAIL RCT. Health Technol Assess 2020; 24:1-190. [PMID: 33174528 DOI: 10.3310/hta24570] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Clinical trials show that antimicrobial-impregnated central venous catheters reduce catheter-related bloodstream infection in adults and children receiving intensive care, but there is insufficient evidence for use in newborn babies. OBJECTIVES The objectives were (1) to determine clinical effectiveness by conducting a randomised controlled trial comparing antimicrobial-impregnated peripherally inserted central venous catheters with standard peripherally inserted central venous catheters for reducing bloodstream or cerebrospinal fluid infections (referred to as bloodstream infections); (2) to conduct an economic evaluation of the costs, cost-effectiveness and value of conducting additional research; and (3) to conduct a generalisability analysis of trial findings to neonatal care in the NHS. DESIGN Three separate studies were undertaken, each addressing one of the three objectives. (1) This was a multicentre, open-label, pragmatic randomised controlled trial; (2) an analysis was undertaken of hospital care costs, lifetime cost-effectiveness and value of information from an NHS perspective; and (3) this was a retrospective cohort study of bloodstream infection rates in neonatal units in England. SETTING The randomised controlled trial was conducted in 18 neonatal intensive care units in England. PARTICIPANTS Participants were babies who required a peripherally inserted central venous catheter (of 1 French gauge in size). INTERVENTIONS The interventions were an antimicrobial-impregnated peripherally inserted central venous catheter (coated with rifampicin-miconazole) or a standard peripherally inserted central venous catheter, allocated randomly (1 : 1) using web randomisation. MAIN OUTCOME MEASURE Study 1 - time to first bloodstream infection, sampled between 24 hours after randomisation and 48 hours after peripherally inserted central venous catheter removal. Study 2 - cost-effectiveness of the antimicrobial-impregnated peripherally inserted central venous catheter compared with the standard peripherally inserted central venous catheters. Study 3 - risk-adjusted bloodstream rates in the trial compared with those in neonatal units in England. For study 3, the data used were as follows: (1) case report forms and linked death registrations; (2) case report forms and linked death registrations linked to administrative health records with 6-month follow-up; and (3) neonatal health records linked to infection surveillance data. RESULTS Study 1, clinical effectiveness - 861 babies were randomised (antimicrobial-impregnated peripherally inserted central venous catheter, n = 430; standard peripherally inserted central venous catheter, n = 431). Bloodstream infections occurred in 46 babies (10.7%) randomised to antimicrobial-impregnated peripherally inserted central venous catheters and in 44 (10.2%) babies randomised to standard peripherally inserted central venous catheters. No difference in time to bloodstream infection was detected (hazard ratio 1.11, 95% confidence interval 0.73 to 1.67; p = 0.63). Secondary outcomes of rifampicin resistance in positive blood/cerebrospinal fluid cultures, mortality, clinical outcomes at neonatal unit discharge and time to peripherally inserted central venous catheter removal were similar in both groups. Rifampicin resistance in positive peripherally inserted central venous catheter tip cultures was higher in the antimicrobial-impregnated peripherally inserted central venous catheter group (relative risk 3.51, 95% confidence interval 1.16 to 10.57; p = 0.02) than in the standard peripherally inserted central venous catheter group. Adverse events were similar in both groups. Study 2, economic evaluation - the mean cost of babies' hospital care was £83,473. Antimicrobial-impregnated peripherally inserted central venous catheters were not cost-effective. Given the increased price, compared with standard peripherally inserted central venous catheters, the minimum reduction in risk of bloodstream infection for antimicrobial-impregnated peripherally inserted central venous catheters to be cost-effective was 3% and 15% for babies born at 23-27 and 28-32 weeks' gestation, respectively. Study 3, generalisability analysis - risk-adjusted bloodstream infection rates per 1000 peripherally inserted central venous catheter days were similar among babies in the trial and in all neonatal units. Of all bloodstream infections in babies receiving intensive or high-dependency care in neonatal units, 46% occurred during peripherally inserted central venous catheter days. LIMITATIONS The trial was open label as antimicrobial-impregnated and standard peripherally inserted central venous catheters are different colours. There was insufficient power to determine differences in rifampicin resistance. CONCLUSIONS No evidence of benefit or harm was found of peripherally inserted central venous catheters impregnated with rifampicin-miconazole during neonatal care. Interventions with small effects on bloodstream infections could be cost-effective over a child's life course. Findings were generalisable to neonatal units in England. Future research should focus on other types of antimicrobial impregnation of peripherally inserted central venous catheters and alternative approaches for preventing bloodstream infections in neonatal care. TRIAL REGISTRATION Current Controlled Trials ISRCTN81931394. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 57. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Ruth Gilbert
- UCL Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, University College London, London, UK.,Health Data Research UK, London, UK
| | - Michaela Brown
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Rita Faria
- Centre for Health Economics, University of York, York, UK
| | - Caroline Fraser
- UCL Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Chloe Donohue
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Naomi Rainford
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | | | | | - Jon Dorling
- Division of Neonatal-Perinatal Medicine, Dalhousie University IWK Health Centre, Halifax, NS, Canada
| | - Jim Gray
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Katie Harron
- UCL Great Ormond Street Institute of Child Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Tracy Moitt
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - William McGuire
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Laura Bojke
- Centre for Health Economics, University of York, York, UK
| | - Carrol Gamble
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, UK
| | - Sam J Oddie
- Centre for Reviews and Dissemination, University of York, York, UK.,Bradford Neonatology, Bradford Royal Infirmary, Bradford, UK
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14
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Sohail MR, Corey GR, Wilkoff BL, Poole JE, Mittal S, Kennergren C, Greenspon AJ, Cheng A, Lande JD, Lexcen DR, Tarakji KG. Clinical Presentation, Timing, and Microbiology of CIED Infections: An Analysis of the WRAP-IT Trial. JACC Clin Electrophysiol 2020; 7:50-61. [PMID: 33478712 DOI: 10.1016/j.jacep.2020.07.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/14/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This study characterized the microbiology of major cardiac implantable electronic device (CIED) infections that occurred during the WRAP-IT (Worldwide Randomized Antibiotic Envelope Infection Prevention Trial) study. BACKGROUND The WRAP-IT study offers a unique opportunity for further understanding of the pathogens involved in major CIED infections in a prospective dataset, with implications for clinical practice and infection management. METHODS A total of 6,800 patients randomized 1:1 to receive an antibacterial envelope or not (control subjects) were included in this analysis. Patient characteristics, infection manifestation (pocket vs. systemic), and infection microbiology were evaluated through all follow-up (36 months). Data were analyzed using Cox proportional hazards regression. RESULTS A total of 3,371 patients received an envelope, and 3,429 patients were control subjects. Major CIED infection occurred in 32 patients who received an envelope and 51 control subjects (36-month Kaplan-Meier estimated event rate, 1.3% and 1.9%, respectively; p = 0.046). A 61% reduction in major pocket infection was observed within 12 months of the procedure in the envelope group (hazard ratio: 0.39, 95% confidence interval: 0.21 to 0.73; p = 0.003). Among 76 patients with major infections who had a sample taken, causative pathogens were identified in 47 patients. Staphylococcus species were the predominate pathogen (n = 31) and envelope use resulted in a 76% reduction in Staphylococcus-related pocket infections (n = 4 vs. 17; p = 0.010). Envelope use was not associated with delayed onset of pocket infections and did not affect the presentation of infections. CONCLUSIONS Antibacterial envelope use resulted in a significant reduction of major CIED pocket infections and was particularly effective against Staphylococcus species, the predominant cause of pocket infections. (Worldwide Randomized Antibiotic Envelope Infection Prevention Trial [WRAP-IT]; NCT02277990).
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Affiliation(s)
- M Rizwan Sohail
- Department of Medicine and Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.
| | - G Ralph Corey
- Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Bruce L Wilkoff
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeanne E Poole
- Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Charles Kennergren
- Cardiothoracic Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Arnold J Greenspon
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alan Cheng
- Cardiac Rhythm & Heart Failure (CRHF) Therapy Development and Clinical Research, Medtronic, Mounds View, Minnesota, USA
| | - Jeffrey D Lande
- Cardiac Rhythm & Heart Failure (CRHF) Therapy Development and Clinical Research, Medtronic, Mounds View, Minnesota, USA
| | - Daniel R Lexcen
- Cardiac Rhythm & Heart Failure (CRHF) Therapy Development and Clinical Research, Medtronic, Mounds View, Minnesota, USA
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15
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Bandyopadhyay S, Jones A, McLean A, Sterner M, Robbins C, Cunningham M, Walters M, Doddapaneni K, Keitel I, Gallagher C. Slippery liquid infused fluoropolymer coating for central lines to reduce catheter associated clotting and infections. Sci Rep 2020; 10:14973. [PMID: 32917923 PMCID: PMC7486915 DOI: 10.1038/s41598-020-71711-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 08/18/2020] [Indexed: 11/08/2022] Open
Abstract
Thrombosis and infections are two grave, interrelated problems associated with the use of central venous catheters (CVL). Currently used antibiotic coated CVL has limited clinical success in resisting blood stream infection and may increase the risk of emerging antibiotic resistant strains. We report an antibiotic-free, fluoropolymer-immobilized, liquid perfluorocarbon-coated peripherally inserted central catheter (PICC) line and its effectiveness in reducing catheter associated thrombosis and pathogen colonization, as an alternative to antibiotic coated CVL. Commercially available polyurethane PICC catheter was modified by a three-step lamination process, with thin fluoropolymer layers to yield fluoropolymer-polyurethane-fluoropolymer composite structure before applying the liquid perfluorocarbon (LP). This high throughput process of modifying commercial PICC catheters with fluoropolymer is quicker, safer and shows higher thromboresistance than fluorinated, omniphobic catheter surfaces, produced by previously reported self-assembled monolayer deposition techniques. The LP immobilized on the fluoropolymer is highly durable in physiological flow conditions for over 60 days and continue to resist Staphylococcus colonization.
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Affiliation(s)
| | - Andrew Jones
- FreeFlow Medical Devices LLC, Lancaster, PA, USA
| | | | | | | | | | - Mark Walters
- Shared Material Instrumentation Facility, Duke University, Durham, NC, USA
| | | | - Isaac Keitel
- FreeFlow Medical Devices LLC, Lancaster, PA, USA
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16
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Patel P, Tayebjee M. Antimicrobial envelopes for CIEDs — Too early for routine use? Int J Cardiol 2020; 315:57-58. [DOI: 10.1016/j.ijcard.2020.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/13/2020] [Indexed: 11/30/2022]
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17
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Reitzel RA, Rosenblatt J, Gerges BZ, Jarjour A, Fernández-Cruz A, Raad II. The potential for developing new antimicrobial resistance from the use of medical devices containing chlorhexidine, minocycline, rifampicin and their combinations: a systematic review. JAC Antimicrob Resist 2020; 2:dlaa002. [PMID: 34222960 PMCID: PMC8210168 DOI: 10.1093/jacamr/dlaa002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 12/04/2019] [Accepted: 12/15/2019] [Indexed: 12/13/2022] Open
Abstract
Background Catheter infections remain one of the most persistent adverse events causing significant morbidity, economic impact and mortality. Several strategies have been proposed to reduce these infections including the use of catheters embedded with antibiotics and/or antiseptics. One reoccurring challenge is the fear that antimicrobial medical devices will induce resistance. The aim of this systematic review is to evaluate the evidence for induced antimicrobial resistance caused by exposure to antimicrobial medical devices. Methods Four electronic databases [MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus] were screened for studies published between 1983 and 2019 regarding assessment of microbial resistance with use of medical devices containing chlorhexidine, minocycline, rifampicin or combinations thereof. Development of new resistance, selection for tolerant organisms and 'no change in resistance' were assessed. Results Forty-four publications, grouped by study type and stratified by drug assessed, were included for analyses. The majority of studies found no change in resistance after exposure to antimicrobial medical devices (13 in vitro, 2 in vivo, 20 clinical). Development of new resistance was commonly reported with the use of rifampicin as a single agent and only reported in one study assessing the minocycline/rifampicin combination (M/R); however, the increase in MIC was well below clinical relevance. Conclusions Emergence of new resistance to combinations of M/R, minocycline/rifampicin/chlorhexidine (M/R/CH) and chlorhexidine/silver sulfadiazine (CHXSS) was rare. No clinical trials confirmed its occurrence and some refuted it. The risk of development of new resistance to these antimicrobial combinations appears more fear-based than substantiated by clinical and experimental evidence but warrants continued surveillance.
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Affiliation(s)
- Ruth A Reitzel
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Joel Rosenblatt
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bahgat Z Gerges
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Andrew Jarjour
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ana Fernández-Cruz
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control and Employee Health, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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18
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Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, Govil D, Mishra RC, Samavedam S, Pandit RA, Savio RD, Clerk AM, Srinivasan S, Juneja D, Ray S, Sahoo TK, Jakkinaboina S, Jampala N, Jain R. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020; 24:S6-S30. [PMID: 32205954 PMCID: PMC7085816 DOI: 10.5005/jp-journals-10071-g23183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE Short-term central venous catheterization (CVC) is one of the commonly used invasive interventions in ICU and other patient-care areas. Practice and management of CVC is not standardized, varies widely, and need appropriate guidance. Purpose of this document is to provide a comprehensive, evidence-based and up-to-date, one document source for practice and management of central venous catheterization. These recommendations are intended to be used by critical care physicians and allied professionals involved in care of patients with central venous lines. METHODS This position statement for central venous catheterization is framed by expert committee members under the aegis of Indian Society of Critical Care Medicine (ISCCM). Experts group exchanged and reviewed the relevant literature. During the final meeting of the experts held at the ISCCM Head Office, a consensus on all the topics was made and the recommendations for final document draft were prepared. The final document was reviewed and accepted by all expert committee members and after a process of peer-review this document is finally accepted as an official ISCCM position paper.Modified grade system was utilized to classify the quality of evidence and the strength of recommendations. The draft document thus formulated was reviewed by all committee members; further comments and suggestions were incorporated after discussion, and a final document was prepared. RESULTS This document makes recommendations about various aspects of resource preparation, infection control, prevention of mechanical complication and surveillance related to short-term central venous catheterization. This document also provides four appendices for ready reference and use at institutional level. CONCLUSION In this document, committee is able to make 54 different recommendations for various aspects of care, out of which 40 are strong and 14 weak recommendations. Among all of them, 42 recommendations are backed by any level of evidence, however due to paucity of data on 12 clinical questions, a consensus was reached by working committee and practice recommendations given on these topics are based on vast clinical experience of the members of this committee, which makes a useful practice point. Committee recognizes the fact that in event of new emerging evidences this document will require update, and that shall be provided in due time. ABBREVIATIONS LIST ABHR: Alcohol-based hand rub; AICD: Automated implantable cardioverter defibrillator; BSI: Blood stream infection; C/SS: CHG/silver sulfadiazine; Cath Lab: Catheterization laboratory (Cardiac Cath Lab); CDC: Centers for Disease Control and Prevention; CFU: Colony forming unit; CHG: Chlorhexidine gluconate; CL: Central line; COMBUX: Comparison of Bedside Ultrasound with Chest X-ray (COMBUX study); CQI: Continuous quality improvement; CRBSI: Catheter-related blood stream infection; CUS: Chest ultrasonography; CVC: Central Venous Catheter; CXR: Chest X-ray; DTTP: Differential time to positivity; DVT: Deep venous thrombosis; ECG: Electrocardiography; ELVIS: Ethanol lock and risk of hemodialysis catheter infection in critically ill patients; ER: Emergency room; FDA: Food and Drug Administration; FV: Femoral vein; GWE: Guidewire exchange; HD catheter: Hemodialysis catheter; HTS: Hypertonic saline; ICP: Intracranial pressure; ICU: Intensive Care Unit; IDSA: Infectious Disease Society of America; IJV: Internal jugular vein; IPC: Indian penal code; IRR: Incidence rate ratio; ISCCM: Indian Society of Critical Care Medicine; IV: Intravenous; LCBI: Laboratory confirmed blood stream infection; M/R: Minocycline/rifampicin; MBI-LCBI: Mucosal barrier injury laboratory-confirmed bloodstream infection; MRSA: Methicillin-resistant Staphylococcus aureus; NHS: National Health Service (UK); NHSN: National Healthcare Safety Network (USA); OT: Operation Theater; PICC: Peripherally-inserted central catheter; PIV: Peripheral intravenous line; PL: Peripheral line; PVI: Povidone-iodine; RA: Right atrium; RCT: Randomized controlled trial; RR: Relative risk; SCV/SV: Subclavian vein; ScVO2: Central venous oxygen saturation; Sn: Sensitivity; SOP: Standard operating procedure; SVC: Superior vena cava; TEE: Transesophageal echocardiography; UPP: Useful Practice Points; USG: Ultrasonography; WHO: World Health Organization. HOW TO CITE THIS ARTICLE Javeri Y, Jagathkar G, Dixit S, Chaudhary D, Zirpe KG, Mehta Y, et al. Indian Society of Critical Care Medicine Position Statement for Central Venous Catheterization and Management 2020. Indian J Crit Care Med 2020;24(Suppl 1):S6-S30.
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Affiliation(s)
- Yash Javeri
- Department of Critical Care, Anesthesia and Emergency Medicine, Regency Health, Lucknow, Uttar Pradesh, India, , e-mail:
| | - Ganshyam Jagathkar
- Department of Critical Care Medicine, Medicover Hospital, Hyderabad, Telangana, India, e-mail:
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, e-mail:
| | - Dhruva Chaudhary
- Department of Pulmonary and Critical Care, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, , e-mail:
| | - Kapil Gangadhar Zirpe
- Department of Neuro Trauma Unit, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
| | - Yatin Mehta
- Department of Critical Care and Anesthesiology, Medanta The Medicity, Sector-38, Gurgaon, Haryana, India, Extn. 3335, e-mail:
| | - Deepak Govil
- Department of Critical Care, Medanta Hospital, The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Rajesh C Mishra
- Department of Critical Care, Saneejivini Hospital, Vastrapur, Ahmedabad, Gujarat, India, , e-mail:
| | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Rahul Anil Pandit
- Department of Intensive Care Unit, Fortis Hospital, Mumbai, Maharashtra, India, , e-mail:
| | - Raymond Dominic Savio
- Department of Critical Care Medicine, Apollo Hospital, Chennai, Tamil Nadu, India, e-mail:
| | - Anuj M Clerk
- Department of Intensive Care, Services Sunshine Global Hospital, Surat, Gujarat, India, e-mail:
| | - Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospital, New Delhi, India, , e-mail:
| | - Deven Juneja
- Department of Critical Care Medicine, Max Superspecialty Hospital, New Delhi, India, , e-mail:
| | - Sumit Ray
- Department of Critical Care, Artemis Hospital, Gurugram, Haryana, India, e-mail:
| | - Tapas Kumar Sahoo
- Department of Critical Care, Medanta Hospital, Ranchi, Jharkhand, India, , e-mail:
| | - Srinivas Jakkinaboina
- Department of Critical Care Medicine, Citizens Specialty Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Nandhakishore Jampala
- Department of Critical Care, Medicover Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Ravi Jain
- Department of Critical Care Medicine, Nayati Medicity, Mathura, Uttar Pradesh, India, , e-mail:
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Basu R, Eggington S. Intrinsic properties of medical devices: considerations for economic evaluation. Expert Rev Pharmacoecon Outcomes Res 2019; 19:619-626. [PMID: 31721598 DOI: 10.1080/14737167.2020.1693268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: In recent decades, medical devices (MDs) have increasingly become an integral part of patient care. However, when it comes to designing and appraising economic models, researchers typically follow pharmaceutical templates (e.g. CHEERS) to assess their economic viability. This study evaluates the generalizability of four device-specific criteria, as recommended by the recent MedtechHTA project, of learning curve, incremental innovation, dynamic pricing, and organizational impact with a broader group of MDs including diagnostics and implantables. The purpose was to determine the applicability of these criteria to a broader range of MDs.Areas Covered: We determined the extent to which these criteria could be applied to each device type and attempted to identify common themes. We performed a literature search using PubMed and Google of a range of devices to understand the clinical significance, operation, and economic viability.Expert Opinion: Our findings suggest that the four characteristics are not applicable to all device types. Prior evaluation of a device's intrinsic properties (such as longevity and device location) and its FDA risk classification could help to indicate the applicability of the criteria. Documenting this process when assessing the additional four criteria on the CHEERS checklist would improve the transparency of future economic evaluations.
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Affiliation(s)
- Rituparna Basu
- Health Economics and Outcomes Research, Minimally Invasive Therapies Group (MITG), Medtronic, Mansfield, MA, USA
| | - Simon Eggington
- Global Health Policy, Reimbursement and Health Economics, Medtronic International Trading Sarl, Tolochenaz, Switzerland
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20
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Kong F, Cai X, Zhai S, Wang R, Zheng X, Ma Y, Bi H, Wang D. Possible mechanisms of the antimicrobial effects of polypeptide‑enriched Gastrodia elata Blume extracts. Mol Med Rep 2019; 20:4723-4730. [PMID: 31702024 DOI: 10.3892/mmr.2019.10706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/05/2019] [Indexed: 11/06/2022] Open
Abstract
The present study aimed to evaluate the antimicrobial activity and the possible mechanisms of activity of polypeptide‑enriched Gastrodia elata extracts (GEP) against the gram‑negative bacteria Escherichia coli and Pseudomonas aeruginosa, the gram‑positive bacterium Staphylococcus aureus and the fungus Candida albicans. The antimicrobial activity of GEP was first confirmed by determining the minimum inhibitory concentration by growth curve analysis. GEP was found to damage the cell wall and membrane of the microorganisms tested, as revealed by the morphological changes visible through scanning electron microscopy, and by the observed leakage of alkaline phosphatase and β‑galactosidase from cells. GEP was demonstrated to perturb the metabolism of the microorganisms, especially the tricarboxylic acid cycle, as indicated by the reduced intracellular activity of succinate dehydrogenase, malate dehydrogenase and ATPases, including the Na+/K+‑ATPase and the Ca2+‑ATPase. In addition, GEP caused the leakage of the genetic material of the bacteria and the fungus, as indicated by the increased OD260. The results of the present study indicated that GEP may exert its antimicrobial activity by damaging cell walls and membranes, causing the leakage of genetic material, and by perturbing cellular metabolism.
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Affiliation(s)
- Fange Kong
- School of Life Sciences, Jilin University, Changchun, Jilin 130012, P.R. China
| | - Xueying Cai
- School of Life Sciences, Jilin University, Changchun, Jilin 130012, P.R. China
| | - Siyu Zhai
- School of Life Sciences, Jilin University, Changchun, Jilin 130012, P.R. China
| | - Ruochen Wang
- School of Life Sciences, Jilin University, Changchun, Jilin 130012, P.R. China
| | - Xiaoyi Zheng
- Division of Nephrology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Yue Ma
- Department of Radiology, The First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Hui Bi
- Department of Anesthesiology, Hospital of Stomatology, Jilin University, Changchun, Jilin 130021, P.R. China
| | - Di Wang
- School of Life Sciences, Jilin University, Changchun, Jilin 130012, P.R. China
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21
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Assessment of the Potential for Inducing Resistance in Multidrug-Resistant Organisms from Exposure to Minocycline, Rifampin, and Chlorhexidine Used To Treat Intravascular Devices. Antimicrob Agents Chemother 2019; 63:AAC.00040-19. [PMID: 30833430 DOI: 10.1128/aac.00040-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 02/24/2019] [Indexed: 02/07/2023] Open
Abstract
To assess the potential for the induction of antimicrobial resistance following repeated subinhibitory exposures to the combination minocycline (MIN), rifampin (RIF), and chlorhexidine (CHX), a total of 29 clinical microbial pathogenic isolates were repeatedly exposed to subinhibitory concentrations of MIN, RIF, and CHX for 20 passages. MICs of the MIN, RIF, and CHX combination were assessed at each passage to evaluate the potential for resistance to have been induced. The combination of MIN, RIF, and CHX showed significant antimicrobial efficacy and synergy against organisms resistant to all 3 individual components (MIC of ≥16 μg/ml for MIN or MIC of ≥4 μg/ml for RIF or CHX). Among the organisms originally resistant to 2 or more individual components and the organisms originally susceptible to 2 or more individual components, there was no evidence that organisms became resistant following 20 repeated subinhibitory exposure cycles to the triple combination. The risk of resistance developing to the triple combination is extremely low because microbes are inhibited or killed before resistance can simultaneously emerge to all three agents. Surveillance studies monitoring the development of resistance should be conducted in a clinical setting.
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Oger PC, Piesse C, Ladram A, Humblot V. Engineering of Antimicrobial Surfaces by Using Temporin Analogs to Tune the Biocidal/antiadhesive Effect. MOLECULES (BASEL, SWITZERLAND) 2019; 24:molecules24040814. [PMID: 30813478 PMCID: PMC6412374 DOI: 10.3390/molecules24040814] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/19/2019] [Accepted: 02/20/2019] [Indexed: 11/16/2022]
Abstract
Proliferation of resistant bacteria on biomaterials is a major problem leading to nosocomial infections. Due to their broad-spectrum activity and their ability to disrupt bacterial membranes through a rapid membranolytic mechanism, antimicrobial peptides (AMPs) are less susceptible to the development of bacterial resistance and therefore represent good candidates for surface coating strategies to prevent biofilm formation. In this study, we report on the covalent immobilization of temporin-SHa, a small hydrophobic and low cationic antimicrobial peptide exhibiting broad-spectrum activity, and (SHa) analogs on modified gold surfaces. Several analogs derived from SHa with either a carboxamidated ([K3]SHa, d-[K3]SHa) or a carboxylated C-terminus ([K3]SHa-COOH) were used to achieve peptide grafting on gold surfaces modified by a thiolated self-assembled monolayer (SAM). Surface functionalization was characterized by polarization modulation infrared reflection absorption spectroscopy (PM-RAIRS) and X-ray photoemission spectroscopy (XPS). The antibacterial properties of the temporin-functionalized surfaces were tested against the Gram-positive Listeria ivanovii. Direct visualization of the peptide effects on the bacterial membrane was investigated by scanning electron microscopy equipped with a field emission gun (SEM-FEG). All active temporin analogs were successfully grafted and display significant antibacterial activity (from 80 to 90% killing efficiency) in addition to a 2-fold decrease of bacterial adhesion when all d-SHa analogs were used.
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Affiliation(s)
- Pierre-Carl Oger
- Sorbonne Université, CNRS, Laboratoire de Réactivité de Surface, LRS UMR CNRS 7197, F-75252 Paris, France.
| | - Christophe Piesse
- Sorbonne Université, CNRS, Institut de Biologie Paris-Seine, IBPS, F-75252 Paris, France.
| | - Ali Ladram
- Sorbonne Université, CNRS, Institut de Biologie Paris-Seine, IBPS, F-75252 Paris, France.
| | - Vincent Humblot
- Sorbonne Université, CNRS, Laboratoire de Réactivité de Surface, LRS UMR CNRS 7197, F-75252 Paris, France.
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Kagan E, Salgado CD, Banks AL, Marculescu CE, Cantey JR. Peripherally inserted central catheter-associated bloodstream infection: Risk factors and the role of antibiotic-impregnated catheters for prevention. Am J Infect Control 2019; 47:191-195. [PMID: 30180989 DOI: 10.1016/j.ajic.2018.07.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/08/2018] [Accepted: 07/08/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Antimicrobial-impregnated (AIP) peripherally inserted central catheters (PICCs) may lower risk of central line-associated bloodstream infection (CLABSI) compared with nonantimicrobial-impregnated (NAIP) catheters. We sought to assess risk factors for CLABSI with a focus on the effect of AIP PICCs. METHODS CLABSI rate was determined among patients who received PICCs from July 2009 through June 2012 using a retrospective study design. A nested case-control study matched for operators (interventional radiology [IR], infectious diseases [IDs], and the nurse venous access team [VAT]) was conducted to assess risks for PICC CLABSI. RESULTS Eighty-nine PICC CLABSIs (1.66%) occurred among 5,372 PICC placements a mean of 32 days after placement. Higher infection risk (1.75) was observed for IR-placed PICCs compared with ID-placed PICCs (P = .02). In addition, higher infection risk (4.22) was observed for IR-placed PICCS compared with VAT-placed PICCs (P = .0008). IR-placed NAIP catheters, as indicated by multivariate analysis, revealed a 5.45-fold greater CLABSI risk compared with AIP catheters (P < .0005). Other risk factors included chemotherapy, placement of a tunneled catheter, leukemia, and AIDS. CONCLUSIONS PICC CLABSIs were highest among patients receiving NAIP catheters in this large study. Highest risk occurred with placement of a tunneled catheter, AIDS, leukemia, and if the indication for PICC was chemotherapy. Our study suggests that the AIP PICC should be considered in all patients receiving PICCs.
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24
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Shaw CM, Shah S, Kapoor BS, Cain TR, Caplin DM, Farsad K, Knuttinen MG, Lee MH, McBride JJ, Minocha J, Robilotti EV, Rochon PJ, Strax R, Teo EYL, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Central Venous Access. J Am Coll Radiol 2018; 14:S506-S529. [PMID: 29101989 DOI: 10.1016/j.jacr.2017.08.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 01/15/2023]
Abstract
Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Colette M Shaw
- Principal Author, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | - Shrenik Shah
- Research Author, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | - Drew M Caplin
- Hofstra Northwell School of Medicine, Manhasset, New York
| | | | | | - Margaret H Lee
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Jeet Minocha
- University of California San Diego, San Diego, California
| | - Elizabeth V Robilotti
- Memorial Sloan Kettering Cancer Center, New York, New York; Infectious Diseases Society of America
| | - Paul J Rochon
- University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | | | - Elrond Y L Teo
- Emory University School of Medicine, Atlanta, Georgia; Society of Critical Care Medicine
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25
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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 2018; 64:S131-S140. [PMID: 28475779 DOI: 10.1093/cid/cix019] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background The efficacy of antimicrobial central venous catheters (CVCs) remains questionable. In this network meta-analysis, we aimed to assess the comparative efficacy of antimicrobial CVC impregnations in reducing catheter-related infections in adults. Methods We searched 4 electronic databases (Medline, the Cochrane Central Register of Controlled Trials, Embase, CINAHL) and internet sources for randomized controlled trials, ongoing clinical trials, and unpublished studies up to August 2016. Studies that assessed CVCs with antimicrobial impregnation with nonimpregnated catheters or catheters with another impregnation were included. Primary outcomes were clinically diagnosed sepsis, catheter-related bloodstream infection (CRBSI), and all-cause mortality. We performed a network meta-analysis to estimate risk ratio (RR) with 95% confidence interval (CI). Results Sixty studies with 17255 catheters were included. The effects of 14 impregnations were investigated. Both CRBSI and catheter colonization were the most commonly evaluated outcomes. Silver-impregnated CVCs significantly reduced clinically diagnosed sepsis compared with silver-impregnated cuffs (RR, 0.54 [95% CI, .29-.99]). When compared to no impregnation, significant CRBSI reduction was associated with minocycline-rifampicin (RR, 0.29 [95% CI, .16-.52]) and silver (RR, 0.57 [95% CI, .38-.86]) impregnations. No impregnations significantly reduced all-cause mortality. For catheter colonization, significant decreases were shown by miconazole-rifampicin (RR, 0.14 [95% CI, .05-.36]), 5-fluorouracil (RR, 0.34 [95% CI, .14-.82]), and chlorhexidine-silver sulfadiazine (RR, 0.60 [95% CI, .50-.72]) impregnations compared with no impregnation. None of the studies evaluated antibiotic/antiseptic resistance as the outcome. Conclusions Current evidence suggests that the minocycline-rifampicin-impregnated CVC appears to be the most effective in preventing CRBSI. However, its overall benefits in reducing clinical sepsis and mortality remain uncertain. Surveillance for antibiotic resistance attributed to the routine use of antimicrobial-impregnated CVCs should be emphasized in future trials.
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Affiliation(s)
| | - Nai Ming Lai
- School of Pharmacy, Monash University Malaysia.,School of Medicine, Taylor's University Lakeside Campus, Malaysia
| | - Anucha Apisarnthanarak
- Division of Infectious Diseases, Faculty of Medicine, Thammasat University Hospital, Pratumthani, Thailand
| | - Nathorn Chaiyakunapruk
- School of Pharmacy, Monash University Malaysia.,School of Population Health, University of Queensland, Brisbane, Australia.,Center of Pharmaceutical Outcomes Research, Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand ; and.,School of Pharmacy, University of Wisconsin, Madison
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26
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Darouiche RO. Antimicrobial Coating of Devices for Prevention of Infection: Principles and Protection. Int J Artif Organs 2018; 30:820-7. [DOI: 10.1177/039139880703000912] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Device-associated infections are responsible for about half of nosocomial infections and can cause major medical and economical sequelae. Despite adherence to basic infection control measures, which constitute the mainstay for preventing infection, infections associated with certain devices continue to exist at unacceptably high rates. Potentially-preventive, antimicrobial-utilizing strategies include systemic antibiotic prophylaxis and local administration of antimicrobial agents (antibiotics or antiseptics), which includes antimicrobial irrigation of the surgical field, placement of antimicrobial carriers, antiseptic cleansing of the skin, dipping of surgical implants in antimicrobial solutions, and inserting antimicrobial-coated implants. Since bacterial colonization of the indwelling device is a prelude to infection, prevention of device colonization may lead to a lower rate of clinical infection. Different approaches for antimicrobial coating of devices have been variably successful in preventing device-associated infections. Optimal characteristics of antimicrobial coating can help predict the likelihood and degree of clinical protection against infection. This review addresses the impact of device-related infection, antimicrobial-utilizing approaches for preventing infection, clinical protection afforded by different types of antimicrobial coating, characteristics that predict the ability of antimicrobial coating of devices to prevent clinical infection, and future directions of antimicrobial coating.
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Affiliation(s)
- R. O. Darouiche
- Center for Prostheses Infection and Infectious Disease Section, Michael E. Debakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, Texas - USA
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27
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Rosenblatt J, Reitzel RA, Viola GM, Vargas-Cruz N, Selber J, Raad I. Sodium Mercaptoethane Sulfonate Reduces Collagenolytic Degradation and Synergistically Enhances Antimicrobial Durability in an Antibiotic-Loaded Biopolymer Film for Prevention of Surgical-Site Infections. BIOMED RESEARCH INTERNATIONAL 2017; 2017:3149536. [PMID: 29238713 PMCID: PMC5697372 DOI: 10.1155/2017/3149536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 10/09/2017] [Indexed: 11/26/2022]
Abstract
Implant-associated surgical-site infections can have significant clinical consequences. Previously we reported a method for prophylactically disinfecting implant surfaces in surgical pockets, where an antibiotic solution containing minocycline (M) and rifampin (R) was applied as a solid film in a crosslinked biopolymer matrix that partially liquefied in situ to provide extended prophylaxis. Here we studied the effect of adding sodium 2-mercaptoethane sulfonate (MeSNA) on durability of prophylaxis in an in vitro model of implant-associated surgical-site infection. Adding MeSNA to the M/R biopolymer, antimicrobial film extended the duration for which biofilm formation by multidrug-resistant Pseudomonas aeruginosa (MDR-PA) was prevented on silicone surfaces in the model. M/R films with and without MeSNA were effective in preventing colonization by methicillin-resistant Staphylococcus aureus. Independent experiments revealed that MeSNA directly inhibited proteolytic digestion of the biopolymer film and synergistically enhanced antimicrobial potency of M/R against MDR-PA. Incubation of the MeSNA containing films with L929 fibroblasts revealed no impairment of cellular metabolic activity or viability.
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Affiliation(s)
- Joel Rosenblatt
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Ruth A. Reitzel
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - George M. Viola
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Nylev Vargas-Cruz
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Jesse Selber
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Issam Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Ghamrawi S, Bouchara JP, Tarasyuk O, Rogalsky S, Lyoshina L, Bulko O, Bardeau JF. Promising silicones modified with cationic biocides for the development of antimicrobial medical devices. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2017; 75:969-979. [PMID: 28415553 DOI: 10.1016/j.msec.2017.03.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 03/02/2017] [Accepted: 03/02/2017] [Indexed: 12/20/2022]
Abstract
We have tested silicones containing 2% or 5% of the cationic biocides polyhexamethylene guanidine dodecylbenzenesulfonate (PHMG-DBS), 1-octyl-3-methylimidazolium tetrafluoroborate (OMIM-BF4) or 1-dodecyl-3-methylimidazolium tetrafluoroborate (DMIM-BF4) against the major relevant bacterial and yeast species in health care-associated infections (HCAI). Study conducted according to the international standard ISO 22196 revealed that silicones containing 2% or 5% DMIM-BF4 or 5% PHMG-DBS presented the highest antimicrobial activity, leading to a logarithmic growth reduction of 3.03 to 6.46 and 3.65 to 4.85 depending on the bacterial or fungal species. Heat-pretreated silicones containing 2% DMIM-BF4 kept a high activity, with at least a 3-log reduction in bacterial growth, except against P. aeruginosa where there was only a 1.1-log reduction. After 33days, the release ratio of cationic biocide from silicone films containing 5% of DMIM-BF4 was found to be 5.6% in pure water and 1.9% in physiological saline solution, respectively. No leaching of PHMG-DBS polymeric biocide was detected under the same conditions. These results demonstrate unambiguously that silicones containing 2% DMIM-BF4 or 5% PHMG-DBS present high antimicrobial activity, as well as high leaching resistance and therefore may be good candidates for the development of safer medical devices.
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Affiliation(s)
- Sarah Ghamrawi
- Groupe d'Etude des Interactions Hôte-Pathogène, EA 3142, UNIV Angers, UNIV Brest, Université Bretagne - Loire, Angers, France
| | - Jean-Philippe Bouchara
- Groupe d'Etude des Interactions Hôte-Pathogène, EA 3142, UNIV Angers, UNIV Brest, Université Bretagne - Loire, Angers, France; Laboratoire de Parasitologie-Mycologie, Centre Hospitalier Universitaire, Angers, France
| | - Oksana Tarasyuk
- Institute of Bioorganic Chemistry and Petrochemistry, National Academy of Science of Ukraine, 50 Kharkivske Schose, Kyiv 02160, Ukraine
| | - Sergiy Rogalsky
- Institute of Bioorganic Chemistry and Petrochemistry, National Academy of Science of Ukraine, 50 Kharkivske Schose, Kyiv 02160, Ukraine
| | - Lyudmila Lyoshina
- Institute of Cell Biology and Genetic Engineering of National Academy of Science of Ukraine, 48 Academika Zabolotnoho Str., Kyiv 03143, Ukraine
| | - Olga Bulko
- Institute of Cell Biology and Genetic Engineering of National Academy of Science of Ukraine, 48 Academika Zabolotnoho Str., Kyiv 03143, Ukraine
| | - Jean-François Bardeau
- Institut des Molécules et Matériaux du Mans, UMR CNRS 6283, Université du Maine, Université Bretagne - Loire, Avenue Olivier Messiaen, 72085 Le Mans Cedex 9, France.
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Viola GM, Rosenblatt J, Raad II. Drug eluting antimicrobial vascular catheters: Progress and promise. Adv Drug Deliv Rev 2017; 112:35-47. [PMID: 27496702 DOI: 10.1016/j.addr.2016.07.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 06/14/2016] [Accepted: 07/26/2016] [Indexed: 12/13/2022]
Abstract
Vascular catheters are critical tools in modern healthcare yet present substantial risks of serious bloodstream infections that exact significant health and economic burdens. Drug-eluting antimicrobial vascular catheters have become important tools in preventing catheter-related bloodstream infections and their importance is expected to increase as significant initiatives are expanded to eliminate and make the occurrence of these infections unacceptable. Here we review clinically significant and emerging drug-eluting antimicrobial catheters within the categories of antibiotic, antiseptic, novel bioactive agents and energy-enhanced drug eluting antimicrobial catheters. Important representatives of each category are reviewed from the standpoints of mechanisms of action, physical-chemical properties, safety, in vitro and clinical effectiveness.
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Affiliation(s)
- George M Viola
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Joel Rosenblatt
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
| | - Issam I Raad
- Department of Infectious Diseases, Infection Control, and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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30
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Harron K, Mok Q, Dwan K, Ridyard CH, Moitt T, Millar M, Ramnarayan P, Tibby SM, Muller-Pebody B, Hughes DA, Gamble C, Gilbert RE. CATheter Infections in CHildren (CATCH): a randomised controlled trial and economic evaluation comparing impregnated and standard central venous catheters in children. Health Technol Assess 2016; 20:vii-xxviii, 1-219. [PMID: 26935961 DOI: 10.3310/hta20180] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Impregnated central venous catheters (CVCs) are recommended for adults to reduce bloodstream infection (BSI) but not for children. OBJECTIVE To determine the effectiveness of impregnated compared with standard CVCs for reducing BSI in children admitted for intensive care. DESIGN Multicentre randomised controlled trial, cost-effectiveness analysis from a NHS perspective and a generalisability analysis and cost impact analysis. SETTING 14 English paediatric intensive care units (PICUs) in England. PARTICIPANTS Children aged < 16 years admitted to a PICU and expected to require a CVC for ≥ 3 days. INTERVENTIONS Heparin-bonded, antibiotic-impregnated (rifampicin and minocycline) or standard polyurethane CVCs, allocated randomly (1 : 1 : 1). The intervention was blinded to all but inserting clinicians. MAIN OUTCOME MEASURE Time to first BSI sampled between 48 hours after randomisation and 48 hours after CVC removal. The following data were used in the trial: trial case report forms; hospital administrative data for 6 months pre and post randomisation; and national-linked PICU audit and laboratory data. RESULTS In total, 1859 children were randomised, of whom 501 were randomised prospectively and 1358 were randomised as an emergency; of these, 984 subsequently provided deferred consent for follow-up. Clinical effectiveness - BSIs occurred in 3.59% (18/502) of children randomised to standard CVCs, 1.44% (7/486) of children randomised to antibiotic CVCs and 3.42% (17/497) of children randomised to heparin CVCs. Primary analyses comparing impregnated (antibiotic and heparin CVCs) with standard CVCs showed no effect of impregnated CVCs [hazard ratio (HR) 0.71, 95% confidence interval (CI) 0.37 to 1.34]. Secondary analyses showed that antibiotic CVCs were superior to standard CVCs (HR 0.43, 95% CI 0.20 to 0.96) but heparin CVCs were not (HR 1.04, 95% CI 0.53 to 2.03). Time to thrombosis, mortality by 30 days and minocycline/rifampicin resistance did not differ by CVC. Cost-effectiveness - heparin CVCs were not clinically effective and therefore were not cost-effective. The incremental cost of antibiotic CVCs compared with standard CVCs over a 6-month time horizon was £1160 (95% CI -£4743 to £6962), with an incremental cost-effectiveness ratio of £54,057 per BSI avoided. There was considerable uncertainty in costs: antibiotic CVCs had a probability of 0.35 of being dominant. Based on index hospital stay costs only, antibiotic CVCs were associated with a saving of £97,543 per BSI averted. The estimated value of health-care resources associated with each BSI was £10,975 (95% CI -£2801 to £24,751). Generalisability and cost-impact - the baseline risk of BSI in 2012 for PICUs in England was 4.58 (95% CI 4.42 to 4.74) per 1000 bed-days. An estimated 232 BSIs could have been averted in 2012 using antibiotic CVCs. The additional cost of purchasing antibiotic CVCs for all children who require them (£36 per CVC) would be less than the value of resources associated with managing BSIs in PICUs with standard BSI rates of > 1.2 per 1000 CVC-days. CONCLUSIONS The primary outcome did not differ between impregnated and standard CVCs. However, antibiotic-impregnated CVCs significantly reduced the risk of BSI compared with standard and heparin CVCs. Adoption of antibiotic-impregnated CVCs could be beneficial even for PICUs with low BSI rates, although uncertainty remains whether or not they represent value for money to the NHS. Limitations - inserting clinicians were not blinded to allocation and a lower than expected event rate meant that there was limited power for head-to-head comparisons of each type of impregnation. Future work - adoption of impregnated CVCs in PICUs should be considered and could be monitored through linkage of electronic health-care data and clinical data on CVC use with laboratory surveillance data on BSI. TRIAL REGISTRATION ClinicalTrials.gov NCT01029717. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katie Harron
- Institute of Child Health, University College London, London, UK
| | - Quen Mok
- Great Ormond Street Hospital, London, UK
| | - Kerry Dwan
- Medicines for Children Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | - Colin H Ridyard
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Tracy Moitt
- Medicines for Children Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | | | | | | | - Berit Muller-Pebody
- Healthcare Associated Infection and Antimicrobial Resistance (HCAI & AMR) Department, National Infection Service, Public Health England, London, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Carrol Gamble
- Medicines for Children Clinical Trials Unit, University of Liverpool, Liverpool, UK
| | - Ruth E Gilbert
- Institute of Child Health, University College London, London, UK
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32
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Yousif A, Chaftari AM, Michael M, Jordan M, Al Hamal Z, Hussain A, Elizabeth N, Jiang Y, Hachem R, Raad I. The influence of using antibiotic-coated peripherally inserted central catheters on decreasing the risk of central line-associated bloodstream infections. Am J Infect Control 2016; 44:1037-40. [PMID: 26897695 DOI: 10.1016/j.ajic.2015.12.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 11/26/2022]
Abstract
The use of peripherally inserted central catheters (PICCs) has increased over the past few years due to their less serious insertion complications. The purpose of the present study was to determine whether patients receiving PICCs impregnated with minocycline and rifampin had a lower rate of CLABSI compared with a concurrent control group of patients receiving uncoated PICCs.
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33
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Kondo Y, Ueda M, Kobayashi Y, Schwab JO. New horizon for infection prevention technology and implantable device. J Arrhythm 2016; 32:297-302. [PMID: 27588153 PMCID: PMC4996843 DOI: 10.1016/j.joa.2016.02.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 12/25/2015] [Accepted: 02/12/2016] [Indexed: 01/30/2023] Open
Abstract
There has been a significant increase in the number of patients receiving cardiovascular implantable electronic devices (CIED) over the last two decades. CIED infection represents a serious complication after CIED implantation and is associated with significant morbidity and mortality. Recently, newly advanced technologies have offered attractive and suitable therapeutic alternatives. Notably, the leadless pacemaker and anti-bacterial envelope decrease the potential risk of CIED infection and the resulting mortality, when it does occur. A completely subcutaneous implantable cardioverter defibrillator is also an alternative to the transvenous implantable cardioverter defibrillator (ICD), as it does not require implantation of any transvenous or epicardial leads. Among the patients who require ICD removal and subsequent antibiotics secondary to infection, the wearable cardioverter defibrillator represents an alternative approach to inpatient monitoring for the prevention of sudden cardiac death. In this review paper, we aimed to introduce the advanced technologies and devices for prevention of CIED infection.
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Affiliation(s)
- Yusuke Kondo
- Department of Medicine-Cardiology, University of Bonn, Sigmund-Freud Str. 25, 53127 Bonn, Germany
- Department of Cardiology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Marehiko Ueda
- Department of Cardiology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Yoshio Kobayashi
- Department of Cardiology, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Joerg O. Schwab
- Department of Medicine-Cardiology, University of Bonn, Sigmund-Freud Str. 25, 53127 Bonn, Germany
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Reffuveille F, Nicol M, Dé E, Thébault P. Design of an anti-adhesive surface by a pilicide strategy. Colloids Surf B Biointerfaces 2016; 146:895-901. [PMID: 27469573 DOI: 10.1016/j.colsurfb.2016.07.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 07/01/2016] [Accepted: 07/19/2016] [Indexed: 01/08/2023]
Abstract
Biofilm formation on surfaces is one of major problems in medical, cosmetic and food industries. Nowadays any efficient treatment is known, as consequence, research of new strategies to inhibit biofilm formation is urgent. Recently, virstatin, which interferes with bacterial type IV pili formation, has demonstrated a capacity to inhibit biofilm formation developed by Acinetobacter baumannii after 24h. In this study, we aim to elaborate anti-adhesive surfaces preventing biofilm development by the covalent immobilization of virstatin on silicon surface. Surfaces were functionalized by self-assembled monolayers of two aminosilanes (11-aminoundecyltrimethoxysilane (AUTMS) and 3-aminopropyltrimethoxysilane (APTMS)). Then, virstatin (2mM) was immobilized on those modified surfaces. We observed an increase in surface hydrophobicity of AUTMS modified substratum leading to an increase of A. baumannii ATCC 17978 adhesion (after 4h). Immobilization of virstatin molecule on APTMS modified surface was efficient to decrease cell attachment by 32.1±5.7% compared to unmodified surface. As virstatin is known to inhibit type IV pili formation in solution, the observed decrease of bacterial adhesion might be due to this pilicide action. We also demonstrated that hydrophobicity of strains plays a role in adhesion according to surface properties. In conclusion, immobilized virstatin succeeded to inhibit bacterial attachment of various Acinetobacter baumannii strains comparing to APTMS modified support.
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Affiliation(s)
- Fany Reffuveille
- Normandie Univ, UNIROUEN, INSA Rouen, CNRS, PBS, 76000 Rouen, France
| | - Marion Nicol
- Normandie Univ, UNIROUEN, INSA Rouen, CNRS, PBS, 76000 Rouen, France
| | - Emmanuelle Dé
- Normandie Univ, UNIROUEN, INSA Rouen, CNRS, PBS, 76000 Rouen, France
| | - Pascal Thébault
- Normandie Univ, UNIROUEN, INSA Rouen, CNRS, PBS, 76000 Rouen, France.
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Majumder A, Scott JR, Novitsky YW. Evaluation of the Antimicrobial Efficacy of a Novel Rifampin/Minocycline-Coated, Noncrosslinked Porcine Acellular Dermal Matrix Compared With Uncoated Scaffolds for Soft Tissue Repair. Surg Innov 2016; 23:442-55. [PMID: 27354551 DOI: 10.1177/1553350616656280] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Despite meticulous aseptic technique and systemic antibiotics, bacterial colonization of mesh remains a critical issue in hernia repair. A novel minocycline/rifampin tyrosine-coated, noncrosslinked porcine acellular dermal matrix (XenMatrix AB) was developed to protect the device from microbial colonization for up to 7 days. The objective of this study was to evaluate the in vitro and in vivo antimicrobial efficacy of this device against clinically isolated methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli. Methods XenMatrix AB was compared with 5 existing uncoated soft tissue repair devices using in vitro methods of zone of inhibition (ZOI) and scanning electron microscopy (SEM) at 24 hours following inoculation with MRSA or E coli These devices were also evaluated at 7 days following dorsal implantation and inoculation with MRSA or E coli (60 male New Zealand white rabbits, n = 10 per group) for viable colony-forming units (CFU), abscess formation and histopathologic response, respectively. Results In vitro studies demonstrated a median ZOI of 36 mm for MRSA and 16 mm for E coli for XenMatrix AB, while all uncoated devices showed no inhibition of bacterial growth (0 mm). SEM also demonstrated no visual evidence of MRSA or E coli colonization on the surface of XenMatrix AB compared with colonization of all other uncoated devices. In vivo XenMatrix AB demonstrated complete inhibition of bacterial colonization, no abscess formation, and a reduced inflammatory response compared with uncoated devices. Conclusion We demonstrated that XenMatrix AB possesses potent in vitro and in vivo antimicrobial efficacy against clinically isolated MRSA and E coli compared with uncoated devices.
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Affiliation(s)
- Arnab Majumder
- University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Jeffrey R Scott
- Brown University, Providence, RI, USA C. R. Bard, Inc (Davol), Warwick, RI, USA
| | - Yuri W Novitsky
- University Hospitals Case Medical Center, Cleveland, OH, USA
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Successful Salvage of Central Venous Catheters in Patients with Catheter-Related or Central Line-Associated Bloodstream Infections by Using a Catheter Lock Solution Consisting of Minocycline, EDTA, and 25% Ethanol. Antimicrob Agents Chemother 2016; 60:3426-32. [PMID: 27001822 DOI: 10.1128/aac.02565-15] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 03/14/2016] [Indexed: 12/15/2022] Open
Abstract
In cancer patients with long-term central venous catheters (CVC), removal and reinsertion of a new CVC at a different site might be difficult because of the unavailability of accessible vascular sites. In vitro and animal studies showed that a minocycline-EDTA-ethanol (M-EDTA-EtOH) lock solution may eradicate microbial organisms in biofilms, hence enabling the treatment of central line-associated bloodstream infections (CLABSI) while retaining the catheter in situ Between April 2013 and July 2014, we enrolled 30 patients with CLABSI in a prospective study and compared them to a historical group of 60 patients with CLABSI who had their CVC removed and a new CVC inserted. Each catheter lumen was locked with an M-EDTA-EtOH solution for 2 h administered once daily, for a total of 7 doses. Patients who received locks had clinical characteristics that were comparable to those of the control group. The times to fever resolution and microbiological eradication were similar in the two groups. Patients with the lock intervention received a shorter duration of systemic antibiotic therapy than that of the control patients (median, 11 days versus 16 days, respectively; P < 0.0001), and they were able to retain their CVCs for a median of 74 days after the onset of bacteremia. The M-EDTA-EtOH lock was associated with a significantly decreased rate of mechanical and infectious complications compared to that of the CVC removal/reinsertion group, who received a longer duration of systemic antimicrobial therapy. (This study has been registered at ClinicalTrials.gov under registration no. NCT01539343.).
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Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. Infect Control Hosp Epidemiol 2016. [DOI: 10.1017/s0899823x00193870] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Lorente L. Antimicrobial-impregnated catheters for the prevention of catheter-related bloodstream infections. World J Crit Care Med 2016; 5:137-142. [PMID: 27152256 PMCID: PMC4848156 DOI: 10.5492/wjccm.v5.i2.137] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 12/21/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
Central venous catheters are commonly used in critically ill patients. Such catheterization may entail mechanical and infectious complications. The interest in catheter-related infection lies in the morbidity, mortality and costs that it involved. Numerous contributions have been made in the prevention of catheter-related infection and the current review focuses on the possible current role of antimicrobial impregnated catheters to reduce catheter-related bloodstream infections (CRBSI). There is evidence that the use of chlorhexidine-silver sulfadiazine (CHSS), rifampicin-minocycline, or rifampicin-miconazol impregnated catheters reduce the incidence of CRBSI and costs. In addition, there are some clinical circumstances associated with higher risk of CRBSI, such as the venous catheter access and the presence of tracheostomy. Current guidelines for the prevention of CRBSI recommended the use of a CHSS or rifampicin-minocycline impregnated catheter in patients whose catheter is expected to remain in place > 5 d and if the CRBSI rate has not decreased after implementation of a comprehensive strategy to reduce it.
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Lorente L. What is new for the prevention of catheter-related bloodstream infections? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:119. [PMID: 27127772 DOI: 10.21037/atm.2016.03.10] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
After the publication in 2011 of latest guidelines of the Centers for Disease Control and Prevention (CDC) for the prevention of catheter-related bloodstream infections (CRBSI) some interesting findings have been published in that field. There has been published that skin disinfection with chlorhexidine alcohol reduced the risk of CRBSI compared to skin disinfection with povidone iodine alcohol, that the implementation of quality improvement interventions reduced the incidence of CRBSI, that the use of chlorhexidine impregnated dressing compared to standard dressings reduced the risk of CRBSI and catheter related cost in an health economic model, and that the use of antimicrobial/antiseptic impregnated catheters reduced the incidence of CRBSI and catheter related cost in clinical studies.
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Affiliation(s)
- Leonardo Lorente
- Department of Critical Care, Hospital Universitario de Canarias, Ofra s/n, La Laguna 38320, Santa Cruz de Tenerife, Spain
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Lai NM, Chaiyakunapruk N, Lai NA, O'Riordan E, Pau WSC, Saint S. Catheter impregnation, coating or bonding for reducing central venous catheter-related infections in adults. Cochrane Database Syst Rev 2016; 3:CD007878. [PMID: 26982376 PMCID: PMC6517176 DOI: 10.1002/14651858.cd007878.pub3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The central venous catheter (CVC) is essential in managing acutely ill patients in hospitals. Bloodstream infection is a major complication in patients with a CVC. Several infection control measures have been developed to reduce bloodstream infections, one of which is impregnation of CVCs with various forms of antimicrobials (either with an antiseptic or with antibiotics). This review was originally published in June 2013 and updated in 2016. OBJECTIVES Our main objective was to assess the effectiveness of antimicrobial impregnation, coating or bonding on CVCs in reducing clinically-diagnosed sepsis, catheter-related blood stream infection (CRBSI), all-cause mortality, catheter colonization and other catheter-related infections in adult participants who required central venous catheterization, along with their safety and cost effectiveness where data were available. We undertook the following comparisons: 1) catheters with antimicrobial modifications in the form of antimicrobial impregnation, coating or bonding, against catheters without antimicrobial modifications and 2) catheters with one type of antimicrobial impregnation against catheters with another type of antimicrobial impregnation. We planned to analyse the comparison of catheters with any type of antimicrobial impregnation against catheters with other antimicrobial modifications, e.g. antiseptic dressings, hubs, tunnelling, needleless connectors or antiseptic lock solutions, but did not find any relevant studies. Additionally, we planned to conduct subgroup analyses based on the length of catheter use, settings or levels of care (e.g. intensive care unit, standard ward and oncology unit), baseline risks, definition of sepsis, presence or absence of co-interventions and cost-effectiveness in different currencies. SEARCH METHODS We used the standard search strategy of the Cochrane Anaesthesia, Critical and Emergency Care Review Group (ACE). In the updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), MEDLINE (OVID SP; 1950 to March 2015), EMBASE (1980 to March 2015), CINAHL (1982 to March 2015), and other Internet resources using a combination of keywords and MeSH headings. The original search was run in March 2012. SELECTION CRITERIA We included randomized controlled trials (RCTs) that assessed any type of impregnated catheter against either non-impregnated catheters or catheters with another type of impregnation in adult patients cared for in the hospital setting who required CVCs. We planned to include quasi-RCT and cluster-RCTs, but we identified none. We excluded cross-over studies. DATA COLLECTION AND ANALYSIS We extracted data using the standard methodological procedures expected by Cochrane. Two authors independently assessed the relevance and risk of bias of the retrieved records. We expressed our results using risk ratio (RR), absolute risk reduction (ARR) and number need to treat to benefit (NNTB) for categorical data and mean difference (MD) for continuous data, where appropriate, with their 95% confidence intervals (CIs). MAIN RESULTS We included one new study (338 participants/catheters) in this update, which brought the total included to 57 studies with 16,784 catheters and 11 types of impregnations. The total number of participants enrolled was unclear, as some studies did not provide this information. Most studies enrolled participants from the age of 18, including patients in intensive care units (ICU), oncology units and patients receiving long-term total parenteral nutrition. There were low or unclear risks of bias in the included studies, except for blinding, which was impossible in most studies due to the catheters that were being assessed having different appearances. Overall, catheter impregnation significantly reduced catheter-related blood stream infection (CRBSI), with an ARR of 2% (95% CI 3% to 1%), RR of 0.62 (95% CI 0.52 to 0.74) and NNTB of 50 (high-quality evidence). Catheter impregnation also reduced catheter colonization, with an ARR of 9% (95% CI 12% to 7%), RR of 0.67 (95% CI 0.59 to 0.76) and NNTB of 11 (moderate-quality evidence, downgraded due to substantial heterogeneity). However, catheter impregnation made no significant difference to the rates of clinically diagnosed sepsis (RR 1.0, 95% CI 0.88 to 1.13; moderate-quality evidence, downgraded due to a suspicion of publication bias), all-cause mortality (RR 0.92, 95% CI 0.80 to 1.07; high-quality evidence) and catheter-related local infections (RR 0.84, 95% CI 0.66 to 1.07; 2688 catheters, moderate quality evidence, downgraded due to wide 95% CI).In our subgroup analyses, we found that the magnitudes of benefits for impregnated CVCs varied between studies that enrolled different types of participants. For the outcome of catheter colonization, catheter impregnation conferred significant benefit in studies conducted in ICUs (RR 0.70;95% CI 0.61 to 0.80) but not in studies conducted in haematological and oncological units (RR 0.75; 95% CI 0.51 to 1.11) or studies that assessed predominantly patients who required CVCs for long-term total parenteral nutrition (RR 0.99; 95% CI 0.74 to 1.34). However, there was no such variation for the outcome of CRBSI. The magnitude of the effects was also not affected by the participants' baseline risks.There were no significant differences between the impregnated and non-impregnated groups in the rates of adverse effects, including thrombosis/thrombophlebitis, bleeding, erythema and/or tenderness at the insertion site. AUTHORS' CONCLUSIONS This review confirms the effectiveness of antimicrobial CVCs in reducing rates of CRBSI and catheter colonization. However, the magnitude of benefits regarding catheter colonization varied according to setting, with significant benefits only in studies conducted in ICUs. A comparatively smaller body of evidence suggests that antimicrobial CVCs do not appear to reduce clinically diagnosed sepsis or mortality significantly. Our findings call for caution in routinely recommending the use of antimicrobial-impregnated CVCs across all settings. Further randomized controlled trials assessing antimicrobial CVCs should include important clinical outcomes like the overall rates of sepsis and mortality.
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Affiliation(s)
- Nai Ming Lai
- Taylor's UniversitySchool of MedicineSubang JayaMalaysia
| | - Nathorn Chaiyakunapruk
- Faculty of Pharmaceutical SciencesCenter of Pharmaceutical Outcomes Research, Department of Pharmacy PracticeNaresuan UniversityPhitsanulokThailand65000
- Monash University MalaysiaSchool of PharmacySelangorSelangorMalaysia47500
| | - Nai An Lai
- Queen Elizabeth II Jubilee HospitalIntensive Care UnitCnr Troughton and Kessels RoadsCoopers PlainsQueenslandAustralia4108
| | - Elizabeth O'Riordan
- The University of Sydney and The Children's Hospital at WestmeadFaculty of Nursing and MidwiferySydneyNew South WalesAustralia2006
| | - Wilson Shu Cheng Pau
- Hospital Tuanku JaafarDepartment of PaediatricsJalan RasahSerembanNegeri Sembilan Darul KhususMalaysia70300
| | - Sanjay Saint
- Ann Arbor VA Medical Center and the University of Michigan Health SystemDepartment of Internal MedicineAnn ArborMichiganUSA
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Hambsch ZJ, Kerfeld MJ, Kirkpatrick DR, McEntire DM, Reisbig MD, Youngblood CF, Agrawal DK. Arterial Catheterization and Infection: Toll-like Receptors in Defense against Microorganisms and Therapeutic Implications. Clin Transl Sci 2015; 8:857-70. [PMID: 26271949 PMCID: PMC4703511 DOI: 10.1111/cts.12320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Radial artery catheterization has become a preferred route over femoral artery catheterization, in order to monitor the blood pressure of hemodynamically unstable patients or for repeated sampling of arterial blood gases. While the incidence of catheter-related infection is lower in the radial artery than the femoral artery, infection remains a major issue that requires attention. In this review of the literature, we discuss infectious complications of radial artery catheterization, with a focus on various risk factors and establishing the most common causative agents. We also critically review the role of the innate immune system involving Toll-like receptors (TLRs) in host-defense, with the goal of establishing a common pathway used by the innate immune system via TLRs to combat the pathogens that most commonly cause infection in radial artery catheterization. If this pathway can be therapeutically manipulated to preemptively attack pathogenic agents, immunomodulation may be an option in reducing the incidence of infection in this procedure.
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Affiliation(s)
- Zakary J. Hambsch
- Center for Clinical & Translational Science and Department of AnesthesiologyCreighton University School of MedicineOmahaNebraskaUSA
| | - Mitchell J. Kerfeld
- Center for Clinical & Translational Science and Department of AnesthesiologyCreighton University School of MedicineOmahaNebraskaUSA
| | - Daniel R. Kirkpatrick
- Center for Clinical & Translational Science and Department of AnesthesiologyCreighton University School of MedicineOmahaNebraskaUSA
| | - Dan M. McEntire
- Center for Clinical & Translational Science and Department of AnesthesiologyCreighton University School of MedicineOmahaNebraskaUSA
| | - Mark D. Reisbig
- Center for Clinical & Translational Science and Department of AnesthesiologyCreighton University School of MedicineOmahaNebraskaUSA
| | - Charles F. Youngblood
- Center for Clinical & Translational Science and Department of AnesthesiologyCreighton University School of MedicineOmahaNebraskaUSA
| | - Devendra K. Agrawal
- Center for Clinical & Translational Science and Department of AnesthesiologyCreighton University School of MedicineOmahaNebraskaUSA
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Lefebvre L, Noyon E, Georgescu D, Proust V, Alexandru C, Leheurteur M, Thery JC, Savary L, Rigal O, Di Fiore F, Veyret C, Clatot F. Port catheter versus peripherally inserted central catheter for postoperative chemotherapy in early breast cancer: a retrospective analysis of 448 patients. Support Care Cancer 2015; 24:1397-403. [PMID: 26342484 DOI: 10.1007/s00520-015-2901-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/09/2015] [Indexed: 10/23/2022]
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New Technology: Heparin and Antimicrobial-Coated Catheters. J Vasc Access 2015; 16 Suppl 9:S48-53. [DOI: 10.5301/jva.5000376] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2015] [Indexed: 11/20/2022] Open
Abstract
Although tunneled hemodialysis catheter must be considered the last option for vascular access, it is necessary in some circumstances in the dialysis patient. Thrombosis and infections are the main causes of catheter-related comorbidity. Fibrin sheath, intimately related with the biofilm, is the precipitating factor of this environment, determining catheter patency and patient morbidity. Its association with bacterial overgrowth and thrombosis has led to the search of multiple preventive measures. Among them is the development of catheter coatings to prevent thrombosis and infections. There are two kinds of treatments to cover the catheter surface: antithrombotic and antimicrobial coatings. In nondialysis-related settings, mainly in intensive care units, both have been shown to be efficient in the prevention of catheter-related infection. This includes heparin, silver, chlorhexidine, rifampicine and minocycline. In hemodialysis population, however, few studies on surface-treated catheters have been made and they do not provide evidence that shows complication reduction. The higher effectiveness of coatings in nontunneled catheters may depend on the short average life of these devices. Hemodialysis catheters need to be used over long periods of time and require clinical trials to show effectiveness of coatings over long periods. This also means greater knowledge of biofilm etiopathogeny and fibrin sheath development.
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Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals: 2014 Update. ACTA ACUST UNITED AC 2015. [DOI: 10.1017/s0195941700095412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their central line-associated bloodstream infection (CLABSI) prevention efforts. This document updates “Strategies to Prevent Central Line-Associated Bloodstream Infections in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.
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Marschall J, Mermel LA, Fakih M, Hadaway L, Kallen A, O'Grady NP, Pettis AM, Rupp ME, Sandora T, Maragakis LL, Yokoe DS. Strategies to prevent central line-associated bloodstream infections in acute care hospitals: 2014 update. Infect Control Hosp Epidemiol 2015; 35:753-71. [PMID: 25376071 DOI: 10.1086/676533] [Citation(s) in RCA: 305] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Rosenblatt J, Viola GM, Reitzel RA, Jamal MA, Crosby MA, Raad I. Novel in situ liquefying antimicrobial wrap for preventing tissue expander infections following breast reconstructive surgeries. J Biomed Mater Res B Appl Biomater 2015; 104:369-74. [PMID: 25809618 DOI: 10.1002/jbm.b.33399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 01/23/2015] [Accepted: 02/08/2015] [Indexed: 01/18/2023]
Abstract
Breast reconstruction surgeries using tissue expanders (TEs) have highly reported infection rates. To decrease this, we developed a method for disinfecting TEs and surgical pockets, where an antimicrobial solution was applied as a solid film at implantation that subsequently liquefied in situ to provide extended prophylaxis. Silicone discs cut from TEs were covered with gelatin-based films containing minocycline (M) and rifampin (R). Discs and films soaked in saline were subsequently challenged with pathogen at days 1, 3, 7, and 10 and quantified for potential biofilm formation. Discs that were not harvested at each specific time points were refreshed with sterile saline. The discs were challenged with clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA), methicillin-resistant Staphylococcus epidermidis (MRSE), and multidrug-resistant Pseudomonas aeruginosa (MDR-PA). Recoveries of adherent organisms from uncovered silicone discs and gelatin-wrapped discs without added antimicrobial agents were >5 × 10(4) CFU/disc for each organism at each time point. Experimental 0.1%M/0.05%R gelatin films completely inhibited all challenge organisms from attaching to the silicone (p < 0.05) at each time point through day 10. Cytotoxicity was assessed by incubating films with HEK-293T human fibroblasts. There were no significant differences in HEK-293T cell survival between controls and any of the antimicrobial films. The in situ liquefying, bioabsorable, antimicrobial wrap prevented biofilm formation by microorganisms on silicone surfaces in vitro with minimal cytotoxicity.
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Affiliation(s)
- Joel Rosenblatt
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, 77030
| | - George M Viola
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, 77030
| | - Ruth A Reitzel
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, 77030
| | - Mohamed A Jamal
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, 77030
| | - Melissa A Crosby
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, 77030
| | - Issam Raad
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, 77030
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Raad II. Zero Tolerance for Catheter-Related Bloodstream Infections: The Unnegotiable Objective. Infect Control Hosp Epidemiol 2015; 29:951-3. [DOI: 10.1086/591939] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Baskin KM, Hunnicutt C, Beck ME, Cohen ED, Crowley JJ, Fitz CR. Long-term central venous access in pediatric patients at high risk: conventional versus antibiotic-impregnated catheters. J Vasc Interv Radiol 2014; 25:411-8. [PMID: 24581464 DOI: 10.1016/j.jvir.2013.11.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/19/2013] [Accepted: 11/20/2013] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To study selective use of antibiotic-impregnated catheters in children at increased risk of venous catheter-related infections (CRIs). MATERIALS AND METHODS From December 2008 to June 2009, 428 peripherally inserted central catheters (PICCs) were placed by the interventional radiology service of a large metropolitan children's hospital. This retrospective study analyzed demographic and outcome data for the 125 patients in this group at high risk for venous CRI. Patients at high risk were those with active systemic infection, previous complicated central venous access, intensive care unit (ICU) admission, intestinal failure, transplantation, complex congenital heart disease, or renal failure. Patients (age, 7.6 y ± 7.0; 73 male and 52 female) received a conventional or antibiotic-impregnated PICC, with 17 receiving more than one catheter. RESULTS Of the 146 of 428 qualifying patient encounters (34%), 53 patients received an antibiotic-impregnated PICC and 93 received a conventional PICC, representing 5,080 total catheter-days (CDs). The rates of CRIs per 1,000 CDs, including catheter exit site infections and catheter-related bloodstream infections, were 0.86 for antibiotic-impregnated PICCs and 5.5 for conventional PICCs (P = .036). A propensity-based model predicts 15-fold greater infection-free survival over the lifetime of the catheter in patients who receive an antibiotic-impregnated PICC (P < .001). Antibiotic-impregnated PICC recipients with active infection or ICU admission at the time of insertion had no catheter-associated infections, compared with 3.42 and 9.46 infections per 1,000 CDs, respectively, for patients who received conventional PICCs. Patients with intestinal failure had 1.49 and 10 infections per 1,000 CDs with antibiotic-impregnated versus conventional PICCs, respectively. CONCLUSIONS Antibiotic-impregnated long-term PICCs significantly improve infection-free catheter survival in pediatric patients at high risk.
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Affiliation(s)
- Kevin M Baskin
- Advanced Interventional Institute, Cranberry Township, Pittsburgh, Pennsylvania.
| | | | - Megan E Beck
- Medical College of Wisconsin, Madison, Wisconsin
| | - Elan D Cohen
- Center for Research on Healthcare, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John J Crowley
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Charles R Fitz
- Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Chauhan A, Bernardin A, Mussard W, Kriegel I, Estève M, Ghigo JM, Beloin C, Semetey V. Preventing Biofilm Formation and Associated Occlusion by Biomimetic Glycocalyxlike Polymer in Central Venous Catheters. J Infect Dis 2014; 210:1347-56. [DOI: 10.1093/infdis/jiu249] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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Lebeaux D, Fernández-Hidalgo N, Chauhan A, Lee S, Ghigo JM, Almirante B, Beloin C. Management of infections related to totally implantable venous-access ports: challenges and perspectives. THE LANCET. INFECTIOUS DISEASES 2014; 14:146-59. [DOI: 10.1016/s1473-3099(13)70266-4] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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