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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 8  |  Issue : 2  |  Page : 49-53

Central line-associated bloodstream infection in pediatric oncology patients in Qatar: A prospective study


1 Pediatric Hematology and Oncology Department, Hamad Medical Corporation, Doha, Qatar
2 Pharmacy Department, Hamad Medical Corporation, Doha, Qatar
3 Medical Research Center, Hamad Medical Corporation, Doha, Qatar
4 Pediatric Infectious Disease Department, Hamad Medical Corporation, Doha, Qatar
5 Nursing Department, Hamad Medical Corporation, Doha, Qatar
6 Pediatric Hematology and Oncology Department; Medical Research Center, Hamad Medical Corporation, Doha, Qatar

Date of Web Publication17-Jul-2017

Correspondence Address:
Tayseer Alsaad
Pediatric Hematology and Oncology Department, Hamad Medical Corporation, P.O. Box 3050, Doha
Qatar
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/joah.joah_13_17

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  Abstract 


Objective: To assess the central line-associated bloodstream infection (CLABSI) rate and risk factors in hospitalized pediatric oncology patients in Qatar.
Materials and Methods: A prospective, observational study was conducted in pediatric oncology department at Hamad Medical Corporation, Qatar between January 1, 2013 and December 31, 2014. All children <14 years of age with malignancy who required a central line catheter were included.
Results: Thirty-seven subcutaneous tunneled catheters were inserted. Majority of the patients were younger than 10 years of age (88%), and the male-to-female ratio was 1.3:1. Leukemia was the most frequently encountered diagnosis. The overall mean central venous catheter (CVC) infection rate was 4.12 CLABSI per 1000 CVC days (95% confidence interval 2.41, 7.05). Thirteen catheters were infected (35.1%), of which 11 catheters were Porta-a-Cath, and two catheters were Hickman double lumen line. Gram-negative bacteria were found in 69.2% of the CLABSI cases, and no fungal infection was detected. Gender, age, type of disease, and type of catheter were not associated with increased risk for CLABSI (P > 0.05). The mean number of days with neutropenia was more in the patients who had CLABSI 73.5 ± 44.5 compared to the patients who did not have CLABSI 48.9 ± 52.1, but the difference did not reach statistical significance (P = 0.140).
Conclusion: The incidence rate of CLABSI continues to be a concern in hospitalized pediatric oncology patients in Qatar. This study showed that mean CVC infection rate was 4.12 CLABSI per 1000 CVC days. Gram-negative bacteria CLABSI were the dominant organism in this group of patients and catheters.

Keywords: Bloodstream infection, central catheter, CLABSI, pediatric oncology


How to cite this article:
Alsaad T, Qaisuddin M, AlSaad D, Chandra P, AlAbd O, Nasser AA, Janahi M, Pilari A, Morsi H. Central line-associated bloodstream infection in pediatric oncology patients in Qatar: A prospective study. J Appl Hematol 2017;8:49-53

How to cite this URL:
Alsaad T, Qaisuddin M, AlSaad D, Chandra P, AlAbd O, Nasser AA, Janahi M, Pilari A, Morsi H. Central line-associated bloodstream infection in pediatric oncology patients in Qatar: A prospective study. J Appl Hematol [serial online] 2017 [cited 2017 Aug 19];8:49-53. Available from: http://www.jahjournal.org/text.asp?2017/8/2/49/210826




  Introduction Top


Central venous catheters (CVCs) are frequently used in patients with cancer, because they provide long-term venous access for blood testing, drug administration including chemotherapy, and occasionally total or partial parenteral nutrition.[1],[2],[3]

The types of CVCs devices used in oncology patients have been greatly increased, and the frequently used long-term devices include surgically implanted cuffed tunneled CVCs, peripherally inserted CVCs, subcutaneous implanted ports, and percutaneous noncuffed or tunneled catheters.[2] The use of CVCs was estimated to be 3 million per year in the United States and one quarter million in the United Kingdom.[4],[5]

The use of CVC can lead to central line-associated bloodstream infection (CLABSI). Among hospitalized pediatric hematology/oncology patients, the pooled mean CLABSI rates per 1000 catheter-days was 2.3 for permanent CVCs and 4.6 for temporary CVCs.[6] CLABSI is associated with serious morbidity and mortality. The catheter-related bloodstream infection attributable mortality varies between 0 and 35%. Furthermore, CLABSI increases the length of stay and health care costs, especially in children with cancer in which signs and symptoms may be altered due to neutropenia and/or steroid administration.[4],[7],[8],[9] CLABSI can cost an average of 45,000$ per infection.[10]

The center for disease prevention and control (CDC) provides detailed definitions and diagnosis criteria for CLABSI. Briefly, CLABSI is a primary bloodstream infection that develops in a patient with a central line in place after a period of 48 hours from insertion before the onset of bloodstream infections that is not related to infection at other sites. The culturing of catheter tips or peripheral blood is not a criterion for CLABSI. CLABSI requires confirmed bloodstream infections of either a recognized pathogen in ≥1 blood culture unrelated to an infection on another site, or in the case of common skin contaminant, signs of systemic infections such as fever, hypotension, or chills with no apparent alternative infections focus and ≥2 positive blood culture drawn on separate occasions.[11]

Data about the rates of CLABSI in hospitalized pediatric oncology patients are limited. Identifying risk factors for CLABSI is an essential part of prevention and management of infection. To our knowledge, no published data are available about CLABSI in hospitalized pediatric oncology patients in Qatar. Our Pediatric Oncology Unit represents all Qatar children population below 14 years of age, because it is the only center for treatment for children with cancer. The aim of the current study is to assess the incidence rate of CLABSI and its risk factors in hospitalized pediatric oncology patients in Qatar.


  Material and Methods Top


Study design

This is a prospective, observational study that was conducted over 2 years between January 1, 2013 and December 31, 2014 in Pediatric Oncology Unit, Pediatric Department, Hamad General Hospital, Hamad Medical Corporation, Qatar.

Participants

The study included all hospitalized children <14 years of age with confirmed cancer and had central line catheter inserted. The patients who were equal to or more than 14 years of age, and the patients who did not complete chemotherapy course due to different causes were excluded.

Type of catheters

Two types of subcutaneous catheters were used. Porta-a-Cath was implanted with reservoir under the skin and the tip in the vena-cava or right atrium of the heart. The other type is the subcutaneous tunneled double lumen Hickman catheter, which was inserted under the skin with textured cuff, and this was used for the patients who were expected to need bone marrow transplant as part of their future treatment plan. Catheter insertion was performed by pediatric surgeon under general anesthesia in the theater.

Data collection

Data collected included the patients’ age, gender, type of disease, dates of catheter insertion, daily catheter situation, cultures, and sensitivities. In addition, information about absolute neutrophil counts (ANC) and length of periods of neutropenia that the patients experienced was collected.

Diagnosis of central line-associated bloodstream infection

The diagnosis of CLABSI was performed following the recommendations of CDC 2011 as mentioned earlier.[11]

Ethical considerations

The study was conducted following the good clinical practice guidelines. Waiver of informed consent and ethical approval were obtained from the Institutional Review Board, Hamad Medical Corporation (approval number 13010/13).

Statistical analysis

A well-structured data capture form was designed and created to collect all required data. The quality of data (review of completeness, data verification, validation and accuracy, security, and confidentiality of data) was performed and maintained by lead research investigators. Categorical and continuous values were expressed as frequency (percentage) and mean ± standard deviation (SD) or median and interquartile range as appropriate. Descriptive statistics were used to summarize all demographic, clinical, laboratory, and other characteristics of the patients. The Kolmogorov–Smirnov test or Q-Q plot as appropriate was used to test the normality of the data. Associations between two or more qualitative variables were assessed using chi-square (χ2) test, Fisher’s exact test, or Yates corrected chi-square as appropriate. Quantitative variable means between the two independent groups were analyzed using unpaired "t" and Mann–Whitney U tests. Kaplan–Meier curve measuring time to CLABSI was generated to describe time to CLABSI over the time after CVL insertion for the entire sample. The Kaplan–Meier survival curve was used to calculate how long a CVC (PORT and Hick) stayed in place without infection at 6 months, 1 year, and 2 years. Pictorial presentations of the key results were made using appropriate statistical graphs. All P values presented were two-tailed, and P values <0.05 were considered as statistically significant. All statistical analyses were performed using the IBM SPSS Statistics, Statistical Package for the Social Sciences version 22.0 software (IBM Corporation, New York, United States).


  Results Top


Over 2 years, there were 37 subcutaneous tunneled catheters inserted in 33 patients. Demographic, laboratory, and other clinical characteristics are shown in [Table 1]. The mean age was 5.5 ± 3.8 years, and the male-to-female ratio was 1.3:1. Leukemia was the most frequently encountered diagnosis (60.6%). The number of Porta-a-Cath CVC was 31 (84%), and Hickman CVC was 6 (16%).
Table 1: Demographic, clinical, laboratory, and other related characteristics

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As shown in [Table 2] and [Table 3], the overall mean CVC infection incidence rate was 4.12 CLABSI per 1000 CVC days (95% confidence interval 2.41, 7.050). Thirteen catheters were infected (35.1%). Eleven of the Prota-a-Cath CVC were infected (36%) compared to two of the Hickman double lumen line (33%).
Table 2: Association of demographic, clinical, laboratory, and other parameters with CLABSI

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Table 3: Incidence of CLABSI cases per 1000 line days according to demographic, laboratory, and other clinical characteristics

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Nine infections were caused by gram-negative bacteria (69%), four were caused by gram-positive bacteria (31%), and none with fungal infections. The mean duration of infection was 3.1 ± 2.7 days, ANC at the time of infection was 0 in seven patients (53%) and from 1 to 1500 cell/μL in four patients (30%). CVC infections happened in the groups with leukemia and lymphoma and none happened in the solid tumor including brain tumors, and with time, less infection happened with CVC as shown in [Figure 1].
Figure 1: Kaplan–Meier survival curve analysis showed proportion without central line-associated bloodstream infection (CLABSI) in pediatric oncology patients

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As presented in [Table 2], baseline characteristics including gender, age, type of disease, and type of catheter were not associated with increased risk for CLABSI (P > 0.05). The mean number of days with neutropenia was more in the patients who had CLABSI 73.5 ± 44.5 compared to the patients who did not have CLABSI 48.9 ± 52.1, despite that the difference was not statistically significant (P = 0.14).





CLABSI presents a huge threat to the pediatric oncology patients. Studies reporting the rates of CLABSI and its risk factors are limited in this critical population. This study assessed the incidence and risk factors for CLABSI over a 2-year period in the hospitalized pediatric oncology patients in Qatar.

Our study found that the overall mean CVC infection incidence rate was 4.12 CLABSI per 1000 CVC days. CLABSI incidence rate varies widely between studies.[3],[12],[13] In the most recent report from the National Healthcare Safety Network, the pooled mean CLABSI rates per 1000 catheter-days in pediatric general hematology/oncology ward were 2.1 for both permanent and temporary CVCs, whereas in the solid tumor ward, they were 0.4 and 0.7 for permanent and temporary CVCs, respectively.[14] Comparing the incidence rate of CLABSI between studies is challenging because of variations in study populations and setting, type of catheter, insertion technique and maintenance bundles, and prophylactic use of antibiotics. In addition, the case definition of CLABSI differs between studies, which might lead to variations in the incidence rate of CLABSI.[3]

In our study, 53.8% of the patients had zero ANC at the time of infection, and 85% of the patients had ANC ≤1500/μL including zero neutrophils. The mean number of days with neutropenia was more in the patients who had CLABSI 73.5 ± 44.5 days compared to the patients who did not have CLABSI 48.9 ± 52.1 days; however, the difference was not statistically significant (P = 0.14). These results are consistent with previously reported studies, where neutropenia was not consistently associated with increased risk for CLABSI in the pediatric oncology patients.[15],[16] On the other hand, other studies found that neutropenia can be a risk factor for CLABSI.[17],[18]The tunneled CVC such as Broviac or Hickman was found to be associated with a higher risk for CLABSI than totally implanted device such as Porta-a-Cath.[3] In our study, CVCs infection rate was very similar between Porta-a-Cath (36%) and Hickman (33%).

It has been reported that the most commonly involved microorganisms in CLABSI and CVC are gram-positive bacteria,[3],[6] and this occurs by extraluminal and intraluminal routes. In our study, only 30.8% of the patients were infected with gram-positive bacteria, whereas 69.2% were infected with gram-negative bacteria. This may be due to that most of our patient with Porta-a-Cath under the skin which may eliminate the external extraluminal route with good aseptic techniques.

In our study, long-term catheters carried a comparatively low risk for CLABSI in a decreasing manner with time for CLABSI per 1000 days as demonstrated in [Figure 1].

The study has some limitations. The total number of patients on Hickman catheters was small; therefore, the results are difficult to be generalized at this point. Another limitation is that the study included only the hospitalized pediatric oncology patients with CVC, and does not present data of ambulatory patients.

Further reduction in the observed rates of CLABSI in our pediatric oncology patients can be achieved through continuous education and training of the staff on the insertion and maintenance care bundles, accompanied by direct visual monitoring or through assessment of the knowledge of the staff.

In conclusion, the incidence rate of CLABSI continues to be of concern in the pediatric oncology patients. The role of neutropenia and type of catheter in increasing risk for CLABSI needs to be further investigated. Although the study had a limited number of patients, it adds that gram-negative bacteria CLABSI may be the dominant organism in this group of patients and catheters.

Acknowledgements

This work received a grant from Hamad Medical Research Center, Hamad Medical Corporation, Qatar (reference number 13010/13). We would like to thank the staff and medical team working in Pediatric Oncology Unit in Hamad Medical Corporation for their support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tomlinson D, Mermel LA, Ethier MC, Matlow A, Gillmeister B, Sung L. Defining bloodstream infections related to central venous catheters in patients with cancer: A systematic review. Clin Infect Dis 2011;53:697-710.  Back to cited text no. 1
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Schiffer CA, Mangu PB, Wade JC, Camp-Sorrell D, Cope DG, El-Rayes BF et al. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2013;31:1357-70.  Back to cited text no. 2
    
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Wagner M, Bonhoeffer J, Erb TO, Glanzmann R, Häcker FM, Paulussen M et al. Prospective study on central venous line associated bloodstream infections. Arch Dis Child 2011;96:827-31.  Back to cited text no. 3
    
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Edgeworth J. Intravascular catheter infections. J Hosp Infect 2009;73:323-30.  Back to cited text no. 4
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The Joint Commission. Preventing Central Line-Associated Bloodstream Infections: A Global Challenge, A Global Perspective. Oak Brook, IL: Joint Commission Resources; 2012 May. Available from: http://www.PreventingCLABSIs.pdf. [Last accessed on 2017 May 11].  Back to cited text no. 5
    
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Kelly M, Conway M, Wirth K, Potter-Bynoe G, Billett AL, Sandora TJ. Moving CLABSI prevention beyond the ICU: Risk factors in pediatric oncology patients. Infect Control Hosp Epidemiol 2011;32:1079-85.  Back to cited text no. 6
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Wilson MZ, Rafferty C, Deeter D, Comito MA, Hollenbeak CS. Attributable costs of central line-associated bloodstream infections in a pediatric hematology/oncology population. Am J Infect Control 2014;42:1157-60.  Back to cited text no. 7
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Goudie A, Dynan L, Brady PW, Rettiganti M. Attributable cost and length of stay for central line-associated bloodstream infections. Pediatrics 2014;133:e1525-32.  Back to cited text no. 8
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Tsai HC, Huang LM, Chang LY, Lee PI, Chen JM, Shao PL et al. Central venous catheter-associated bloodstream infections in pediatric hematology-oncology patients and effectiveness of antimicrobial lock therapy. J Microbiol Immunol Infect 2015;48:639-46.  Back to cited text no. 9
    
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Rinke ML, Chen AR, Bundy DG, Colantuoni E, Fratino L, Drucis KM et al. Implementation of a central line maintenance care bundle in hospitalized pediatric oncology patients. Pediatrics 2012;130:e996-1004.  Back to cited text no. 10
    
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O’Grady N, Alexander M, Burns L, Dellinger P, Garland J, Heard S et al. Guidelines for the Prevention of Intravascular Catheter-Related Infections. Center of Disease Prevention and Control (CDC); 2011. Available from: http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf. [Last accessed on 2017 May 11].  Back to cited text no. 11
    
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Rinke ML, Milstone AM, Chen AR, Mirski K, Bundy DG, Colantuoni E et al. Ambulatory pediatric oncology CLABSIs: Epidemiology and risk factors. Pediatr Blood Cancer 2013;60:1882-9.  Back to cited text no. 12
    
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Advani S, Reich NG, Sengupta A, Gosey L, Milstone AM. Central line-associated bloodstream infection in hospitalized children with peripherally inserted central venous catheters: Extending risk analyses outside the intensive care unit. Clin Infect Dis 2011;52:1108-15.  Back to cited text no. 13
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Margaret A, Edwards JR, Allen-Bridson K, Gross C, Malpiedi PJ, Peterson KD et al. National Healthcare Safety Network (NHSN) report, data summary for 2013, device-associated module. Am J Infect Control 2015;43:206-21.  Back to cited text no. 14
    
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Simon A, Ammann RA, Bode U, Fleischhack G, Wenchel HM, Schwamborn D et al. Healthcare-associated infections in pediatric cancer patients: Results of a prospective surveillance study from university hospitals in Germany and Switzerland. BMC Infect Dis 2008;8:70.  Back to cited text no. 15
    
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Viscoli C, Castagnola E, Giacchino M, Cesaro S, Properzi E, Tucci F et al. Bloodstream infections in children with cancer: A multicentre surveillance study of the Italian Association of Paediatric Haematology and Oncology. Eur J Cancer 1999;35:770-4.  Back to cited text no. 16
    
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Kelly MS, Conway M, Wirth KE, Potter-Bynoe G, Billett AL, Sandora TJ. Microbiology and risk factors for central line-associated bloodstream infections among pediatric oncology outpatients: A single institution experience of 41 cases. J Pediatr Hematol Oncol 2013;35:e71-6.  Back to cited text no. 17
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Wurzel CL, Halom K, Feldman JG, Rubin LG. Infection rates of Broviac-Hickman catheters and implantable venous devices. Am J Dis Child 1988;142:536-40.  Back to cited text no. 18
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