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Factors contributing to increased infection rates in patients with implanted chest ports
JVIR
’
Scientific Session
Sunday
2:50 PM
promising local tumor control but larger experience and longer follow-up is needed to confirm these data.
Scientific Session 4 Venous Access and Intervention Sunday, April 14, 2013 1:30 PM – 3:00 PM Room: 289
Abstract No. 33
Evaluating cryoablation of metastatic lung/pleura tumors in patients - safety and efficacy (eclipse) preliminary safety outcomes T. de Baere, D.A. Woodrum, F. Abtin, P. Littrup, G. Farouil; 1Institut de Cancerologie Gustave Roussy, VILLEJUIF Cedex, France; 2Mayo Clinic, Rochester, MN; 3 Unv. of California-Los Angeles, Los Angeles, CA; 4 Karmanos Cancer Institute, Detroit, MI Purpose: To assess the safety and efficacy of cryoablation in local tumor control for lung metastases r3.5 cm in patients with pulmonary metastatic disease. Materials and Methods: Twenty-two patients (13 males, 9 females; mean age 60 years) with up to 3 unilaterally or a maximum of 5 metastases bilaterally were enrolled in a prospective study and underwent CT guided cryoablation (Galil Medical, Arden Hills, MN). Patient Follow-up including CT imaging was assessed at 1 week, 3 and 6 months. The primary endpoint for the study is local tumor control assessed by a modified RECIST. Complications were assessed using the CTCAE 4. Results: A total of 36 tumors were treated in 22 patients over 27 cryoablation procedures. Sixty-eight percent (n¼15) of the patients had one tumor, 23% (n¼5) had 2 to 3 tumors and 9% (n¼2) of the patients had greater than 3 tumors. The mean tumor size was 1.5 cm (range 0.7 to 3.2 cm), and 91% (n¼20) of patients had unilateral disease. Colon and Renal carcinoma were the two most common primary cancer diagnoses accounting for 41% (n¼9) and 18% (n¼4) of the treated population respectively. General anesthesia was employed in 63% (n¼17) or conscious/ sedation in 37% (n¼10) of procedures. One to 6 probes per patient (mean¼1.9) were used for a treatment time of 45 to 176 min. (mean¼97). Four chest tubes (15%) were placed in 27 procedures. All reported adverse events were classified as CTCAE grade 1 or 2. The most common events occurring within 30 days of the procedure were pneumothorax 15% (n¼4), pulmonary embolism 26% (n¼7), and chest wall pain 19% (n¼5), associated with 27 procedures. All resolved with minimal to no intervention. We did not encountered major hemorrhage to the lung or the pleura. After a median follow-up time of 3 months (15 patients at 3 months and 5 patients at 6 months) local tumor control rate is 100% with 6 patients demonstrating new distant tumor at 3 months. Conclusion: Cryoablation of metastatic lung tumors r3.5 cm appears to be a safe. Our preliminary results seem to demonstrate
S23
1:30 PM
Abstract No. 34
Factors contributing to increased infection rates in patients with implanted chest ports N.E. Tadeo, S.B. White, J. Williams, J.A. Molnar, R.A. Hieb, S.M. Tutton, W.S. Rilling, E.J. Hohenwalter, P. Patel; Vascular/Interventional Radiology, Medical College of Wisconsin, Milwaukee, WI Purpose: The purpose of this study was to identify factors that may contribute to increased infection rates in implanted chest ports (CP). Specifically, the aim of our study was to determine whether accessing a CP within 7 days of insertion affects the risk of infection. Materials and Methods: A query of our QI database was performed to determine a cohort of patients that had undergone CP placement between 5/13/2008 and 4/4/2012. During this time period, 1,352 chest ports were implanted. Patients were evaluated for infections occurring both within and after 30 days of implantation. Infections are defined as positive blood cultures, positive tip cultures, or pus/cellulitis at the site of CP insertion. To assess risk factors for infection, we collected the following data: age, indication for procedure, diagnosis, inpatient vs. outpatient status at the time of CP insertion, site of CP placement, device inserted (single vs. double lumen), date of initial access, type of initial infusion and laboratory data including, WBC, ANC, platelet count and INR. Results: Of the 1,352 CPs implanted, 15 infections were seen within 30 days of insertion (infection rate 0.01%) and 43 infections were observed after 30 days. Statistical comparisons of categorical variables were made in patients with infections occurring within 30 days using Fisher’s Test or the Exact Pearson Chi-Square test. Of the variables examined, differences in age, indication for procedure, diagnosis, WBC, ANC, platelet count, INR, site of access and date of initial access were not found to be statistically significant. Single vs. double lumen CP approached statistical significance (po0.0657), with double lumen CPs having a 3.49% rate of infection vs. 0.95% in the single lumen CPs. Type of initial infusion was also significant (po0.0044, df¼5), infection rate after chemotherapy infusion was 0.88% vs. transfusion 20% (po0.004, df¼1). Inpatient status at time of CP insertion occurred at a rate of 9% vs. 0.55% in outpatients (po.0001, OR 18, 95% CI 5.5-60).
SUNDAY: Scientific Sessions
of CuS nanoparticles was increased by 173% in HepG2 and 52% in SKOV3.ip1.luc cells, compared to controls without electroporation (p o 0.05). Electroporation induced uptake of CuSsiRNA in SKOV3.ip1.luc cell, which subsequently expressed 25% lower levels of luciferase than control groups (p o 0.05). Fluorescence microscope revealed that siRNA was predominantly located in cytosol after electroporation. Conclusion: We developed an in vitro cell model to simulate the peripheral sub-lethal regions of IRE. CuS-siRNA nanoparticles were delivered into carcinoma cells during electroporation and down-regulated the expression of luciferase. Future studies will evaluate the therapeutic efficacy of this combined method in invitro and in-vivo experiments after delivery of therapeutic nanoparticles.
’
S24
’
Sunday
Scientific Session
SUNDAY: Scientific Sessions
Conclusion: Accessing a CP within 7 days of insertion did not result in a higher rate of infection. However, when CP were implanted in the inpatient setting, the odds of infection increased 18 fold.
1:38 PM
Abstract No. 35
Bacteriophage antimicrobial-lock technique for staphylococcus aureus central venous catheterrelated infection: an in-vivo evaluation M.P. Lungren, B.E. Paxton, R. Kankotia, I. Falk, D. Christensen, C.Y. Kim; Radiology, Duke University, Durham, NC Purpose: Bacteriophages are viruses that selectively infect and kill bacteria. The purpose of this project was to determine whether a bacteriophage antimicrobial lock technique can reduce bacterial colonization and biofilm formation on indwelling central venous catheters in a rabbit model. Materials and Methods: This study was performed in 10 female New Zealand white rabbits (weight range 3-4 kg). Broviac catheters (4.2 French, BARD access systems, NJ) were inserted into the jugular vein under image guidance and tunneled in an intrascapular position. Catheters were then inoculated for 24h with broth culture of Methicillin sensitive staphylococcus aureus (0.5 McFarland standard). The inoculate was aspirated and rabbits were randomized into two equal groups for 24h: (i) untreated controls (heparinized saline lock), (ii) Bacteriophage antimicrobial-lock (Staphylococcal Bacteriophage K, propagated titer 4 108). At the completion of the experiment blood cultures were obtained via peripheral veins, the catheters were removed for quantitative culture and scanning electron microscopic analyses, and the animals were sacrificed. Statistical testing for substantial differences in distal catheter segment colonization was carried out using the rank sum test. Results: Mean distal catheter segment colony forming units (CFU) per cm2 as a measure of biofilm was significantly decreased in experimental animals compared to controls (control 1.2 105 CFU/cm2, experimental 7.58 103, P ¼ 0.016). Scanning electron microscopic analysis of the catheter segments demonstrated qualitative reduction of biofilm in treated catheter segments compared to untreated controls. Blood culture results were not significantly different between the groups (control 3/5 positive (60%), experimental 4/5 positive (80%), (p¼1.0). Conclusion: In a rabbit model, treatment of infected central venous catheters with a bacteriophage antimicrobial-lock technique significantly reduced bacterial colonization and biofilm presence. Our data suggests that bacteriophage lock solution may be a feasible strategy for prevention and treatment of central venous catheter infections.
1:46 PM
Abstract No. 36
Impact of transitioning to antibiotic-impregnated PICCs on blood stream infection rate at a large tertiary institution
’
JVIR
J.J. Stenz, S. Schwartz, D.L. Croteau, T. Campbell; Radiology, Henry Ford Hospital, Detroit, MI Purpose: Catheter-related blood stream infections (CRBSIs) are associated with high morbidity and mortality as well as significant economic burden. These infections increase the length of hospitalization 7-21 days while costing an extra $23, 424 ⫾ 5,184.1 Consequently, to reduce the risk of CRBSIs, our institution transitioned to minocycline/rifampin-impregnated PICCs in April 2012. The aim of this study is to compare the rate of BSIs associated with antibiotic-impregnated versus non-impregnated PICCs. Materials and Methods: A retrospective analysis of BSIs associated with minocycline/rifampin-impregnated versus nonimpregnated PICCs was performed in conjunction with our infectious disease department. The rate of BSIs associated with the new antibiotic-impregnated PICCs placed from 4/1/2012 through 8/31/2012 was compared to the rate of BSIs associated with non-impregnated PICCs placed from 1/1/2011 through 12/ 31/2011. Results: A total of 1,515 minocycline/rifampin-impregnated PICCs were placed at our institution from 4/1/2012 through 8/ 31/2012. There were 12 documented BSIs associated with these PICCs (6 patients had multiple catheters). A total of 4,516 nonimpregnated PICCs were placed from 1/1/2011 through 12/31/ 2011. There were 31 documented BSIs associated with these PICCs (7 patients had multiple catheters). Approximately 1 out of every 126 antibiotic-impregnated PICCs was associated with a BSI while approximately 1 out of every 146 non-impregnated PICCs was associated with a BSI. Conclusion: The transition from non-impregnated to minocycline/rifampin-impregnated PICCs has not decreased the rate of CRBSIs at our institution. However, the cohort size is limited as this has been a recent change. This study is also limited by the high proportion of patients with multiple catheters in the antibiotic-impregnated group. Further analysis will be performed as more PICCs are placed. References 1. Weber DJ, Rutala WA. Central line-associated bloodstream infections: prevention and management. Infect Dis Clin North Am. 2011;25:77-102.
1:54 PM
Abstract No. 37
Conductive catheter inhibits bacterial colonization H. Amalou, A. Ranjan, L. Chow, A.H. Negussie, S. Xu, B.J. Wood; Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD Purpose: To characterize a novel prototype conductive catheter for the ability to inhibit bacterial colonization in bacterial culture and to optimize the electrical parameters for safe use in patients. Materials and Methods: A custom vascular access device catheter was designed and fabricated with conductive elements as well as 2 electrodes at the catheter tip, separated by a conductive segment that required the electrical current to travel from one electrode to another at the distal end of the catheter. Catheters were innoculated with Staph aureus (28 10 9 CFU) and incubated with and without exposure to electrical current at pre-selected current levels and durations. After exposures,
’
Scientific Session
Sunday
2:50 PM
promising local tumor control but larger experience and longer follow-up is needed to confirm these data.
Scientific Session 4 Venous Access and Intervention Sunday, April 14, 2013 1:30 PM – 3:00 PM Room: 289
Abstract No. 33
Evaluating cryoablation of metastatic lung/pleura tumors in patients - safety and efficacy (eclipse) preliminary safety outcomes T. de Baere, D.A. Woodrum, F. Abtin, P. Littrup, G. Farouil; 1Institut de Cancerologie Gustave Roussy, VILLEJUIF Cedex, France; 2Mayo Clinic, Rochester, MN; 3 Unv. of California-Los Angeles, Los Angeles, CA; 4 Karmanos Cancer Institute, Detroit, MI Purpose: To assess the safety and efficacy of cryoablation in local tumor control for lung metastases r3.5 cm in patients with pulmonary metastatic disease. Materials and Methods: Twenty-two patients (13 males, 9 females; mean age 60 years) with up to 3 unilaterally or a maximum of 5 metastases bilaterally were enrolled in a prospective study and underwent CT guided cryoablation (Galil Medical, Arden Hills, MN). Patient Follow-up including CT imaging was assessed at 1 week, 3 and 6 months. The primary endpoint for the study is local tumor control assessed by a modified RECIST. Complications were assessed using the CTCAE 4. Results: A total of 36 tumors were treated in 22 patients over 27 cryoablation procedures. Sixty-eight percent (n¼15) of the patients had one tumor, 23% (n¼5) had 2 to 3 tumors and 9% (n¼2) of the patients had greater than 3 tumors. The mean tumor size was 1.5 cm (range 0.7 to 3.2 cm), and 91% (n¼20) of patients had unilateral disease. Colon and Renal carcinoma were the two most common primary cancer diagnoses accounting for 41% (n¼9) and 18% (n¼4) of the treated population respectively. General anesthesia was employed in 63% (n¼17) or conscious/ sedation in 37% (n¼10) of procedures. One to 6 probes per patient (mean¼1.9) were used for a treatment time of 45 to 176 min. (mean¼97). Four chest tubes (15%) were placed in 27 procedures. All reported adverse events were classified as CTCAE grade 1 or 2. The most common events occurring within 30 days of the procedure were pneumothorax 15% (n¼4), pulmonary embolism 26% (n¼7), and chest wall pain 19% (n¼5), associated with 27 procedures. All resolved with minimal to no intervention. We did not encountered major hemorrhage to the lung or the pleura. After a median follow-up time of 3 months (15 patients at 3 months and 5 patients at 6 months) local tumor control rate is 100% with 6 patients demonstrating new distant tumor at 3 months. Conclusion: Cryoablation of metastatic lung tumors r3.5 cm appears to be a safe. Our preliminary results seem to demonstrate
S23
1:30 PM
Abstract No. 34
Factors contributing to increased infection rates in patients with implanted chest ports N.E. Tadeo, S.B. White, J. Williams, J.A. Molnar, R.A. Hieb, S.M. Tutton, W.S. Rilling, E.J. Hohenwalter, P. Patel; Vascular/Interventional Radiology, Medical College of Wisconsin, Milwaukee, WI Purpose: The purpose of this study was to identify factors that may contribute to increased infection rates in implanted chest ports (CP). Specifically, the aim of our study was to determine whether accessing a CP within 7 days of insertion affects the risk of infection. Materials and Methods: A query of our QI database was performed to determine a cohort of patients that had undergone CP placement between 5/13/2008 and 4/4/2012. During this time period, 1,352 chest ports were implanted. Patients were evaluated for infections occurring both within and after 30 days of implantation. Infections are defined as positive blood cultures, positive tip cultures, or pus/cellulitis at the site of CP insertion. To assess risk factors for infection, we collected the following data: age, indication for procedure, diagnosis, inpatient vs. outpatient status at the time of CP insertion, site of CP placement, device inserted (single vs. double lumen), date of initial access, type of initial infusion and laboratory data including, WBC, ANC, platelet count and INR. Results: Of the 1,352 CPs implanted, 15 infections were seen within 30 days of insertion (infection rate 0.01%) and 43 infections were observed after 30 days. Statistical comparisons of categorical variables were made in patients with infections occurring within 30 days using Fisher’s Test or the Exact Pearson Chi-Square test. Of the variables examined, differences in age, indication for procedure, diagnosis, WBC, ANC, platelet count, INR, site of access and date of initial access were not found to be statistically significant. Single vs. double lumen CP approached statistical significance (po0.0657), with double lumen CPs having a 3.49% rate of infection vs. 0.95% in the single lumen CPs. Type of initial infusion was also significant (po0.0044, df¼5), infection rate after chemotherapy infusion was 0.88% vs. transfusion 20% (po0.004, df¼1). Inpatient status at time of CP insertion occurred at a rate of 9% vs. 0.55% in outpatients (po.0001, OR 18, 95% CI 5.5-60).
SUNDAY: Scientific Sessions
of CuS nanoparticles was increased by 173% in HepG2 and 52% in SKOV3.ip1.luc cells, compared to controls without electroporation (p o 0.05). Electroporation induced uptake of CuSsiRNA in SKOV3.ip1.luc cell, which subsequently expressed 25% lower levels of luciferase than control groups (p o 0.05). Fluorescence microscope revealed that siRNA was predominantly located in cytosol after electroporation. Conclusion: We developed an in vitro cell model to simulate the peripheral sub-lethal regions of IRE. CuS-siRNA nanoparticles were delivered into carcinoma cells during electroporation and down-regulated the expression of luciferase. Future studies will evaluate the therapeutic efficacy of this combined method in invitro and in-vivo experiments after delivery of therapeutic nanoparticles.
’
S24
’
Sunday
Scientific Session
SUNDAY: Scientific Sessions
Conclusion: Accessing a CP within 7 days of insertion did not result in a higher rate of infection. However, when CP were implanted in the inpatient setting, the odds of infection increased 18 fold.
1:38 PM
Abstract No. 35
Bacteriophage antimicrobial-lock technique for staphylococcus aureus central venous catheterrelated infection: an in-vivo evaluation M.P. Lungren, B.E. Paxton, R. Kankotia, I. Falk, D. Christensen, C.Y. Kim; Radiology, Duke University, Durham, NC Purpose: Bacteriophages are viruses that selectively infect and kill bacteria. The purpose of this project was to determine whether a bacteriophage antimicrobial lock technique can reduce bacterial colonization and biofilm formation on indwelling central venous catheters in a rabbit model. Materials and Methods: This study was performed in 10 female New Zealand white rabbits (weight range 3-4 kg). Broviac catheters (4.2 French, BARD access systems, NJ) were inserted into the jugular vein under image guidance and tunneled in an intrascapular position. Catheters were then inoculated for 24h with broth culture of Methicillin sensitive staphylococcus aureus (0.5 McFarland standard). The inoculate was aspirated and rabbits were randomized into two equal groups for 24h: (i) untreated controls (heparinized saline lock), (ii) Bacteriophage antimicrobial-lock (Staphylococcal Bacteriophage K, propagated titer 4 108). At the completion of the experiment blood cultures were obtained via peripheral veins, the catheters were removed for quantitative culture and scanning electron microscopic analyses, and the animals were sacrificed. Statistical testing for substantial differences in distal catheter segment colonization was carried out using the rank sum test. Results: Mean distal catheter segment colony forming units (CFU) per cm2 as a measure of biofilm was significantly decreased in experimental animals compared to controls (control 1.2 105 CFU/cm2, experimental 7.58 103, P ¼ 0.016). Scanning electron microscopic analysis of the catheter segments demonstrated qualitative reduction of biofilm in treated catheter segments compared to untreated controls. Blood culture results were not significantly different between the groups (control 3/5 positive (60%), experimental 4/5 positive (80%), (p¼1.0). Conclusion: In a rabbit model, treatment of infected central venous catheters with a bacteriophage antimicrobial-lock technique significantly reduced bacterial colonization and biofilm presence. Our data suggests that bacteriophage lock solution may be a feasible strategy for prevention and treatment of central venous catheter infections.
1:46 PM
Abstract No. 36
Impact of transitioning to antibiotic-impregnated PICCs on blood stream infection rate at a large tertiary institution
’
JVIR
J.J. Stenz, S. Schwartz, D.L. Croteau, T. Campbell; Radiology, Henry Ford Hospital, Detroit, MI Purpose: Catheter-related blood stream infections (CRBSIs) are associated with high morbidity and mortality as well as significant economic burden. These infections increase the length of hospitalization 7-21 days while costing an extra $23, 424 ⫾ 5,184.1 Consequently, to reduce the risk of CRBSIs, our institution transitioned to minocycline/rifampin-impregnated PICCs in April 2012. The aim of this study is to compare the rate of BSIs associated with antibiotic-impregnated versus non-impregnated PICCs. Materials and Methods: A retrospective analysis of BSIs associated with minocycline/rifampin-impregnated versus nonimpregnated PICCs was performed in conjunction with our infectious disease department. The rate of BSIs associated with the new antibiotic-impregnated PICCs placed from 4/1/2012 through 8/31/2012 was compared to the rate of BSIs associated with non-impregnated PICCs placed from 1/1/2011 through 12/ 31/2011. Results: A total of 1,515 minocycline/rifampin-impregnated PICCs were placed at our institution from 4/1/2012 through 8/ 31/2012. There were 12 documented BSIs associated with these PICCs (6 patients had multiple catheters). A total of 4,516 nonimpregnated PICCs were placed from 1/1/2011 through 12/31/ 2011. There were 31 documented BSIs associated with these PICCs (7 patients had multiple catheters). Approximately 1 out of every 126 antibiotic-impregnated PICCs was associated with a BSI while approximately 1 out of every 146 non-impregnated PICCs was associated with a BSI. Conclusion: The transition from non-impregnated to minocycline/rifampin-impregnated PICCs has not decreased the rate of CRBSIs at our institution. However, the cohort size is limited as this has been a recent change. This study is also limited by the high proportion of patients with multiple catheters in the antibiotic-impregnated group. Further analysis will be performed as more PICCs are placed. References 1. Weber DJ, Rutala WA. Central line-associated bloodstream infections: prevention and management. Infect Dis Clin North Am. 2011;25:77-102.
1:54 PM
Abstract No. 37
Conductive catheter inhibits bacterial colonization H. Amalou, A. Ranjan, L. Chow, A.H. Negussie, S. Xu, B.J. Wood; Radiology and Imaging Sciences, National Institutes of Health, Bethesda, MD Purpose: To characterize a novel prototype conductive catheter for the ability to inhibit bacterial colonization in bacterial culture and to optimize the electrical parameters for safe use in patients. Materials and Methods: A custom vascular access device catheter was designed and fabricated with conductive elements as well as 2 electrodes at the catheter tip, separated by a conductive segment that required the electrical current to travel from one electrode to another at the distal end of the catheter. Catheters were innoculated with Staph aureus (28 10 9 CFU) and incubated with and without exposure to electrical current at pre-selected current levels and durations. After exposures,