title: Catheter-related polymicrobial bloodstream infections among pediatric bone marrow transplant outpatients--Atlanta, Georgia, 2007.
abstract: OBJECTIVE
  To identify risk factors for polymicrobial bloodstream infections (BSIs) in pediatric bone marrow transplant (BMT) outpatients attending a newly constructed clinic affiliated with a children's hospital.
  
  
  METHODS
  All 30 outpatients treated at a new BMT clinic during September 10-21, 2007, were enrolled in a cohort study. The investigation included interviews, medical records review, observations, and bacterial culture and molecular typing of patient and environmental isolates. Data were analyzed using exact conditional logistic regression.
  
  
  RESULTS
  Thirteen patients experienced BSIs caused by 16 different, predominantly gram-negative organisms. Presence of a tunneled catheter (odds ratio [OR], 19.9 [95% confidence interval {CI}, 2.4-infinity), catheter access (OR, 13.7 [95% CI, 1.8-infinity]), and flushing of a catheter with predrawn saline (OR, 12.9 [95% CI, 1.0-766.0]) were independently associated with BSI. The odds of experiencing a BSI increased by a factor of 16.8 with each additional injection of predrawn saline (95% CI, 1.8-827.0). Although no environmental source of pathogens was identified, interviews revealed breaches in recommended infection prevention practice and medication handling. Saline flush solutions were predrawn, and multiple doses were obtained from single-dose preservative-free vials to avoid delays in patient care.
  
  
  CONCLUSIONS
  We speculate that infection prevention challenges in the new clinic, combined with successive needle punctures of vials, facilitated extrinsic contamination and transmission of healthcare-associated pathogens. We recommend that preservative-free single-use vials not be punctured more than once. Use of single-use prefilled saline syringes might prevent multiuse of single-use saline vials. Storage of saline outside a medication supply system might be advisable. Before opening new clinic facilities, hospitals should consider conducting a mock patient flow exercise to identify infection control challenges.
authors.affiliation: Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA. petra.wiersma@gmail.com
authors.forename: Petra
authors.initials: P
authors.lastname: Wiersma
authors.forename: Sarah
authors.initials: S
authors.lastname: Schillie
authors.forename: Harry
authors.initials: H
authors.lastname: Keyserling
authors.forename: J Renee
authors.initials: JR
authors.lastname: Watson
authors.forename: Anindya
authors.initials: A
authors.lastname: De
authors.forename: Shailendra N
authors.initials: SN
authors.lastname: Banerjee
authors.forename: Cherie L
authors.initials: CL
authors.lastname: Drenzek
authors.forename: Kathryn E
authors.initials: KE
authors.lastname: Arnold
authors.forename: Christina
authors.initials: C
authors.lastname: Shivers
authors.forename: Lea
authors.initials: L
authors.lastname: Kendrick
authors.forename: Lydia Gonzalez
authors.initials: LG
authors.lastname: Ryan
authors.forename: Bette
authors.initials: B
authors.lastname: Jensen
authors.forename: Judith
authors.initials: J
authors.lastname: Noble-Wang
authors.forename: Arjun
authors.initials: A
authors.lastname: Srinivasan
mesh_terms: D000293:Adolescent; D016026:Bone Marrow Transplantation / Q000009:adverse effects*; D055499:Catheter-Related Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D002405:Catheterization, Central Venous / Q000009:adverse effects; D002408:Catheters, Indwelling / Q000009:adverse effects / Q000382:microbiology; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D005260:Female; D005845:Georgia; D016905:Gram-Negative Bacterial Infections / Q000453:epidemiology* / Q000382:microbiology / Q000517:prevention & control; D006776:Hospitals, Pediatric / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D017053:Infection Control / Q000379:methods; D008297:Male; D010044:Outpatient Clinics, Hospital; D010045:Outpatients / Q000706:statistics & numerical data*; D012307:Risk Factors