In situ endoluminal brushing: a safe technique for the diagnosis of catheter-related bloodstream infection.

We assessed the safety of the endoluminal brush technique for the in situ diagnosis of central-venous-catheter (CVC)-related bloodstream infection (CRBSI). The endoluminal brush was used to investigate patients with suspected CRBSI by sampling the CVC lumen to within 3-5 cm of the catheter tip (the brush was kinked to mark the length required). Quantitative peripheral blood cultures were taken 1 min pre-brushing and 1 min and 1h post-brushing. In addition, a 1 mL sample of through-catheter blood was aspirated immediately pre- and post-brushing, and aliquots were directly plated on to blood agar to determine the load of CVC-associated bacteria. After CVC removal, catheter tips were sent for culture using the Maki roll and modified Cleri flush techniques. Of 139 suspected cases, 61 (45%) had confirmed episodes of CRBSI. No patients experienced fever or rigors, or had evidence of embolic phenomena after CVC endoluminal brushing. There was no difference overall in pre-brushing and 1-min post-brushing peripheral blood bacterial counts (P < 0.702). Peripheral and CVC blood bacterial counts were significantly reduced 1h post-brushing (P < 0.03 and P < 0.001, respectively), possibly due to removal of endoluminal biomass. The endoluminal brush technique can be safely used to diagnose CRBSI without the need for CVC removal, provided that the brush is not allowed to protrude beyond the tip of the catheter.

Randomized clinical trials to determine the role of topical glyceryl trinitrate in peripheral intravenous nutrition.

BACKGROUND: The contribution of glyceryl trinitrate (GTN) to prevention of peripheral vein thrombophlebitis (PVT) during peripheral intravenous nutrition delivered by fine-bore midline intravenous catheter is unclear. The aim of this study was to establish its role. METHODS: Two consecutive randomized clinical trials were conducted. In trial 1 patients were randomized to receive standard peripheral intravenous nutrition containing heparin and hydrocortisone with or without the placement of a topical GTN patch (triple therapy or dual therapy). In trial 2 patients were randomized to receive standard peripheral intravenous nutrition with either dual therapy or topical GTN alone (monotherapy). RESULTS: Dual therapy was as effective as triple therapy in preventing PVT (incidence 10 of 37 versus 11 of 39 patients respectively). Dual therapy reduced the incidence and increased the time to onset of PVT compared with monotherapy (14 of 41 versus 22 of 35 patients respectively, P = 0.012; median 17.3 (95 per cent confidence interval (c.i.) 13.4 to 21.1) versus 8.9 (95 per cent c.i. 6.7 to 11.0) days, P = 0.007). CONCLUSION: Use of a topical GTN patch confers no benefit when peripheral intravenous nutrition is delivered via a fine-bore midline intravenous catheter.

DNA fingerprinting analysis of coagulase negative staphylococci implicated in catheter related bloodstream infections.

AIMS: The epidemiological assessment of cases of coagulase negative staphylococcal catheter related bloodstream infection. METHODS: Two hundred and thirty patients with suspected catheter related bloodstream infection were evaluated over a two year period. Central venous catheters were cultured both endoluminally and extraluminally. Peripheral blood, catheter hubs, skin entry, and skin control sites were also cultured. Pulsed field gel electrophoresis (PFGE) was used to DNA fingerprint coagulase negative staphylococci isolated from patients with presumptive catheter related bloodstream infection. RESULTS: Sixty cases of catheter related bloodstream infection were identified, 21 of which were attributed to coagulase negative staphylococci. Two hundred and ninety four separate isolates of coagulase negative staphylococci from the 21 cases of catheter related bloodstream infection were subjected to PFGE (mean of 14 for each case). Catheter related bloodstream infection was only confirmed by PFGE analysis in 16 of the 21 cases because in the remaining five cases peripheral blood and central venous catheter coagulase negative staphylococci isolates were different. Skin entry, control skin, and central venous catheter hub isolates matched peripheral blood isolates in six, four, and seven cases, respectively. Coagulase negative staphylococci isolates could not be cultured from the patients' own skin in seven cases of catheter related bloodstream infection. Central venous catheter lumens were colonised in all cases of catheter related bloodstream infection compared with 44-81% of cases that had positive external surface catheter tip cultures, depending on the threshold used to define significant growth. CONCLUSIONS: Catheter related bloodstream infection as a result of coagulase negative staphylococci may be over stated in about a quarter of cases, unless a discriminatory technique is used to fingerprint isolates. No single, simplistic route of bacterial contamination of central venous catheters was identified, but endoluminal catheter colonisation is invariably present in cases of catheter related bloodstream infection.

Laparoscopic adjustable gastric banding: surgical and radiological approach.

BACKGROUND: The laparoscopically-placed adjustable gastric band (LAGB) is a minimally invasive, adjustable and completely reversible operation. We report 3 years experience. METHODS: Between May 1998 and January 2001, we operated on a consecutive series of 50 patients (8 male/42 female). Mean age of patients was 37 years (30-48). Mean preoperative BMI was 43 kg/m2 (range 38-55). RESULTS: Mean operative time was 130 minutes (range 75-150), and the conversion rate was 6%. Mean hospital stay was 2.8 days (range 2-10). Postoperatively 7/50 (14%) of patients had dysphagia and subsequently 2 (4%) developed gastric pouch dilatation. 2/50 (4%) had non-fatal pulmonary embolism and 2/50 (4%) developed gastroesophageal reflux. Overall morbidity was 32%. There has been no mortality. 6 weeks postoperatively, patients had adjustment of the band by the radiologists. Follow-up has been up to 30 months. Mean excess weight loss at 6 months was 30% (range 26-35%, N = 50), at 12 months 52% (range 44-55%, N = 42), at 24 months 60% (range 55-65%, N = 14) and at 30 months 62% (range 58-64%, N = 8). 5 patients have reached their ideal body weight. CONCLUSIONS: LAGB is safe and effective, even early in the learning curve. The radiologist plays a distinct role. A multi-disciplinary team approach is essential for optimal results. Long-term results are pending.

Rapid diagnosis of central-venous-catheter-related bloodstream infection without catheter removal.

BACKGROUND: Current methods for the diagnosis of bloodstream infection related to central venous catheters (CVC) are slow and in many cases require catheter removal. Since most CVC that are removed on suspicion of causing infection prove not to be infected, removal of catheters unnecessarily exposes patients to the risks associated with reinsertion. METHODS: The gram stain and acridine-orange leucocyte cytospin test (AOLC) is rapid (30 min), inexpensive, and requires only 100 microL catheter blood (treated with edetic acid) and the use of light and ultraviolet microscopy. We assessed the gram stain and AOLC test in suspected cases of catheter-related bloodstream infection, in comparison with two methods requiring catheter removal (tip roll and tip flush), and a third technique, done in situ (endoluminal brush) in conjunction with quantitative peripheral-blood cultures. FINDINGS: 128 cases of suspected catheter-related bloodstream infection were assessed in 124 adult surgical patients (median duration of CVC placement was 16 days). In 112 (88%) cases CVC blood was obtainable. Catheter-related bloodstream infection was diagnosed in 50 cases (culture of the same organism from the catheter, in significant numbers, and from peripheral-blood culture). The sensitivity of the gram stain and AOLC test was 96% and the specificity was 92%, with a positive predictive value of 91% and a negative predictive value of 97%. By comparison, the tip-roll, tip-flush, and endoluminal-brush methods had sensitivities of 90%, 95%, and 92%, and specificities of 55%, 76%, and 98%, respectively. INTERPRETATION: The gram stain and AOLC test is a simple, and rapid method for the diagnosis of catheter-related bloodstream infection. This diagnostic method compares favourably with other diagnostic methods, particularly those that require the removal of the catheter, and can permit early targeted antimicrobial therapy.

Evaluation of a novel endoluminal brush method for in situ diagnosis of catheter related sepsis.

AIMS: To determine the accuracy of a novel endoluminal brush method for the diagnosis of catheter related sepsis (CRS), which is performed in situ and hence does not require line sacrifice. METHODS: 230 central venous catheters in 216 patients were examined prospectively for evidence of CRS or colonisation using an endoluminal brush method in conjunction with peripheral blood cultures. The results were compared with those obtained using methods that require line sacrifice: extraluminal sampling (Maki roll) or endoluminal sampling (modified Cleri flush) of microorganisms. RESULTS: Only 16% of 128 patients suspected clinically of having line associated infection were confirmed as having CRS. In addition, 2 of 102 patients not suspected of having line associated infection had CRS. Line colonisation was apparent in approximately twice as many catheters using the Maki roll criteria (92%) compared with either the endoluminal brush (43%) or Cleri flush (43%). Furthermore, colonised catheters sampled using the Maki roll technique yielded mixed growth twice as often as when examined by endoluminal methods (17 and 8 cases, respectively). It was rare to detect either only endoluminal (4 of 22 episodes) or extraluminal (1 of 22 episodes) microorganisms in cases of CRS. In contrast, catheters defined as being colonised most frequently (59% of episodes) yielded only significant extraluminal growth. Only one case of CRS (5%) would have been "missed" if lines yielding a negative result from endoluminal brush sampling had been left in situ. Conversely, four episodes of CRS (18%) would not have been diagnosed by relying on extraluminal sampling alone. CONCLUSIONS: Diagnosis of CRS by the endoluminal brush method can be achieved without line sacrifice and is more sensitive (95%) and specific (84%) than extraluminal sampling of the catheter tip by the Maki roll technique (82% and 66%, respectively).