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Leukemia Research xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
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The association of central venous catheter placement timing with infection rates in patients with acute leukemia Eitan Kugler a,∗ , Amos Levi a , Elad Goldberg a,b , Eli Zaig a , Pia Raanani b,c , Mical Paul d a
Department of Medicine F—Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Institute of Hematology, Davidoff Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel d Division of Infectious Diseases, Rambam Health Care Campus and The Ruth and Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel b c
a r t i c l e
i n f o
Article history: Received 21 October 2014 Received in revised form 19 December 2014 Accepted 28 December 2014 Available online xxx Keywords: Induction therapy Infection rate CLABSI
a b s t r a c t Background: Timing of central venous catheter (CVC) insertion among patients with acute leukemia is debatable. Early insertion increases convenience, but might increase infection rates. Methods: We assessed retrospectively the rate of central line-associated bloodstream infections (CLABSI) according to CVC time of insertion in patients with acute leukemia admitted for induction or salvage therapy. The study was conducted in the Hematology Department of a Tertiary hospital in Israel between 2007 and 2011. Early CVC placement was defined as CVC inserted during the first week of induction therapy. CLABSI rate was documented between the seventh day of induction therapy to 30 days after its completion. Results: A total of 127 patients were included. Acute myeloid leukemia was the most common diagnosis (103 patients, 80.5%). Late CVC placement was associated with CLABSI after adjustment to the Charlson comorbidity index (OR 3.4, 95% CI 1.1–10.45), p = 0.03. Conclusion: Delaying CVC placement in adult patients with acute leukemia may be associated with higher rate of CLABSI in the early period after induction therapy. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Hematologic malignancies have been associated with higher central line associated bloodstream infections (CLABSI) rates than solid tumors, being estimated as 2 events per 1000 central catheter days in bone marrow transplant units and 8.2 event per 1000 central catheter days in leukemia units [1]. The use of central venous catheter (CVC) in the management of patients with acute leukemia is common and has made treatment simpler and more convenient to patients, yet it is associated with CLABSI as well as local thrombosis. The optimal timing for CVC placement during induction therapy in relation to CLABSI risk in adult patients with newly diagnosed acute leukemia is unknown. This issue has clinical significance because of the high rate of neutropenia, thrombocytopenia and infections during induction therapy and upon presentation. We report our assessment of early versus late CVC placement and the
risk for CLABSI among patients with acute leukemia admitted for induction or salvage therapy. 2. Methods 2.1. Study design and participants We conducted a retrospective analysis of prospectively collected data from the Hematology Department at the Davidoff Cancer Center, Rabin Medical Center, Israel. We included patients with newly diagnosed acute myeloid leukemia (AML) including acute promyelocytic leukemia (APL), acute lymphoblastic leukemia (ALL) and relapsed acute leukemia admitted for induction therapy to our institute between February 2007 and February 2011. All data was retrieved from a prospectively collected surveillance of infections registry at the hemato-oncology department at our hospital. All patients received induction or salvage therapy per protocol [2,3]. 2.2. Outcome and definitions
∗ Corresponding author. Tel.: +972 54 5434361; fax: +972 3 7764794. E-mail address: [email protected] (E. Kugler).
The exposure variable was early CVC placement, defined as a CVC being inserted between day one to seven of induction therapy
http://dx.doi.org/10.1016/j.leukres.2014.12.017 0145-2126/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kugler E, et al. The association of central venous catheter placement timing with infection rates in patients with acute leukemia. Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2014.12.017
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E. Kugler et al. / Leukemia Research xxx (2015) xxx–xxx
2
Table 1 Baseline patients’ characteristics according to timing of CVC placement. Early placement (N = 109)
Late placement (N = 18)
p Value
Female sex Age (median, range) Relapse Charlson comorbidity index >2 Neutropenia at the time of central venous catheter insertionb
48 (44%) 60 (48–68) 5 (4.06%) 35 (32.1%) 39 (35.8%)
7 (38.9%) 60 (52–69) 0 8 (44.4%) 13 (72.2%)
0.8 0.8a NS 0.42 0.005
Leukemia typec
AML ALL APL
89 (81.7%) 17 (15.6%) 3 (2.8%)
12 (72.2%) 4 (22.2%) 1 (5.6%)
0.6
Disease risk
High Intermediate Low
80 (74.3%) 13 (11.9%) 15 (13.8%)
13 (72.2%) 4 (22.2%) 1 (5.6%)
0.3
a b c
Wilcoxon sum of ranks. Neutropenia defined based on the absolute neutrophil count in automated blood counts (
ARTICLE IN PRESS
LR-5320; No. of Pages 3
Leukemia Research xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Leukemia Research journal homepage: www.elsevier.com/locate/leukres
The association of central venous catheter placement timing with infection rates in patients with acute leukemia Eitan Kugler a,∗ , Amos Levi a , Elad Goldberg a,b , Eli Zaig a , Pia Raanani b,c , Mical Paul d a
Department of Medicine F—Recanati, Beilinson Hospital, Rabin Medical Center, Petah Tikva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Institute of Hematology, Davidoff Center, Beilinson Hospital, Rabin Medical Center, Petah-Tikva, Israel d Division of Infectious Diseases, Rambam Health Care Campus and The Ruth and Bruce Rappaport Faculty of Medicine, Technion—Israel Institute of Technology, Haifa, Israel b c
a r t i c l e
i n f o
Article history: Received 21 October 2014 Received in revised form 19 December 2014 Accepted 28 December 2014 Available online xxx Keywords: Induction therapy Infection rate CLABSI
a b s t r a c t Background: Timing of central venous catheter (CVC) insertion among patients with acute leukemia is debatable. Early insertion increases convenience, but might increase infection rates. Methods: We assessed retrospectively the rate of central line-associated bloodstream infections (CLABSI) according to CVC time of insertion in patients with acute leukemia admitted for induction or salvage therapy. The study was conducted in the Hematology Department of a Tertiary hospital in Israel between 2007 and 2011. Early CVC placement was defined as CVC inserted during the first week of induction therapy. CLABSI rate was documented between the seventh day of induction therapy to 30 days after its completion. Results: A total of 127 patients were included. Acute myeloid leukemia was the most common diagnosis (103 patients, 80.5%). Late CVC placement was associated with CLABSI after adjustment to the Charlson comorbidity index (OR 3.4, 95% CI 1.1–10.45), p = 0.03. Conclusion: Delaying CVC placement in adult patients with acute leukemia may be associated with higher rate of CLABSI in the early period after induction therapy. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction Hematologic malignancies have been associated with higher central line associated bloodstream infections (CLABSI) rates than solid tumors, being estimated as 2 events per 1000 central catheter days in bone marrow transplant units and 8.2 event per 1000 central catheter days in leukemia units [1]. The use of central venous catheter (CVC) in the management of patients with acute leukemia is common and has made treatment simpler and more convenient to patients, yet it is associated with CLABSI as well as local thrombosis. The optimal timing for CVC placement during induction therapy in relation to CLABSI risk in adult patients with newly diagnosed acute leukemia is unknown. This issue has clinical significance because of the high rate of neutropenia, thrombocytopenia and infections during induction therapy and upon presentation. We report our assessment of early versus late CVC placement and the
risk for CLABSI among patients with acute leukemia admitted for induction or salvage therapy. 2. Methods 2.1. Study design and participants We conducted a retrospective analysis of prospectively collected data from the Hematology Department at the Davidoff Cancer Center, Rabin Medical Center, Israel. We included patients with newly diagnosed acute myeloid leukemia (AML) including acute promyelocytic leukemia (APL), acute lymphoblastic leukemia (ALL) and relapsed acute leukemia admitted for induction therapy to our institute between February 2007 and February 2011. All data was retrieved from a prospectively collected surveillance of infections registry at the hemato-oncology department at our hospital. All patients received induction or salvage therapy per protocol [2,3]. 2.2. Outcome and definitions
∗ Corresponding author. Tel.: +972 54 5434361; fax: +972 3 7764794. E-mail address: [email protected] (E. Kugler).
The exposure variable was early CVC placement, defined as a CVC being inserted between day one to seven of induction therapy
http://dx.doi.org/10.1016/j.leukres.2014.12.017 0145-2126/© 2015 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Kugler E, et al. The association of central venous catheter placement timing with infection rates in patients with acute leukemia. Leuk Res (2015), http://dx.doi.org/10.1016/j.leukres.2014.12.017
G Model
ARTICLE IN PRESS
LR-5320; No. of Pages 3
E. Kugler et al. / Leukemia Research xxx (2015) xxx–xxx
2
Table 1 Baseline patients’ characteristics according to timing of CVC placement. Early placement (N = 109)
Late placement (N = 18)
p Value
Female sex Age (median, range) Relapse Charlson comorbidity index >2 Neutropenia at the time of central venous catheter insertionb
48 (44%) 60 (48–68) 5 (4.06%) 35 (32.1%) 39 (35.8%)
7 (38.9%) 60 (52–69) 0 8 (44.4%) 13 (72.2%)
0.8 0.8a NS 0.42 0.005
Leukemia typec
AML ALL APL
89 (81.7%) 17 (15.6%) 3 (2.8%)
12 (72.2%) 4 (22.2%) 1 (5.6%)
0.6
Disease risk
High Intermediate Low
80 (74.3%) 13 (11.9%) 15 (13.8%)
13 (72.2%) 4 (22.2%) 1 (5.6%)
0.3
a b c
Wilcoxon sum of ranks. Neutropenia defined based on the absolute neutrophil count in automated blood counts (
