infection control & hospital epidemiology july 2018, vol. 39, no. 7 concise communication
Blood Stream Infection in Patients on Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure
Soo Jin Na;1 Chi Ryang Chung;1 Hee Jung Choi;2 Yang Hyun Cho;3 Jeong Hoon Yang;1,4 Gee Young Suh;1,5 Kyeongman Jeon, MD, PhD1,5
Bloodstream infection (BSI) occurred in 21 of 121 patients (17%) receiving venovenous extracorporeal membrane oxygenation within the median time of 6 days after initiation (interquartile range, 4–19 days). Longer duration of arterial catheterization and more blood transfusions were independently associated with BSI, which is associated with poor clinical outcomes.
Infect Control Hosp Epidemiol 2018;39:871–874
as other appropriate specimens are performed when a new episode of infection is clinically suspected. Bloodstream infection was defined as satisfying 1 of 2 criteria7,8: (1) the isolation of a recognized pathogen from blood culture or (2) the presence of clinical manifestation and common skin contaminant isolated from at least 2 blood cultures. Infections were classified as pri- mary BSIwhen the organism isolated from blood culture was not related to infection at another site or when the BSI was related to the catheter.7 If the isolated organism from blood culture mat- ched an organism identified from another site, it was classified as a secondary BSI. Only infections occurring >48 hours after initiation of ECMO until decannulation were considered as ECMO-related infections in this study.
results
Bloodstream infection (BSI) is one of the most common complications during extracorporeal membrane oxygenation (ECMO) in patients treated with venoarterial ECMO for car- diac support.1 Compared with patients receiving venoarterial ECMO, patients receiving venovenous ECMO for respiratory support are more commonly exposed to antibiotics and cor- ticosteroids.2 In addition, the duration of venovenous ECMO support is longer than for venoarterial ECMO for cardiac support,3 which affects the rate of BSI.1,4 Therefore, the fea- tures of BSI in patients receiving venovenous ECMO might be different from those in patients receiving venoarterial ECMO. The number of patients receiving venovenous ECMO support in clinical practice is growing.3 However, data on the epide- miology and clinical relevance of BSI during venovenous ECMO remain limited.5,6 Therefore, we investigated the inci- dence, etiologies, risk factors, and clinical outcomes of BSI in patients receiving venovenous ECMO for severe acute respiratory failure in a medical ICU.
methods
This retrospective cohort study included 121 adult patients who received venovenous ECMO for >48 hours at Samsung Medical Center in South Korea between January 2012 and December 2016. We used the ECMO database of our hospital, in which the clinical and laboratory data of patients who received ECMO were prospectively registered, and we con- ducted a retrospective review of patient hospital charts to supplement these data. Routine surveillance blood culture during ECMO is not mandatory in our hospital. However, cultures of blood as well
Overall, the median age of patients receiving venovenous ECMO for respiratory support was 60 years (range, 51–67 years), and 33 patients (27%) were male. Moreover, 36 patients (30%) were immunocompromised: 20 (17%) had hematological malignancies or solid tumor treated with chemotherapy; 10 (8%) had undergone solid organ trans- plantation; and 6 (5%) had undergone high-dose or long-term corticosteroid treatment. Bacterial pneumonia was the most common pulmonary condition causing respiratory failure (41%), followed by acute exacerbation of interstitial lung disease (17%) and viral pneumonia (16%). Themedian duration ofmechanical ventilation (MV) prior to
the initiation of ECMO was 2 days (range, 0–6days),and corti- costeroid treatment was administered to 59 patients (58%). Femoro-jugular and femoro-femoral cannulations were used in 91 patients (75%) and 27 patients (22%), respectively. Every patient had an arterial catheter, and 109 (90%) patients also had a central venous catheter. Broad-spectrum antibiotics and anti- fungal agents were used in 111 patients (92%) and 33 (27%) patients during ECMO support, respectively. The median dura- tion of ECMO was 14 days (range, 7–26 days). Bloodstream infections occurred during ECMO support in
21 patients treated with venovenousECMO(17%; 8.5 episodes per 1,000 ECMO days), and the median time from ECMO initiation to occurrence of BSI was 6 days (range, 4–19 days). However, the frequency of BSI over the duration of venove- nous ECMO did not change (P=.337; for trends, see Supple- mental Figure 1). Primary BSI developed in 4 patients (19%), and half of these were associated with central venous catheter infections. The most common source of secondary BSI was respiratory infections (62%), followed by intra-abdominal infections (10%) and urinary tract infections (10%). Staphy- lococcus aureus and Acinetobacter baumannii were the most commonly identified bacteria. Of the 5 cases of fungemia, Candida tropicalis was identified in 3 patients and Candida albicans was identified in 2 patients.
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