bacteremia during vv ecmo 873
table 2. Predictors of Bloodstream Infection During Extracorporeal Membrane Oxygenation Univariable Analysis
Characteristic Age
Immunocompromised state
Cannulation site for VV ECMO Femoro-jugular
Femoro-femoral veins
Mixed with arterial cannulation Broad-spectrum antibiotics
Corticosteroid Parenteral nutrition support OR
0.99 0.93
Reference 0.54 2.18 1.17 0.83 1.34
Total units of transfused red cell and platelet 1.01 Duration of arterial catheter, week Duration of CVC, week
1.22 1.24
population range widely, from 3.4% to 21.1%,1,4,9–16 Although the incidence of BSI in our study was similar to that reported previously, a recent study that included 100 adult patients treated with venovenous ECMO and who underwent routine blood cultures showed an incidence rate of 35%,5 which is relatively high compared to our study but might be associated with routine surveillance blood culture. Inconsistent with previous reports,1,5,6,9–11 a prolonged
duration of ECMO support was not associated with BSI in our study. However, the longer duration of ECMO might be the result of an adverse effect by BSI rather than a risk factor for BSI.6 In this study, patients with BSI had almost double duration of venovenous ECMO. Using the trends test, we found no significant change in BSI rate across the duration of venovenous ECMO. ECMO patients generally have multiple indwelling catheters including central vein catheters and radial arterial catheters, in addition to the cannulas used for the ECMO circuit. We found that the risk of BSI increased inde- pendently with the duration of arterial catheterization. Therefore, arterial catheters should be examined as a potential source of BSI in patients receiving venovenous ECMO support.17 In addition, a higher number of transfusions was independently associated with BSI. Although the association of blood transfusion with nosocomial infection in critically ill patients has been demonstrated previously,18 no study has specifically addressed the potential association of blood transfusion and BSI in patients receiving ECMO. Patients with prolonged ECMO support have a higher probability of being transfused.19 However, multicollinearity was not found in the regression model (variance inflation factor, 1.080). Gram-negative organisms such as A. baumannii, Steno-
trophomonas maltophilia, and Pseudomonas aeruginosa are common BSI pathogens.5,10,15 Consistent with data obtained in patients received venovenous ECMO,5,10,15 gram-negative bacteria accounted for 38% of BSI in this study. These results were likely related to the facts that cases suspected of con- tamination by common skin contaminants were not diagnosed
95% CI
0.96–1.03 0.33–2.64
0.15–2.02
.699 .896
0.19–25.42 .535 0.43–3.17 0.16–4.20 0.52–3.45 1.00–1.02 1.06–1.41 0.96–1.59
.818 .538 .008 .006 .104
.363 .751
Multivariable Analysis
P Value OR 95% CI 0.99 0.95–1.03
1.17 0.35–3.95 0.65 0.11–3.73
P Value .580
.803
2.04 0.15–28.00 .594 0.62 0.18–2.20 0.29 0.04–2.19 1.03 0.36–2.97 1.01 1.00–1.02 1.25 1.03–1.52 0.92 0.65–1.30
.228 .955 .025 .025 .639
NOTE. CVC, central venous cathether; ECMO, extracorporeal membrane oxygenation; VV, venovenous.
Some studies have demonstrated significantly increased mor- tality rates in pediatric patients with BSI compared with patients without BSI,13 but other studies involving patients receiving venovenous ECMO showed that BSI had no effect on mortality.5,9 In this study, the ECMO-related outcomes, weaning rates, and duration of ECMO support were significantly worse in patients with BSI than in those without BSI. In addition, a trend toward higher mortality among patients with BSI was detected. Therefore, more effective infection control measures are warranted to reduce infections and to improve outcomes in patients receiving ECMO. In summary, the incidence of BSI during venovenous
as BSIs and that 81% of BSIs were secondary BSIs associated with pulmonary, intra-abdominal, or urinary tract infection. Pulmonary infection was most commonly associated with BSI in our study. Schmidt et al1 also demonstrated that ventilator- associated pneumonia was the most common source of BSI and that P. aeruginosa was the most commonly isolated organism from blood culture in adult cardiogenic shock patients with venoarterial ECMO. The impact of BSI on clinical outcomes is controversial.1
ECMO support was as high as 17% in adult patients with severe acute respiratory failure. Longer duration of arterial catheterization and more blood transfusions were indepen- dently associated with BSI, which was associated with poor clinical outcomes.
acknowledgments
Financial support: This work was supported by Samsung Medical Center (grant no. OTX0002901). Potential conflicts of interest: All authors report no conflicts of interest
relevant to this article. Affiliations: 1. Department of Critical Care Medicine, Samsung Medical
Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea; 2. Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of
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