161 Central venous catheter associated bloodstream infections and thrombosis in patients treated for gastroschisis and intestinal atresia Chapter 6 might suffer from underreporting of CLABSI and possibly coding errors since the care for patients suffering from these congenital birth defects is complex and complications are common. It is for instance remarkable that the database study reports a high CLABSI-rate per 1000-line days of 24 in patients treated for gastroschisis, whilst the numerator of this fraction (the incidence of CLABSI) is comparatively low (2%) and the denominator (catheter dwell time) is similar to this study (25 days). Other explanation for our higher incidence might be the definition used for CLABSI. The official CDC definition for CLABSI in young patients demands two separate positive blood cultures in case of a common commensal organism such as CNS, next to signs of infection and no other site of infection than the central venous catheter [11]. At our hospital, a CLABSI is presumed following a single positive culture combined with clinical suspicion of CLABSI in case of no other cause of infection. In case of a common commensal positive blood culture, antibiotic treatment is mostly started without central venous catheter removal. When clinical deterioration occurs, the central venous catheter is eventually removed. If these common commensal positive cultures were caused by contamination instead of a real CLABSI, patients could be expected to improve significantly more without removal of the catheter. Yet, the rate of central venous catheter removal was similar when comparing the CLABSIs caused by common commensal and other positive cultures. Still, it might be that we over-diagnosed patients with CLABSI leading to catheter removal in patients that might have improved by watchful waiting which would be a form of action bias. Better adherence to the existent guidelines on pediatric parenteral nutrition might both decrease central venous catheter associated complications as overly cautious removal of the inserted central venous catheter[15]. Furthermore, prevention could maybe furthermore be realized by the usage of line-lock infusions. For instance, the usage of taurolidine has been shown to decrease the rate of CLABSIs in children who receive TPV at home and is therefore included in the guidelines for this specific cohort[15]. For the patients concerning our study, a well-designed study should be started to investigate the efficacy and safety of different line locks including taurolidine in preventing central line infections. Previous studies described complex gastroschisis as risk factor and, interestingly, prematurity and low birthweight as protective for CLABSI in patients treated for gastroschisis[6, 7]. They suggested that this could be related to a longer NICU submission in premature and/or low birthweight infants which, due to CLABSI prevention protocols in place at the NICU, could lead to a decrease in CLABSIs. In our cohort, we could not confirm these risk factors. Therefore, it seems that, as the previous studies too suggested, these factors are not general risk factors but rather local ones differing from hospital to hospital. Their influences might be limited if all hospitals would adhere to the same guidelines. Studies in neonates and PICU patients in general described male sex, higher birthweight and centrally placed catheters as risk factors which we could also not confirm [4, 16].
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