Hickman catheter infections in patients with malignancies

Antimicrobial activity of polymers coated with iodine-complexed polyvinylpyrrolidone

Polymer-associated infection is a problem of increasing importance in modern medicine. In a new approach to prevent such infections we have modified polyvinylfluoride (TEDLAR) films by graft copolymerization with N-vinylpyrrolidone to which iodine can be complexed. Grafting reaction was performed by the preirradiation technique using an electron accelerator. Grafted films were then treated in Lugol's solution for at least 24 h. Release of free iodine from the films was determined either by titration or using the agar disc diffusion test, showing an iodine release for up to 4-5 days. The antimicrobial activity of the films was tested in bacterial adhesion measurements. Bacterial and fungal cells in the range of 10(3) to 10(6) cfu/cm2 polymer were found on control samples without iodine, whereas on iodine-complexed films no viable cells could be detected at least for 5 days or even longer. Thus, microbial adhesion and growth can be inhibited by iodine-containing polymers.

A comparative efficacy and safety study of teicoplanin plus aztreonam versus gentamicin plus piperacillin in haematology oncology patients with clinically diagnosed septicaemia

Infections due to Gram-positive bacteria, especially coagulase-negative staphylococci, have been increasing in immunocompromised patients during the last 5 years because of an increased use of Hickman catheters and oral gut decontamination with quinolones. Teicoplanin, a new glycopeptide antibiotic, has a long plasma half-life which allows once-a-day bolus administration, making it a 'user friendly' agent. A randomized comparative evaluation of teicoplanin plus aztreonam versus gentamicin plus piperacillin in leukaemic patients with a clinical diagnosis of septicaemia was undertaken. The objectives of this study were (1) to evaluate the efficacy and safety of teicoplanin and aztreonam in comparison to a 'standard antibiotic' regimen and (2) to assess the local and systemic tolerance of these drugs. Results of the study in more than 70 patients to date are presented, and the role of anti-Gram-positive antibiotics in the management of severe sepsis in immunocompromised patients is discussed.

Outpatient percutaneous central venous access in cancer patients

A 1-year experience of percutaneous subclavian catheterization in outpatients with cancer was reviewed to document reliability, safety, and cost. There were 763 catheter insertions attempted with prospective documentation of complications in 664 consecutive patients. Catheter insertion was successful in 722 attempts (95%). There were only 13 pneumothoraces (2%). Thirty catheters required repositioning (4%). The average catheter duration was 191 days (range: 0 to 892 days). Fifty-six catheters (8%) were removed because of suspected infection. Documented catheter sepsis occurred in 21 patients (3%); catheter site infection occurred in 8 patients (1%). Thus, only 0.22 infections per catheter year occurred during this 382 catheter-year experience. The estimated cost of catheter insertion was $562, which is one-third the estimated cost for tunneled catheters ($1,403) and for reservoir devices ($1,738). In our experience, percutaneous subclavian catheterization is a reliable, cost-effective method compared with tunneled or reservoir devices, with an equivalent incidence of catheter-related infections. The cornerstone of our success with this program is a staff dedicated to catheter care and intensive patient education. In centers where a large number of patients require central venous access, percutaneous catheterization should be the technique of choice.

Defining Staphylococcus epidermidis cell wall proteins

Three Staphylococcus epidermidis isolates of differing bacteriophage types were studied to define proteins confined to the cell wall, which were surface exposed and thus available to interact with the host. Three major proteins of 37, 41, and 51 kDa were identified in all whole-cell lysates and cell wall extracts by sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis. Two additional proteins of 18 and 25 kDa became evident by using 125I labeling to delineate surface-exposed proteins. A classification scheme using P1 to P5 to delineate the 51-, 41-, 37-, 25- and 18-kDa proteins is proposed. Additionally, murine immune sera were used to identify two immunodominant proteins of 51 and 25 kDa (P1 and P4, respectively).

Options and limitations of teicoplanin in febrile granulocytopenic patients

During the years 1985-89 three studies on the efficacy and safety of teicoplanin in the treatment of febrile granulocytopenic patients suffering from haematological malignancies were assessed. In the first prospective study, teicoplanin at a dose of 400 mg/d was added to the initial empiric therapy of 65 febrile granulocytopenic episodes. When teicoplanin was given because of proven or presumed Gram-positive infection, 67% of cases were treated successfully. Patients with skin and soft-tissue infections achieved a 78% response rate. The second study on 120 patients was designed as a prospective randomized trial to compare the efficacy and toxicity of ceftazidime with and without teicoplanin. Response was achieved in 25/51 (49%) cases from the ceftazidime and in 33/52 cases (63%) from the combination groups. Seven of 18 (39%) cases with initial bacteraemia in the monotherapy group compared with 10/20 (50%) cases in the combination group responded to the empiric regimen. A retrospective analysis was carried out on the efficacy of teicoplanin in 125 cases of proven Gram-positive Hickman line-associated bacteraemia. Teicoplanin proved to be effective in eradicating 80% of the Staphylococcus epidermidis, 72% of the Staph. aureus, 90% of the 'viridans' streptococci and 67% of the enterococci. Removal of the catheter was required in 13% of cases in order to control the infection, and only one patient died of a catheter-related septicaemia caused by Staph. aureus. The total success rate leaving the catheter in situ was 78%, and 92% if cases with catheter removal were included. Serum levels of teicoplanin were predictable giving a peak and trough concentration on the fourth day of 30.4 +/- 5.0 mg/l and 9.8 +/- 1.7 mg/l. Hearing loss of 20 dB at 8000 Hz was noted in one case and transient liver or kidney disturbances attributable to the drug were observed in 4% of cases.

Prophylactic teicoplanin during insertion of Hickman catheters

With the extensive use of Hickman catheters in patients requiring cytotoxic chemotherapy there is now a resurgence of Gram-positive septicaemia among these patients during the neutropenic periods. We are currently running a prospective randomized study of prophylactic teicoplanin during insertion of Hickman catheters to determine if it reduces the incidence of Gram-positive septicaemia. A total of 44 patients have completed the study (23 in the teicoplanin group and 21 in the control group). The diagnoses were: acute myelogenous leukaemia (13), non-Hodgkin's lymphoma (16), Hodgkin's disease (11), chronic granulocytic leukaemia (3) and acute lymphoblastic leukaemia (1). The number of days between insertion of Hickman catheters and the development of neutropenia was: teicoplanin group: mean 14.7, median 11, range 0-53; control group: mean 11.8, median 10, range 0-37. In the treated patients, there were four episodes of line-associated Gram-positive septicaemia and a total of four organisms were isolated. In the control group, 10 organisms were isolated from a total of nine episodes of line-associated Gram-positive septicaemia. The organisms were: coagulase-negative staphylococci (8), Streptococcus B, (1), Strep. faecalis (1), Strep. mitis (1), alpha streptococcus (1), diphtheriods (1) and Staphylococcus aureus (1). All organisms were sensitive to teicoplanin. No adverse reaction was observed in any patient. Prophylactic teicoplanin during insertion of Hickman catheters may therefore reduce the incidence of line-associated Gram-positive septicaemia in neutropenic patients.

Superior vena caval obstruction in patients with gut failure receiving home parenteral nutrition

Clinical suspicion and venographic conformation were used to diagnose 15 cases of superior vena caval obstruction (SVCO) in 107 home parenteral nutrition (HPN) patients over 379 cumulative years of HPN (3.9 cases/100 patient-years). Patients with SVCO had been on HPN a mean of 51.5 months and had used 6.2 (range 1-50) central catheters, including short- and long-term, before SVCO was diagnosed. The frequency of inflammatory bowel disease (IBD) with SVCO was approximately the same as that in our general HPN population. Positive blood cultures were present immediately preceding the diagnosis of SVCO in 40% (six of 15) of cases. Atypical line placements were noted in two cases. The most common management strategies employed were conversion to enteral feedings in five patients and placement of a new catheter directly into the right atrium by thoracotomy in another five patients. Two of the five with right atrial catheters experienced a postpericardiotomy syndrome (fever, pericardial rub, and pulmonary infiltrates) that responded promptly to indomethacin. The most significant long-term sequela of SVCO was the need for a left jugular vein to right atrial appendage bypass in one patient with chronic venous congestion from her SVCO. Once the SVCO is confirmed, systemic heparinization provides immediate antithrombotic effect and minimizes the risk of pulmonary embolism. The use of streptokinase may result in rapid thrombolysis.

Central venous catheter related sepsis: a clinical review

Central venous catheterization is one of the most common invasive vascular procedures performed in hospitals today. Though catheter related sepsis occurs only in a small percentage of catheterized patients, this complication has a tremendous impact due to the ubiquitous use of central venous catheters and consequent morbidity and even mortality. Recent studies have considerably advanced our knowledge regarding the pathogenesis, diagnosis, and prevention of catheter sepsis. In this paper, current concepts regarding catheter-related sepsis are reviewed, regarding the incidence, pathophysiology, diagnosis, prevention, and therapy of this complication. Particular emphasis is placed upon recent research and clinical advances in this field, which have clarified important question and suggested promising approaches to the prevention and treatment of catheter bacteremia. The excessive morbidity and mortality due to catheter-related sepsis can be markedly decreased, by attention to simple infection control methods, and by future implementation of new experimental techniques.

Staphylococcus aureus bacteremia in patients with Hickman catheters

PURPOSE

Determination of outcome and prognostic variables associated with Staphylococcus aureus bacteremia in patients with Hickman catheters.

PATIENTS AND METHODS

At the University of Washington Medical Center, 37 patients with Hickman catheters and S. aureus bacteremia were studied by retrospective chart review. Clinical features associated with each episode of infection were determined, and the relationships among clinical features, therapy, and outcomes were explored.

RESULTS

Only 18% of all Hickman catheter-associated S. aureus bacteremias and only 10% of those cases with exit site infections were cured without catheter removal. In seven of 41 episodes (17%), death or bacteremic relapse occurred. The best prognosis was found in infections with a low blood culture colony count (less than 1 colony/mL).

CONCLUSION

Hickman catheter-associated bacteremia due to S. aureus has a worse prognosis than other Hickman catheter-associated bacteremias. Early catheter removal should be considered except in cases with a remote, noncatheter focus of infection or in infections with no catheter-related physical signs and blood culture colony counts of less than 1/mL.

Infections related to central venous catheters

Infection is a potentially life-threatening complication of central venous catheterization. Although line-related bacteremias and sepsis are relatively uncommon, the frequent use of central lines in the intensive-care unit makes these infections a common consideration. Semiquantitative culture techniques for analysis of the catheter tip provide evidence for the diagnosis of catheter-related infections. Bacterial growth of more than 15 colony-forming units/plate is typically considered significant. Preventive measures include using sterile insertion techniques, providing meticulous care for the local site, and minimizing the duration of catheter use. The practice of changing lines over a guidewire is controversial. For treatment of most catheter-related infections, the catheter should be removed and antibiotics should be administered if associated systemic infection occurs.

Nosocomial infections in the pediatric patient: an update

Substantial progress has been made in measuring the burden of nosocomial infection in pediatric patients, particularly in certain populations (e.g., critical care, immunocompromised, chronic care, and patients with acquired immunodeficiency syndrome) and after certain procedures (e.g., central catheter lines and open-sternum cardiovascular surgery). Preventive measures, such as the use of goggles, gowns, and gloves, have been subjected to new and additional study. The following report is a summary of recent progress. A review of factors responsible for infection in various patient care populations and settings and recommendations for control are presented.

Infectious complications of indwelling long-term central venous catheters

The long-term CVC allows patients with a variety of diseases to lead a more normal and pain-free life. The use of these catheters has become commonplace in most hospitals, and the physician caring for patients in the ICU will be caring for increasing numbers of patients with an indwelling long-term CVC. Infections of these catheters can be manifested in many different ways: tunnel infections, exit site infections, catheter-related bacteremia, and septic thrombophlebitis. The overwhelming majority of these infections are caused by coagulase-negative staphylococci, but physicians should be aware of the wide variety of organisms that can infect the long-term CVC. The diagnosis of long-term CVC sepsis can be difficult, but the use of quantitative blood cultures for catheters left in place and the Maki method for culturing those catheters that are removed will aid physicians in their quest for diagnostic certainty. The great majority of catheter infections will resolve with antibiotic therapy alone without the need for catheter removal, but there are important exceptions to this general rule. Tunnel infections and fungal long-term CVC infections often require catheter removal for their resolution; septic thrombophlebitis and CR-SCVT require the addition of anticoagulation or fibrinolytic therapy to antibiotic regimens for resolution of the infection, and surgical debridement may be warranted if these modalities fail to resolve the infection.

Assessment of insertion techniques and complication rates of dual lumen central venous catheters in patients with hematological malignancies

One hundred and twenty-three dual lumen silicone rubber central venous catheters were inserted into 101 patients with hematological malignancies undergoing intensive treatment. There was a perioperative complication rate of 13%. Open and closed techniques for inserting the catheter were compared. The operating time needed for introducing the catheter by the closed technique (average, 51 minutes) was significantly shorter (p less than 0.001) than the time needed for the open technique (70 minutes), whereas complication rates were equal in both techniques. On average, the catheters functioned for 149 days. Complications leading to removal were observed in 29.3% of patients, most of which were catheter-related infections (20.4%). Thromboembolic complications leading to removal were less frequent (4.1%) and appeared significantly earlier (p less than 0.001). These data indicate that introduction of the catheter by direct puncture of the subclavian vein is a quick and safe technique, and that this type of catheter is suitable for long-term use, both for infusion and for blood sampling.

Sepsis of vascular catheters. II: In vitro disinfection of colonized tubing

Preparatory to development of in situ disinfection of implanted catheters, silicone rubber tubing colonized by incubation with Staphylococcus aureus, Staphylococcus epidermidis, or Klebsiella pneumoniae was used to test the efficacy of various chemicals in vitro. Protocols sterilizing all segments colonized for 24 h (n = 30) were immersion into 50% povidone iodine for 5 and 60 min, 100% povidone iodine for 5, 15, and 60 min, 1.2 x 10(3) ppm chlorine dioxide for 15 and 60 min, and 1.2 x 10(3) ppm chlorine dioxide buffered to pH 5.1 for 60 min. Immersion in up to 2% chlorhexidine, 7.4% formaldehyde, or 6% sodium hypochlorite for up to 60 min failed to sterilize all segments. None of 117 control segments were sterilized. Segments colonized for seven days were sterilized by immersion into 100% povidone iodine for 15 or 60 min. Use of 1.2 x 10(3) ppm chlorine dioxide for 60 min sterilized 97% of segments tested. Lower concentrations and shorter exposure times failed to sterilize all segments. Eighteen silicone rubber catheters, colonized on the outer surface, were all sterilized within 24 h by a chlorine dioxide solution placed in the lumen and diffusing through the wall to kill the bacteria.

Nosocomial septicemia in the cancer patient: the influence of central venous access devices, neutropenia, and type of malignancy

Nosocomial septicemias that occurred over a 32-month period on an inpatient medical oncology service were reviewed. One hundred four episodes of septicemia occurred in 84 patients, 33% with solid tumors and 67% with leukemia or lymphoma. Sixty were primary septicemias, with the remainder being secondary. Of the 118 isolates recovered, 42% were Gram-positive organisms, 45% Gram-negative organisms, and 13% were fungi. Coagulase-negative staphylococci and Escherichia coli were the most common Gram-positive and Gram-negative isolates, respectively. The effect of the type of malignancy, neutropenic status, and presence of a central venous access device (CVAD) on the isolate(s) recovered was studied. Coagulase-negative staphylococci were more commonly isolated from leukemia-lymphoma patients (26% vs. 3%, P less than .01), while Gram-negative isolates (63% vs. 36%, P = .01), specifically Klebsiella species (21% vs. 5%, P = .02), were more common in solid tumor patients. Staphylococcus aureus was isolated more frequently from non-neutropenic patients than from those with neutropenia (19% vs. 4%, P = .02). Gram-positive isolates were more commonly found in patients with a CVAD (51% vs. 29%, P = .03), in particular coagulase-negative staphylococci (29% vs. 2%, P less than .001). In contrast, Gram-negative isolates (62% vs. 34%, especially Klebsiella species (22% vs. 3%, P less than .01) and S. aureus (18% vs. 5%, P = .07) were more commonly isolated from patients with no CVAD. Neither neutropenia nor the presence of a CVAD predisposed to early mortality. Our data suggest that empiric antimicrobial coverage for presumed nosocomial septicemia in the febrile cancer patient should include vancomycin for patients with a CVAD to cover coagulase-negative staphylococci and a cephalosporin for patients with solid tumors, especially those without a CVAD, to cover Klebsiella species.

A comparison of placement techniques and complications of externalized catheters and implantable port use in children with cancer

The complications associated with the placement and use of Hickman catheters (n = 120), Broviac catheters (n = 146), and implantable ports (n = 93) in children with cancer were analyzed. Percutaneously placed central venous access devices (CVADs) tended to fail less often (P = .86) and to develop infections less often (P = .056) than surgically placed CVADs. The difference in complications with percutaneous versus surgically placed CVADs requires confirmation in a randomized trial to assure they are not a result of differences in patient characteristics. When all catheter failures (removal due to infection, obstruction, or dislodgement) were considered, ports had a significantly longer failure-free duration of use than externalized Hickman and Broviac catheters (P = .0009). Ports also remained infection-free longer than externalized catheters (P = .0014). The greatest risk of infection occurs in the first 100 days of use, particularly for ports. This study demonstrates that for long-term use (greater than 100 days) ports are superior to externalized catheters in children with cancer.

Complications from long-term indwelling central venous catheters in hematologic patients with special reference to infection

Forty-three evaluable patients with hematologic malignancies, mainly acute leukemia, were prospectively randomized to receive a double lumen central venous catheter or a totally implantable venous access system. The mean catheter stay was 166 days (median, 104 days) for the 23 double lumen catheters and 164 days (median, 65 days) for implanted systems. Exit site infections were not encountered in double lumen catheters, but there were two proven infections around the injection port of implanted devices. Tunnel infections did not occur. Seven double lumen catheters and four implanted systems were removed because of infection. Staphylococcus epidermidis was the predominant microorganism cultured from these catheters. Five of nine patients with double lumen catheters and catheter-related S. epidermidis infection and the two patients with implanted systems in whom S. epidermidis was cultured were on selective gut decontamination. The pattern of infection did not seem to be influenced by this regimen. Totally implantable systems proved to be as safe as double lumen central venous lines.

Antimicrobial therapy in special situations, including extended care facilities and the outpatient setting

After implementation of the diagnosis-related group (DRG) payment system by the federal government there has been a shift of medical care, including intravenous antibiotic therapy, from the acute care hospital to the extended care facility and to the patient's home. Antibiotic selection in the extended care facility involves consideration of a number of factors such as the health status of the patient and the common infections that occur in patients in these facilities, which generally are similar to hospital-acquired infections. Home intravenous therapy is appropriate for treatment of some infectious diseases and is generally safe, although a number of infections and other complications may occur and may require consideration by the physician and the home therapy nurse. Common infectious complications and choices of antibiotic therapy in these two settings are reviewed.

Venous access devices utilized in association with intensive cancer chemotherapy

Consistent and reliable venous access is a major component of the management of patients with cancer undergoing chemotherapy. Venous access devices such as the long-term right atrial catheter and the subcutaneous port have become a major aspect of the supportive care of such individuals, with resultant advantages which have improved their quality of life. Yet, the occurrence of infectious and non-infectious complications restricts the usefulness of these devices and warrants a standardized approach to device placement, patient education and the management of such complications. Infectious complications, including exit site and tunnel infections, as well as bacteremias requiring catheter removal occur at a rate of approximately two episodes for every 1000 catheter days, while non-infectious complications occur more frequently. Uniform patient education and catheter care, as well as placement by a single consistent surgeon will decrease the frequency of complications, improve the longevity and function of these venous access devices, while minimizing the associated morbidity.

Bacteremia and fungemia in the immunocompromised patient

Considerable changes have occurred during the 1980s in the clinical nature and diagnosis of bacteremia and fungemia in the immunocompromised patient. Cancer patients with prolonged neutropenia, many with indwelling catheters, and AIDS patients with both T-cell and B-cell deficiencies have changed the spectrum of organisms causing septicemia. There has been a shift to infection with gram-positive bacteria, including mycobacteria, and water-borne organisms, including Acinetobacter spp. and Pseudomonas spp. New blood culture systems, including a lysis-centrifugation system and radiometric methods utilizing resin broth media, remove antagonistic antimicrobial agents, and the lysis-centrifugation system routinely provides quantitation of organisms from the blood. Quantitation has been used to identify sources of infection, to differentiate contamination from true infection, and to monitor the course of antibiotic treatment.

Randomized prospective study comparing vancomycin with teicoplanin in the treatment of infections associated with Hickman catheters

In 72 episodes of suspected or proven Hickman-catheter-associated infection occurring in 59 patients with various hematological disorders, patients were assigned to treatment with either vancomycin or teicoplanin in a randomized nonblinded prospective study. Of 60 episodes evaluable for response, 28 were treated with vancomycin and 32 were treated with teicoplanin. Sixteen infective episodes were microbiologically documented in the vancomycin group, and twenty-one were microbiologically documented in the teicoplanin group. Microbiologically and clinically documented infections treated with vancomycin had an 80% response rate, compared with a 69% response rate for those treated with teicoplanin (P = 0.316). Adverse events occurred in nine (25%) of the episodes in the vancomycin group, compared with three (8%) in the teicoplanin group (P = 0.044). Teicoplanin may provide an effective alternative to vancomycin in the treatment of Hickman-catheter-associated infection in patients with hematological malignancies.

Vascular access in gynecologic cancer using the Groshong right atrial catheter

From December 1986 through July 1987, forty-one Groshong catheters were inserted in 38 patients with invasive gynecologic cancer for a cumulative total of 4170 days of patient use. (mean catheter indwelling time: 93 days; range: 3-300 days). A supraclavicular approach was used to cannulate the brachiocephalic vein in 31 patients. In 6 patients, the subclavian vein was cannulated via an infraclavicular approach, while 4 patients had the catheters placed via external jugular venous cutdown. Thirty-seven catheters were inserted at the bedside without fluoroscopy using the Seldinger technique and a peel-away catheter introducer sheath. A chest x-ray was used to confirm the right atrial position of the catheter. Major complications included two pneumothoraces, and three catheter-related cases of sepsis. A unique feature of the Groshong catheter is a pressure-sensitive two-way valve at the intravascular end, minimizing the potential for air embolism and back-bleeding. This eliminates the need for a heparin flush or external clamping, but permits blood sampling. Catheter insertion and maintenance procedures at bedside are simple, time saving, and cost effective. With the increasing use of continuous chemotherapy infusion protocols, use of vesicant drugs, hyperalimentation, and the need for outpatient therapy, we recommend early placement of the Groshong catheter in the oncology patient.

Infections associated with Hickman catheters in patients with acquired immunodeficiency syndrome

PURPOSE

Hickman catheters are frequently used as convenient long-term venous access in patients with acquired immunodeficiency syndrome (AIDS). These patients seem to be at increased risk for bacterial infections of intravenous devices. The aim of our study was to determine the frequency of Hickman catheter infection in patients with AIDS as compared with that in other patients.

PATIENTS AND METHODS

We analyzed the records of 69 patients who underwent 71 consecutive Hickman catheter placements during a one-year study period.

RESULTS

Forty-six Hickman catheters were inserted in 44 patients with AIDS, and 25 Hickman catheters were placed in 25 other patients. There were 18 infections: 16 occurred in patients with AIDS, and two developed in the control group (p less than 0.05). The 16 infections in AIDS were as follows: five exit site, five septicemias, two tunnel, one septic phlebitis, and three probable Hickman catheter-related. Staphylococcus aureus was responsible for 14 cases (87%); Staphylococcus epidermidis was responsible for four cases (25%). Mean onset of infection was 32 days, but seven patients were diagnosed in the first eight days after Hickman catheter insertion. Fever occurred in all patients with early infection, leukopenia was present only in three; infusion of parenteral nutrition did not increase the risk. Two early infections were fatal. The rate of Hickman catheter infection in patients with AIDS was 0.47 per 100 catheter days, as compared with 0.09 in the control group.

CONCLUSION

Our findings underscore the need for using Hickman catheters only when absolutely indicated in patients with AIDS, since the risk of serious infectious complications appears to be high.

Infections associated with indwelling devices: concepts of pathogenesis; infections associated with intravascular devices

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Pulmonary septic emboli mimicking metastatic rhabdomyosarcoma

Central venous catheters have proven to be an important aid for the care of pediatric patients with malignancies receiving chemotherapy. A rare complication of such catheters is pulmonary septic emboli. This report describes a 15-year-old white girl with rhabdomyosarcoma who developed pulmonary nodules while on chemotherapy. These lesions appeared to be metastatic rhabdomyosarcoma. However, an excisional biopsy showed the lesions to be septic emboli. The patient was placed on antibiotic therapy and responded well. She was able to continue with her "front-line" therapy because the nodules were confirmed not to be metastatic disease.

Continuous venous access in children with urological diseases

The placement of multipurpose silicone right atrial catheters for continuous venous access in children with complex urological diseases has become increasingly necessary. Between September 1985 and September 1987, 26 children with a variety of urological diseases required long-term central venous access, primarily for delivery of chemotherapy and blood products in 13 patients with malignancies, hemodialysis access in 7 undergoing renal transplantation, total parenteral nutrition in 5 (2 of whom were born with cloacal exstrophy), and fluid and antibiotic administration in 1 with dermatomyositis and acute pyelonephritis. Patient age at catheter placement ranged from 1 day to 15 years. A total of 11 complications was encountered during 4,500 catheter days: 10 were mechanical and 1 was infectious in nature. These complications led to replacement of the catheter in 3 patients and the remainder were managed successfully nonoperatively. The surgical techniques involved in placement of these catheters are discussed. The catheters not only allowed many of these patients to receive treatment on an outpatient basis but also ensured their survival. Our favorable experience with prolonged venous access in children should encourage urologists to include these techniques in their armamentarium.

Port-A-Cath in children during long-term chemotherapy: complications and outcome

Complications related to Port-A-Cath were studied prospectively during a period of 32 months in 31 patients, aged 1-18 years, with leukemias and solid tumors. There were 34 Port-A-Cath inserted, and the cumulative time for these catheters kept in place was 5899 days. No complications occurred in 18 patients (19 catheters) kept in place for a cumulative time of 3998 days with an average duration of 210 days (12-550 days). In 13 patients (15 catheters) there were 14 events of systemic infections; seven events were treated successfully with antibiotics, four events necessitated the extraction of the catheter (in one patient a combination of systemic and local infection), and in three events the catheters were kept unused, as the patients were in terminal stages. Nonsystemic complications occurred with five catheters; two local infections, two obstructions (catheters removed), and one local bleeding (catheter kept unused). Appropriate antimicrobial treatment of systemic infections enables the immunocompromised child to keep the Port-A-Cath in place for a long time.

Treatment of an infected silicone right atrial catheter with combined fibrinolytic and antibiotic therapy: case report and review of the literature

Tunnelled silicone rubber right atrial catheters are commonly used to administer long-term total parenteral nutrition (TPN), cancer chemotherapeutic agents, and antimicrobial agents. The indwelling devices potentiate platelet-fibrin thrombi formation, providing a nidus for infection. Although many episodes of sepsis associated with thrombotic tunnelled catheters respond to antimicrobial therapy alone, a significant number require catheter removal. Evidence from case studies and small clinical trials suggests that fibrinolytic agents may increase the response rate and prevent removal of the device when combined with antimicrobial therapy. We present the first case reported of bacterial sepsis secondary to a thrombotic indwelling Hickman catheter for long-term TPN successfully treated with a combination of streptokinase and antibiotic therapies.

Home parenteral nutrition for the child with cancer

Compliance with treatment is greatly increased when the caregiver(s) understand the treatment, the need for the treatment, and the need for strict adherence to sterile technique. When the caregiver is not ready to handle home care of the child, compliance is less than optimal and may be a threat to the child. Parenteral nutrition support can be both safe and effective in children with cancer when the family and health-care team work together. Nutrition support facilitates treatment of the whole child and can help improve his or her quality of life.

Thrombosis: the major Hickman catheter complication in patients with solid tumor

Major complications of Hickman catheter placement (thrombosis and infection) were determined in 168 patients with solid tumor (lung, 79; head and neck, 56; esophagus, 24; and miscellaneous, 9). Catheter-related thrombosis was clinically detected in 22 individuals and was detected at autopsy in six (total 17 percent). The 17 percent figure underestimates the true incidence of thrombosis since only 25 percent of study patients had autopsies. Patients with adenocarcinoma of the lung constituted a high risk group. Nine of 20 (45 percent) of these patients had thrombosis compared to 25, 9, and 16 percent of patients with squamous cell cancers of lung, head and neck and esophagus, respectively (p less than 0.002). Three patients with thrombosis had pulmonary emboli and two died. Thrombosis occurred despite daily heparin catheter flushing. INfections occurred in 11 patients. One had suspected endocarditis, one had a subcutaneous tunnel infection, and nine had exit site infections. All responded to local or systemic antibiotics. Better methods to prevent thrombosis are needed.

Prospective study of infections in indwelling central venous catheters using quantitative blood cultures

PURPOSE

Surgically implanted central venous catheters are widely used in cancer patients in whom there is a need for prolonged venous access for chemotherapy, parenteral nutrition, antibiotics, and blood sampling. This study evaluated catheter infectious complications, including catheter-related sepsis, exit site infection, and tunnel infection. Specifically, an evaluation of the incidence, type, and response to treatment of indwelling catheter infections was performed, and conditions under which the catheter should be removed were delineated.

PATIENTS AND METHODS

During the year of this study, 488 central venous catheters were implanted. Records were maintained on demographic variables, date of catheter implantation, surgeon, white blood cell count, absolute neutrophil count, and underlying diagnosis. Blood for both aerobic and anaerobic culture was collected from each patient. For patients in whom infection developed, clinical features, white blood cell count, absolute neutrophil count, and microbiologic data were noted, as were the clinical course and response to treatment.

RESULTS

A total of 142 episodes of infectious complications were documented. There were 88 episodes of catheter-related sepsis, and 33 of 54 evaluable episodes (61 percent) were successfully treated with antibiotics. There were 34 episodes of exit site infection, and 20 of the 29 evaluable episodes (69 percent) were successfully treated with antibiotics and local care. Of the 20 tunnel infections, only five (25 percent) were successfully treated with antibiotics, and the other 15 required catheter removal for cure. Twelve of the 15 cases requiring catheter removal were caused by Pseudomonas species.

CONCLUSION

On the basis of these results, compulsory removal of the catheter is not required in cases of catheter-related sepsis. Similarly, exit site infections can often be cured by means of antibiotics and local care. However, catheter removal is required to achieve cure in most tunnel infections, particularly if Pseudomonas species are cultured from the exit sites of patients with tunnel infection.

An attachable silver-impregnated cuff for prevention of infection with central venous catheters: a prospective randomized multicenter trial

PURPOSE

Percutaneously inserted central venous catheters are widely used. Catheter-related bacteremia or fungemia is the most frequent serious complication of these catheters. In an attempt to reduce the frequency of such infections, a subcutaneous cuff constructed of a biodegradable collagen matrix impregnated with bactericidal silver was developed. Our goal was to assess, in a multicenter clinical trial, the effectiveness of this cuff in preventing catheter-related infection.

MATERIALS AND METHODS

Central venous catheters needed for fluid or drug therapy, hemodynamic monitoring, or hyperalimentation in patients in three centers were randomly assigned to be inserted with or without the cuff. Patients and catheters in the two groups were comparable in terms of risk factors predisposing to infection, including colonization of skin about the insertion site.

RESULTS

The results with 234 catheters inserted into a new site showed that catheters inserted with the cuff were threefold less likely to be colonized on removal (more than 15 colony-forming units) than were control catheters (28.9 percent versus 9.1 percent, p = 0.002) and were nearly fourfold less likely to produce bacteremia (3.7 percent versus 1.0 percent). Adverse effects from the cuff were not seen. The cuff did not confer protection, however against infection with catheters inserted over a guidewire into old sites. Most of the catheter-related infections identified in this study, including four of the six bacteremias, appear to have been caused by microorganisms colonizing skin about the insertion site, affirming the pathogenetic basis for benefit seen with the cuff in this clinical trial; two may have derived from contamination of the catheter hub.

CONCLUSION

This novel, silver-impregnated, attachable cuff can substantially reduce the incidence of catheter-related infection with most percutaneously inserted central venous catheters, can extend the time catheters can be left in place safely, and can prove cost-beneficial.

Central venous catheter infections

When used wisely, central venous catheters are capable of providing vital circulatory access in any patient with a remarkably low risk of infection or major complication. Tunneled silicone catheters are the route of choice for long-term or outpatient use, particularly for oncology or TPN patients; insertion of such a catheter should occur early in the hospitalization of a newly diagnosed patient on chemotherapy. The greatest experience has accrued with the cuffed silicone catheters (for example, Broviac), but the totally implantable devices (for instance, Port-a-cath) may become the device of choice in pediatric outpatients. For infants, small, percutaneously inserted noncuffed silicone catheters appear to offer the greatest safety. Among acute care patients, percutaneous plastic central venous catheters fulfill a vital role but represent an important source of infection. Scrupulous technique, the minimizing of manipulation, and a readiness to replace the catheter at any suggestion of trouble are important to achieving the best results. Within a given design, it is generally best to use the smallest diameter catheter capable of performing the desired tasks. However, on the basis of currently available data, there need be no hesitation to use a multilumen catheter if the care of the patient demands multiple access ports. The various silicone catheters can usually be left in place while infection is treated, although fungal and certain other infections are more likely to require catheter removal. Percutaneous plastic catheters should be removed or changed over a wire if infection is suspected; if tip culture of the removed catheter is positive, and the catheter was replaced over a wire, then the replacement catheter should be promptly removed.

Bacteraemia related to indwelling central venous catheters: prevention, diagnosis and treatment

Infective episodes in immunocompromised children with indwelling central venous catheters were studied prospectively for one year. Culture of catheter hubs and skin at catheter entry sites during the first six months suggested that hub contamination was important in the pathogenesis of catheter colonization. The incidence of catheter-related bacteraemia, and possible catheter-related bacteraemia, fell by 56.5% following alterations in the protocol for manipulative care of catheters, from 5.82 per 1000 catheter days in the first six months to 2.53 per 1000 catheter days in the subsequent six months. A firm diagnosis of catheter-related bacteraemia was made simply and economically by a pour-plate quantitative blood culture technique. Attempts at eradication of catheter-related bacteraemia without removal of the catheter were successful in all cases.

The value of prophylactic antibiotics during the insertion of long-term indwelling silastic right atrial catheters in cancer patients

Over a 3.5 year period from August 1982 to December 1985, 200 Hickman catheters (Evermed, Medina, WA) were inserted into patients at the King Faisal Specialist Hospital and Research Centre (KFSHRC), Riyadh, Saudi Arabia. One hundred sixty catheters were placed in patients with malignant disease, many of whom were immunosuppressed at the time of catheter insertion. Seventy of 160 (44%) patients received prophylactic antibiotics and 90 (56%) did not. The mean age of each group was 23 years (range, 2 to 70 years), and the patients in each group were statistically similar in sex, underlying disease, and routine preoperative hematologic and biochemical evaluation. Exit-site wound infections occurred in 50 of 90 (55.5%) patients who did not receive prophylaxis and in 12 of 70 (17%) patients who received prophylaxis (P less than 0.0001). There was no statistically significant difference in the incidence of tunnel and incision site infections. The mean duration of antibiotic prophylaxis was 2.9 days (SD, 1.2 days). Organisms cultured from catheter associated infections, included Staphylococcus epidermidis 36, S. aureus 30, Klebsiella pneumoniae 1, Pseudomonas aeruginosa 3, Escherichia coli 1, and diphtheroids non-CDC-JK 3. Vancomycin was used as antibiotic prophylaxis in 64 patients, Kefzol (Eli Lilly, Indianapolis, IN) in one, oxacillin in three, nafcillin in one, and Septra (Burroughs Wellcome, Research Triangle Park, NC) in one. The data indicate that the use of intravenous antibiotic prophylaxis significantly reduces exit site infection and may reduce both tunnel and incision site infection. Prophylactic antibiotic coverage should be provided to patients during insertion of long-term indwelling right atrial catheters.

Vertebral osteomyelitis due to Staphylococcus warneri attributed to a Hickman catheter

A patient with a long-term right atrial (Hickman) catheter developed vertebral osteomyelitis due to Staphylococcus warneri. Documentation of this event--to our knowledge previously unreported--was made possible by use of special studies including plasmid profiles of the coagulase-negative staphylococcal isolates.

Central venous catheters for children with malignant disease: surgical issues

The use of long-term central venous catheters has eliminated the fear and pain of repeated venopunctures for children with malignant disease, but problems still exist for the surgeon. Issues include choice of catheter, site and technique of placement, prevention of infection and accidental displacement, and removal. Five years' experience with 102 catheter placements in 81 children with leukemia or malignant tumors has been reviewed. These catheters remained in place an average of 318 days (32,481 patient days), maintained at home under close nursing supervision. Six months after the last entry in this series, 14 catheters are functioning and 35 patients have died with catheters intact. Fifty-three catheters have been removed because of completion of treatment (29), infection (10), dislodgement (11), and other reasons (3). In these immunocompromised patients, infectious episodes were common (186 episodes) but only ten episodes required removal of the catheter for control (1/3,248 days of use). Central venous catheters are of great help in treatment of children with malignant disease, and with careful attention to detail complications can be minimized. The advantages of central venous catheters are so great that almost all parents now agree to their use from the time the diagnosis is made, despite the possible problems with maintenance, dislodgement, and infection.