Placing of tunneled central venous catheters prior to induction chemotherapy in children with acute lymphoblastic leukemia

Results of a long-term, prospective study on complications of central venous catheter in pediatric patients with hematologic-oncologic diseases

BACKGROUND

Central venous catheter (CVC)-related complications remain a significant cause of morbidity in pediatric hematology-oncology. We prospectively surveyed the incidence of CVC-related complications in children with hematologic-oncologic diseases.

PROCEDURE

Five-hundred-eighty-one CVCs were inserted in 421 patients from January 2010 to June 2022 (153,731 CVC days observation; follow-up data up to December 31, 2022).

RESULTS

Overall, 671 complications were recorded (4.365/1000 CVC days): 49.7% malfunctions (1.88/1000 CVC days, 4.8% of CVC early removals), 23.9% bacteremia (0.90/1000, 15.1%), 19.6% mechanical complications (0.74/1000, 70.2%), 20.1% localized infections (0.76/1000, 17.1%), 0.5% thrombosis (0.02/1000, 33.3%). At multivariate analysis, risk factors for malfunction were Broviac-Hickman type of CVC (hazard ratio [HR] 2.5) or Port-a-cath (HR 3.4) or Proline (HR 4.3), p < .0001; for bacteremia double-lumen CVC (HR 3.2, p < .0001); for mechanical complications age at CVC insertion under median (HR 4.5, p < .0001) and Broviac-Hickman (HR 1.6) or Proline (HR 2.7), p = .01; finally for localized infections Broviac-Hickman (HR 2.9) or Proline (HR 4.4), p = .0001. The 2-year cumulative incidence of premature removal was 23.5%, and risk factors were age at CVC insertion under median (HR 2.4, p < .0001), Broviac-Hickman (HR 2.3) or Proline (HR 4.2), p < .0001.

CONCLUSIONS

Premature removal occurs in approximately 20%-25% of long-term CVCs. A surveillance program has a fundamental role in identifying the risk factors for CVC complications and the areas of intervention to improve CVC management.

Tunnelled external versus implanted port central venous catheters in paediatric oncology: a systematic review and meta-analysis

OBJECTIVE

To evaluate and compare the complications associated with tunnelled external and implanted port (PORT) central venous catheters (CVCs) in children with cancer.

DESIGN

A systematic review in accordance with PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols) guidelines was performed (pre-registered on PROSPERO: CRD42022300869). MEDLINE, Web of Science and the Cochrane Library databases were searched.

PATIENTS

Patients ≤18 years of age with haematological or solid malignancies.

INTERVENTIONS

Studies comparing tunnelled external and PORT CVCs.

MAIN OUTCOMES MEASURES

Infection, mechanical failure, thrombosis, bleeding, acceptability, quality of life (QoL), cost, premature removal, and days from insertion to removal for any reason.

RESULTS

Twenty-three observational studies met the inclusion criteria, representing 6644 devices and 6032 patients. Tunnelled external CVCs were associated with an increased risk for systemic infection (OR 2.10, 95% CI 1.59 to 2.77, p<0.001, 16 studies, 3425 devices). There was no significant difference in the risk of localised infection (OR 1.15, 95% CI 0.66 to 2.01, p=0.62, 5 studies, 979 devices). Tunnelled external CVCs were also associated with a significantly increased risk of mechanical complications (OR 2.47, 95% CI 1.21 to 5.05, p=0.01, 11 studies, 2187 devices) and premature device removal (OR 3.24, 95% CI 1.28 to 8.22, p=0.01, 6 studies, 1514 devices).

CONCLUSION

This study shows that PORTs associate with a reduced risk of infectious and mechanical complications, and a lower overall risk of removal, compared with tunnelled external CVCs in children with cancer. Further work is required to confirm these findings in a prospective randomised trial and to compare cost implications and acceptability to patients and caregivers.

Timing of Central Venous Line Insertion During Induction in Children With Acute Lymphoblastic Leukemia

PURPOSE

Central venous lines (CVL) in children with acute lymphoblastic leukemia (ALL) provide comfortable administration of intensive chemotherapy and blood sampling. The optimal time for the insertion of CVL in patients with ALL during induction therapy is controversial. This study aimed to investigate the frequency of CVL-related complications in children with ALL concerning the time of CVL insertion.

PATIENTS AND METHODS

We reviewed the records of 52 pediatric ALL patients with CVL. CVL placement before or on treatment day 15 was defined as "early insertion", and after treatment day 15 was defined as "late insertion". Demographics, preoperative blood counts, type of central line, time of CVL placement, CVL-related complications, and blood counts during complications were all noted. All the data were collected from those with the first catheter use.

RESULTS

CVL was placed ≤15 days in 26 patients (50%) and after 15 days in 26 patients (50%). Regarding the infection rates, no statistical difference was found between early and late CVL-inserted groups ( P =n.s.). Five patients developed thrombosis, and risk was found to be similar between early and late CVL-inserted groups ( P =n.s.). Catheter-related mechanical complications were recorded in 7 patients (3 in early and 4 in late CVL-inserted group, ( P =n.s.).

CONCLUSION

The present study showed no relation between the timing of CVL placement during induction therapy and the occurrence of infection and thrombosis. Our results suggest that CVL can be placed safely at the time of diagnosis or early induction treatment to provide a comfortable administration of chemotherapy and decrease painful blood samplings.

Risk factors for catheter-related infection in children with cancer: A systematic review and meta-analysis

RATIONALE

To understand the risk factors for catheter-related infection during treatment of pediatric cancer is essential to implement measures to prevent its occurrence.

BACKGROUND

We performed a comprehensive systematic review of the literature with meta-analysis to identify and synthesize the main risk factors for catheter-related infection in children undergoing oncological treatment.

METHODS

Systematic searches were conducted in Medline, Embase, Lilacs, and BVS (Biblioteca Virtual em Saúde) until January 2022, following PRISMA guidelines. The search was not limited to language or dates. Risk factors were divided into host-related, assistance-related, and catheter types. We also describe the most common pathogens.

RESULTS

Thirteen studies were included in the review. Diagnosis of hematological neoplasm, the intensity of treatment, blood transfusion in the 4-7 days before the infection, type of long-term catheters (tunneled externalized catheters, double lumen, greater diameter), inpatient treatment, and a longer period of hospitalization were the most consistent risk factors. Metanalysis showed that neutropenia at the moment of catheter placement is not a risk factor for central-line-associated bloodstream infections, however, there is high heterogeneity between studies. Staphylococcus epidermidis was the most common pathogen reported.

CONCLUSIONS

Understanding risk factors is an essential step to reduce morbidity and mortality of catheter-related infection. Education for preventive measures, reduction of hospitalization, wisely choosing the most adequate type of catheter, and the best moment for catheter insertion may reduce the occurrence of catheter-related infection.

Impact of Perioperative Absolute Neutrophil Count on Central Line-Associated Bloodstream Infection in Children With Acute Lymphoblastic and Myeloid Leukemia

Background

There is lack of evidence concerning safety of placement of tunneled central venous catheters (TCVCs) in neutropenic children with acute leukemias. Here, we evaluate the impact of absolute neutrophil count (ANC) at the time of TCVC placement on development of central line-associated bloodstream infections (CLABSI) in children with lymphoblastic (ALL) or myeloid leukemia (AML).

Materials and Methods

A retrospective observational study of children undergoing TCVC placement at a tertiary referral hospital between January 2000 and December 2019 was performed. Traditional and competing-risks regression models were used to estimate the effect of perioperative ANC on development of CLABSI.

Results

A total of 350 children (median age 6.4 [IQR: 3.1–10.9] years) underwent 498 consecutive TCVC implantations in neutropenic (n = 172, 34.5%) and non-neutropenic conditions (n = 326, 65.5%). The median length of observation per TCVC was 217.1 (IQR: 116.1–260.5) days with a total of 99,681 catheter days (CD). There were no differences in early (within first 30 days after TCVC placement) and overall CLABSI rates between neutropenic and non-neutropenic patients (HR 1.250, p = 0.502; HR 1.633, p = 0.143). We identified female sex (HR 2.640, p = 0.006) and the use of TCVC for treatment of relapsed leukemia (HR 4.347, p < 0.0001) as risk factors for early CLABSI and the use of double-lumen catheters (HR 2.607, p = 0.003) and use of TCVCs during leukemia relapse (HR 2.004, p = 0.005) for overall study period.

Conclusion

The placement of TCVC in children with neutropenia undergoing anticancer therapy for acute leukemia is safe and not associated with an elevated rate of CLABSI.

Selection and Insertion of Vascular Access Devices in Pediatrics: A Systematic Review

OBJECTIVE

To critically review the evidence for the selection and insertion of pediatric vascular access devices (VADs).

DATA SOURCES

Data were sourced from the US National Library of Medicine, Cumulative Index to Nursing and Allied Health, the Cochrane Library databases, Embase, and international clinical trial databases.

STUDY SELECTION

Clinical practice guidelines, systematic reviews, cohort designs, randomized control trials (RCTs), quasi RCTs, before-after trials, or case-control studies that reported on complications and/or risk as well as reliability of VADs in patients aged 0 to 18 years were included.

DATA EXTRACTION

Articles were independently reviewed to extract and summarize details on the number of patients and catheters, population, age of participants, VAD type, study method, indication, comparators, and the frequency of VAD failure or complications.

RESULTS

VAD selection and insertion decision-making in general hospitalized and some specialized patient populations were well evidenced. The use of single-lumen devices and ultrasound-guided techniques was also broadly supported. There was a lack of RCTs, and for neonates, cardiac patients, patients with difficult venous access, midline catheters, catheter-to-vein ratio, and near-infrared devices, the lack of evidence necessitated broadening the review scope.

LIMITATIONS

Limitations include the lack of formal assessment of the quality of evidence and the lack of RCTs and systematic reviews. Consequently, clinical decision-making in certain pediatric populations is not guided by strong, evidence-based recommendations.

CONCLUSIONS

This is the first synthesis of available evidence for the selection and insertion of VADs in pediatric patients and is important for determining the appropriateness of VADs in pediatric patients.

Risk factors for central line-associated bloodstream infections in children with tunneled central venous catheters

BACKGROUND

Central line-associated bloodstream infections (CLABSIs) are among the most common complications of central venous catheters (CVCs). The aim of this study was to examine the epidemiology of CLABSIs in tunneled CVCs and analyze their risk factors in a general pediatric population.

METHODS

Children with a tunneled CVC inserted at the University Children's Hospital Zürich between January 2009 and December 2015 were eligible for the study. The influence of CVC dwell time on the risk of CLABSI was examined using life tables. Hazard ratios (HRs) for CLABSIs were analyzed using Cox regression for age and diagnosis with cluster robust standard errors.

RESULTS

Fifty-five CLABSIs were observed in 193 patients with 284 tunneled CVCs. Overall, CVCs in children with gastrointestinal disorders and in children 2 to 5 years of age showed the highest incidence rates of 6.06 and 5.85 CLABSIs per 1,000 catheter days, respectively, during the first 90 days after placement. Gastrointestinal disease (HR, 3.89; 95% CI, 2.19-6.90; P < .001) and age 2 to 5 years (HR, 2.48; 95% CI, 1.45-4.22; P = .001) were identified as independent risk factors for CLABSI. In children without gastrointestinal disease, tunneled CVCs showed an increasing risk of CLABSI after a dwell time of 90 days.

CONCLUSIONS

The need for tunneled CVCs requires the evaluation of targeted CLABSI prevention measures, especially in young children with underlying gastrointestinal disease.

The risk of bloodstream infection associated with totally implantable venous access ports in cancer patient: a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to provide evidence-based guidance to better understand the risk of central line-associated bloodstream infection (CLABSI) in cancer patients who received totally implantable venous access ports (TIVAPs) compared with those who received external central venous catheters (CVCs).

METHODS

A systematic search of PubMed, Web of science, Embase, and the Cochrane Library was carried out from inception through Oct 2018, with no language restrictions. Trials examining the risk of CLABSI in cancer patients who received TIVAPs compared with those who received external CVCs were included. Two reviewers independently reviewed, extracted data, and assessed the risk of bias of each study. A random-effect model was used to estimate relative risks (RRs) with 95% CIs.

RESULTS

In all, 26 studies involving 27 cohorts and 5575 patients reporting the incidence of CLABSI in patients with TIVAPs compared with external CVCs were included. Pooled meta-analysis of these trials revealed that TIVAPs were associated with a significant lower risk of CLABSI than were external CVCs (relative risk [RR], 0.44; 95% confidence interval [CI], 0.31-0.62; P < 0.00001), which was confirmed by trial sequential analysis for the cumulative z curve entered the futility area. Subgroup analyses demonstrated that CLABSI reduction was greatest in adult patients (RR [95% CI], 0.35 [0.22-0.56]) compared with pediatric patients who received TIVAPs (RR [95% CI], 0.55 [0.38-0.79]).

CONCLUSIONS

TIVAP can significantly reduce the risk of CLABSI compared with external CVCs.

Reduced central line infection rates in children with leukemia following caregiver training: A quality improvement study

Infections are a leading cause of morbidity and mortality in children with acute leukemia. Central-line (CL) devices increase this population's risk of serious infections.Within the context of a quality improvement (QI) project, we tested the effect of caregiver education on CL management on the CL-associated bloodstream infection (CLABSI) rate among children with acute leukemia seen at a large referral center in Italy. The intervention consisted of 9 in-person sessions for education and practice using mannequins and children.One hundred and twenty caregivers agreed to participate in the initiative. One hundred and five (87.5%) completed the training, 5 (4.1%) withdrew after the first session, and 10 (8.3%) withdrew during practical sessions. After educational intervention, the overall CLABSI rate was reduced by 46% (from 6.86 to 3.70/1000 CL-days). CLABSI rate was lower in children whose caregivers completed the training (1.74/1000 CL-days, 95% CI 0.43-6.94) compared with those who did not receive any training (12.2/1000 CL-days, 95% CI 7.08-21.0, P < 0.05) or were in-training (3.96/1000 CL-days, 95% CI 1.98-7.91) at the time of infection.Caregiver training in CL management, applied within a multifaceted QI approach, reduced the rate of CLABSI in children with acute leukemia. Specific training and active involvement of caregivers in CL management may be effective to reduce CLABSI in high-risk children.

Surveillance of bloodstream infections in pediatric cancer centers - what have we learned and how do we move on?

Pediatric patients receiving conventional chemotherapy for malignant disease face an increased risk of bloodstream infection (BSI). Since BSI may represent an acute life-threatening event in patients with profound immunosuppression, and show further negative impact on quality of life and anticancer treatment, the prevention of BSI is of paramount importance to improve and guarantee patients' safety during intensive treatment. The great majority of all pediatric cancer patients (about 85%) have a long-term central venous access catheter in use (type Broviac or Port; CVAD). Referring to the current surveillance definitions a significant proportion of all BSI in pediatric patients with febrile neutropenia is categorized as CVAD-associated BSI. This state of the art review summarizes the epidemiology and the distinct pathogen profile of BSI in pediatric cancer patients from the perspective of infection surveillance. Problems in executing the current surveillance definition in this patient population are discussed and a new concept for the surveillance of BSI in pediatric cancer patients is outlined.

Central Venous Catheters and Bloodstream Infection During Induction Therapy in Children With Acute Lymphoblastic Leukemia

The purpose of the study was to assess the risk of first-time bloodstream infection (BSI) according to type of central venous catheter (CVC) during induction therapy in children with acute lymphoblastic leukemia (ALL). Patients eligible for our analysis were all newly diagnosed children with ALL treated at 3 pediatric centers in Denmark between 2008 and 2014. A total of 136 patients were followed from initial CVC placement until first BSI, CVC removal, death, or day 28, whichever occurred first. Thirty-nine BSIs were detected, of which 67% were gram-positive infections, and 59% met the criteria for being CVC associated. The 28-day cumulative incidence of BSI was similar in 77 patients with a nontunneled CVC (28%; 95% confidence interval, 19%-40%) and in 59 patients with a tunneled CVC with external lines (TE) (33%; 95% confidence interval, 23%-47%). Subgroup analyses showed that gram-negative blood isolates occurred more frequently in patients with a TE, and that lower incidences of BSI were detected in patients older than 9 years with a TE, and in patients with T-ALL. It is concluded that the type of CVC inserted at diagnosis has no impact upon the risk of BSI in patients with ALL undergoing induction therapy.

Strategies to Prevent and Manage Thrombotic Complications of Acute Lymphoblastic Leukemia in Children and Young People Vary Between Centers in the United Kingdom

There is a lack of evidence-based guidance for the prevention and management of thrombosis in children and young people treated for acute lymphoblastic leukemia. To determine current UK practice, a survey was sent to 28 centers participating in the Medical Research Council UKALL 2011 trial. Marked variation in practice was noted. In total, 43% of centers defer central venous access device insertion until end of induction for treatment of low-risk disease. Central venous access devices are removed at the end of intensive blocks in 38% and end of treatment in 42%. Duration of anticoagulation for line-associated thrombosis is 6 weeks in 43% and 3 months in 33% and for cerebral sinovenous thrombosis is 3 months in 71% and 6 months in 24%. Platelet transfusion to maintain platelet count >50×10/L, in preference to interrupting therapeutic anticoagulation, is used by 50% for line-associated thrombosis and 73% for cerebral sinovenous thrombosis. Conformity of practice was seen in some areas. In total, 70% treat thrombosis with twice-daily low-molecular weight heparin and 86% monitor antifactor Xa activity levels. In total, 91% reexpose individuals to asparaginase following a thrombotic event. Given this variation in practice, in the absence of high-quality evidence, consensus guidelines may be helpful.

Impact of a modified Broviac maintenance care bundle on bloodstream infections in paediatric cancer patients

Background: During intensive chemotherapy, bloodstream infection (BSI) represents an important complication in paediatric cancer patients. Most patients carry a long-term central venous access device (CVAD). Improved maintenance care of these vascular catheters may decrease the risk of BSI.

Methods: Intervention study (adapted CVAD prevention protocol) with two observation periods (P1: 09-2009 until 05-2011; P2: 09-2011 until 05-2013); prospective surveillance of all laboratory confirmed BSIs. In P2, ready to use sterile NaCl 0.9% syringes were used for CVAD flushing and octenidine/isopropanol for the disinfection of catheter hubs and 3-way stopcocks.

Results: During P1, 84 patients were included versus 81 patients during P2. There were no significant differences between the two patient populations in terms of median age, gender, underlying malignancy or disease status (first illness or relapse). Nearly all CVADs were Broviac catheters. The median duration from implantation to removal of the CVAD was 192 days (Inter-quartile-range (IQR); 110–288 days) in P1 and 191 days (IQR; 103–270 days) in P2. 28 BSI were diagnosed in 22 patients in P1 (26% of all patients experienced at least one BSI) and 15 BSI in 12 patients in P2 (15% of all patients). The corresponding results for incidence density (ID) were 0.44 (CI95 0.29–0.62) for P1 vs. 0.34 (0.19–0.53) BSI per 100 inpatient days for P2 and for incidence rate (IR) 7.76 (5.16–10.86) in P1 vs. 4.75 (2.66–7.43) BSI per 1,000 inpatient CVAD utilization days. In P1, 9 BSI were caused by CoNS vs. only 2 in P2 (IR 2.49; CI95 0.17–4.17 vs. 0.63; CI95 0.08–1.72). In P1 two BSI (7%) lead to early removal of the device. During P2 one CVAD was prematurely removed due to a Broviac-related BSI (6.7%).

Conclusion: The preventive protocol investigated in this study led to a reduction of BSI in paediatric cancer patients. This result was clinically relevant but – due to insufficient power in a single centre observation – the difference did not reach statistical significance. The most pronounced trend in BSI reduction was observed for CoNS infections. Thus, improving maintenance care of the CVAD may result in lower CVAD-linked infection rates. The higher acquisition cost of the ready to use NaCl 0.9% flushing syringes and octenidine/propanol hub disinfection were probably balanced by cost savings in the intervention period.

Complications of Central Venous Access Devices: A Systematic Review

CONTEXT

The failure and complications of central venous access devices (CVADs) result in interrupted medical treatment, morbidity, and mortality for the patient. The resulting insertion of a new CVAD further contributes to risk and consumes extra resources.

OBJECTIVE

To systematically review existing evidence of the incidence of CVAD failure and complications across CVAD types within pediatrics.

DATA SOURCES

Central Register of Controlled Trials, PubMed, and Cumulative Index to Nursing and Allied Health databases were systematically searched up to January 2015.

STUDY SELECTION

Included studies were of cohort design and examined the incidence of CVAD failure and complications across CVAD type in pediatrics within the last 10 years. CVAD failure was defined as CVAD loss of function before the completion of necessary treatment, and complications were defined as CVAD-associated bloodstream infection, CVAD local infection, dislodgement, occlusion, thrombosis, and breakage.

DATA EXTRACTION

Data were independently extracted and critiqued for quality by 2 authors.

RESULTS

Seventy-four cohort studies met the inclusion criteria, with mixed quality of reporting and methods. Overall, 25% of CVADs failed before completion of therapy (95% confidence interval [CI] 20.9%-29.2%) at a rate of 1.97 per 1000 catheter days (95% CI 1.71-2.23). The failure per CVAD device was highest proportionally in hemodialysis catheters (46.4% [95% CI 29.6%-63.6%]) and per 1000 catheter days in umbilical catheters (28.6 per 1000 catheter days [95% CI 17.4-39.8]). Totally implanted devices had the lowest rate of failure per 1000 catheter days (0.15 [95% CI 0.09-0.20]).

LIMITATIONS

The inclusion of nonrandomized and noncomparator studies may have affected the robustness of the research.

CONCLUSIONS

CVAD failure and complications in pediatrics are a significant burden on the health care system internationally.

Central venous catheter-associated bloodstream infections in pediatric hematology-oncology patients and effectiveness of antimicrobial lock therapy

BACKGROUND

Central line-associated bloodstream infection (CLABSI) is a serious complication in hematology-oncology patients. This study aimed to analyze the prevalence of CLABSI and the effectiveness of antimicrobial lock therapy (ALT) in pediatric patients.

METHODS

BSIs of all pediatric hematology-oncology patients admitted to a children's hospital between January 2009 and December 2013 were reviewed. The United States National Healthcare Safety Network and Infectious Diseases Society of America guidelines were used to define CLABSI and catheter-related BSI (CRBSI). The incidence, laboratory and microbiology characteristics, poor outcome, and effectiveness of ALT were analyzed.

RESULTS

There were 246 cases of CLABSI in 146 patients (mean age, 10.0 years), including 66 (26.8%) cases of CRBSI. The incidence of CLABSI was 4.49/1000 catheter-days, and the infection was responsible for 32.9% of the complications these patients developed and 9.3% of contributable mortality. Patients with acute myeloid leukemia had the highest infection density (5.36/1000 patient-days). Enterobacteriaceae (40.2%) and coagulase-negative staphylococci (CoNS; 20.7%) were the predominant pathogens. In multivariate analysis, older age, male sex, elevated C-reactive protein, acute lymphoblastic leukemia, and candidemia were associated with poor outcome. The success rate of ALT was 58.6% (17/29) for the treatment of CoNS and 78.3% (29/37) for Enterobacteriaceae infections. Patients with candidemia (n = 18) had the highest mortality (33.4%) and catheter removal rate (66.7%). Chlorhexidine as the disinfectant decreased the 1-year CLABSI rate from 13.7/1000 to 8.4/1000 catheter-days (p = 0.02).

CONCLUSION

CoNS and Enterobacteriaceae are the predominant pathogens in CLABSI among pediatric hematology-oncology patients. ALT is effective and showed no significant side effect. New disinfection practice and infection control measures can decrease CLABSI.

Infectious morbidity by catheter type in neutropenic children with cancer

BACKGROUND

Three central venous catheters types are commonly used in pediatric cancer: totally implantable catheters (ICs; eg, mediports, portacaths), tunneled externalized catheters (eg Broviac® or Hickman® catheters [Bard Medical]) and peripherally inserted central catheters. While previous studies have examined risks for catheter-related infections, this is the first large multicenter study to compare catheter-associated infectious morbidity through patient outcomes and hospital utilization.

METHODS

A historical cohort analysis was conducted using data from the Pediatric Health Information System reporting 1167 hospitalizations of neutropenic patients with childhood cancer and a central venous catheters. Multivariate analyses controlled for age, ethnicity, gender, malignancy category and transplant status. Outcomes included incidence of serious bacterial infection, mortality, duration of hospitalization, time and use of intensive care unit and antibiotic usage.

RESULTS

Neutropenic cancer patients with totally ICs (n = 429) have a statistically significant approximately 50% decrease in length of hospitalization (P < 0.001), risk for requiring an intensive care unit stay (P = 0.002), documented serious bacterial infection (P = 0.001) and days on antibiotics (P < 0.001) when compared with patients with tunneled externalized catheters (n = 463). Similar differences were found comparing hospitalizations of patients with ICs to those with peripherally inserted central catheters (n = 275). No difference in mortality was observed among catheters groups.

CONCLUSIONS

In neutropenic pediatric oncology patients with a central venous catheters, ICs are associated with the least hospital utilization including shortest duration of hospitalization, intensive care unit time and antibiotic therapy when compared with tunneled external catheters and peripherally inserted central catheters. The impact of differences in catheter-associated infectious morbidity on patient outcomes and hospital utilization should be included in clinical decision making.

Central venous catheters and catheter locks in children with cancer: a prospective randomized trial of taurolidine versus heparin

BACKGROUND

To determine if the catheter lock taurolidine can reduce the number of catheter-related bloodstream infections (CRBSI) in pediatric cancer patients with tunneled central venous catheters (CVC).

PROCEDURE

During a study period of 34 months, 129 newly placed tunneled CVCs in 112 patients were randomly assigned to standard lock with heparin solution or experimental lock with a taurolidine solution (ClinicalTrials.gov Identifier NCT00735813).

RESULTS

Sixty-five CVCs were included in the standard group and 64 CVCs in the experimental group. The groups were comparable regarding patients' characteristics. A total number of 72 bloodstream infections of which 33 were CRBSIs were observed during 39,127 CVC-days. A lower rate of CRBSI (0.4 per 1,000 CVC-days) was observed in the experimental arm compared with the standard arm (1.4 per 1,000 CVC-days, incidence rate ratio (IRR) = 0.26; 95% confidence interval (CI) 0.09-0.61; P = 0.001). A lower rate of total bloodstream infections (1.2 per 1,000 CVC-days) was also observed in the experimental arm compared with the standard arm (2.5 per 1,000 CVC-days, IRR = 0.49; 95% CI 0.29-0.82; P = 0.004). Median interval from catheter insertion until first CRBSI was significantly lower in the standard group (156 days, range 12-602) compared with the experimental group (300 days, range 12-1,176; P = 0.02). Premature removal of the CVC due to infection and overall CVC survival were similar in the two study groups.

CONCLUSION

Locking of long-term tunneled CVC with taurolidine significantly reduces catheter-related bloodstream infections in children with cancer.

Prospective surveillance study of blood stream infections associated with central venous access devices (port-type) in children with acute leukemia: an intervention program

The use of intensive chemotherapy and central devices has improved patients survival, but it is associated with catheter-related blood-stream infections (CRBSI). An educational program was instituted for preventing CRBSI occurrence in acute leukemia pediatric patients having totally implanted central devices. The Centers of Disease Control and Prevention criteria were used as definition for CRBSI. Data collected were age, sex, diagnosis, chemotherapy, inpatient versus outpatient, microbiological data, risk factors, social risk score, and treatment performed. CRBSI rate decreased from 6.7 to 3.7/1000 catheter-days with preventive measures (P=0.05). A further decrease to 1.5/1000 catheter-days was reached after the intensification of the educational program (P=0.01). Severe neutropenia at the time of catheter insertion was related to CRBSI and to infection recurrence (P<0.05). Most of the episodes occurred during induction chemotherapy. Thirty-six CRBSI episodes occurred in 25 of 73 patients. The most frequent microorganism isolated was Staphylococcus spp. Antibiotherapy was successful in 83.3% of episodes. Six patients needed a central venous access device replacement. Our intervention program was successful to decrease the CRBSI rates and its intensification allowed a further decrease, approaching reported rates in this setting. Severe neutropenia at the time of central venous access device insertion was related to CRBSI occurrence and recurrence.

Implantable versus cuffed external central venous catheters for the management of children and adolescents with acute lymphoblastic leukaemia

PURPOSE

The aim of this study was to determine if there is a difference between complications for totally implantable central venous catheters (ports) and tunnelled external central venous catheters (external CVCs) that result in early removal of the central venous catheter (CVC) in children and adolescents with acute lymphoblastic leukaemia (ALL).

METHODS

All children hospitalised between November 1996 and December 2007 with ALL who had a CVC were included retrospectively. We analysed data regarding the patient's first CVC.

RESULTS

We included 322 patients. 254 received a port and 68 received an external CVC. There were 102 CVC complications that required removal of the CVC prior to the completion of chemotherapy (65 in patients with ports, 37 in patients with external CVCs). Overall complications requiring CVC removal were significantly less likely to occur in the patient's with ports (p < 0.001). Ports were significantly less likely to require removal prior to the end of treatment overall (p < 0.001) and for specific complications such as infection (p < 0.001) and dislodgement (p = 0.001). However, when adjusted for disease severity there is no difference in premature CVC removal rates.

CONCLUSION

When patients are risk-stratified for disease severity there is no difference in rates of CVC removal prior to completion of treatment.

Safety of central venous catheter placement at diagnosis of acute lymphoblastic leukemia in children

BACKGROUND

Central venous catheters (CVC) facilitate the management of patients with cancer. Optimal timing for placement of a CVC is controversial. We sought to determine whether early placement in children with acute lymphoblastic leukemia (ALL), a group at high risk for infection and thrombosis, was associated with an increased rate of surgical complications.

PROCEDURE

We evaluated the incidence and risk factors for early surgical complications in children with ALL diagnosed between 2004 and 2009 at a single pediatric cancer center.

RESULTS

One hundred seventy-two patients were studied. There were 17 episodes of bloodstream infection, for a 30-day incidence of 9.8% (95% CI, 5.9-15%). There were no surgical site infections and no CVC was removed due to infection. Early thrombosis occurred in only one patient, 3 days after CVC placement. Infection was not influenced by catheter type, patient age, body mass index, or fever at the time of placement. The infection rate was not statistically higher when the ANC was <500/mm(3) at the time of CVC placement (14.2% vs. 6.8%; P = 0.12).

CONCLUSION

Early CVC placement at the time of diagnosis of ALL was associated with a low surgical complication rate with no catheters requiring removal due to infection. Utilizing our current methods of preoperative preparation, surgical management and postoperative CVC care, early placement of a CVC is safe in children with ALL even when their ANC is <500/mm(3) , but larger cohort studies would be helpful to further clarify this issue.