Port-A-Cath infections in children with cancer

Incidence and Risk Factors for Totally Implantable Venous Access Device Infections in Pediatric Patients With Cancer: A Study of 25,954 Device-Days

BACKGROUND

Totally implantable venous access devices (TIVADs) are frequently used in pediatric patients with cancer owing to their multiple benefits. Despite occasional infections with TIVADs, knowledge of the incidence and risk factors is limited.

METHODS

This retrospective study included pediatric patients with cancer who received TIVAD at Chungbuk National University Hospital from 2001 to 2021. We collected data on demographics, diagnosis, duration of TIVAD use, pathogens, and other risk factors.

RESULTS

During the study period, 55 TIVADs with 25,954 device-days were applied in 49 patients. There were 15 TIVAD infections (15/55, 27.3%), with an infection rate of 0.21 infections per TIVAD per year (0.58 cases/1,000 device-days). TIVAD infections occurred at a median of 5 months (range, 8 days-30 months) after insertion. The most common causative microorganisms were methicillin-resistant coagulase-negative staphylococci (n = 8, 53.3%) followed by Escherichia coli (n = 3, 20.0%). Infection-free TIVAD survival was higher in the group with normal platelet count at insertion (platelet counts ≥ 150,000/μL) than in the group with thrombocytopenia at insertion (platelet counts < 150,000/μL) (81.3% vs. 32.1%, P = 0.004). Device removal was the mainstay of treatment (11/15, 73.3%).

CONCLUSION

TIVAD infection may be related to thrombocytopenia at the time of device insertion. Further studies are needed to identify preventive factors against TIVAD infections in children with cancer.

Percutaneous implantation of peripherally inserted totally implantable venous access systems in the forearm in adolescent patients

BACKGROUND

Children with different underlying malignant diseases require long-term central venous access. As for port systems in a pectoral position, peripherally implanted port systems in the forearm revealed high levels of technical and clinical success in adult cohorts.

OBJECTIVE

To investigate the technical and clinical outcomes of percutaneous central venous port implantation in the forearm in adolescents.

MATERIALS AND METHODS

Between April 2010 and August 2020, 32 children ages 9 to 17 years with underlying malignancy received 35 totally implantable venous access ports (TIVAPs) in the forearm. All venous port systems were peripherally inserted under ultrasound guidance. Correct catheter placement was controlled by fluoroscopy. As primary endpoints, the technical success, rate of complications and catheter maintenance were analyzed. Secondary endpoints were the side of implantation, vein of catheter access, laboratory results on the day of the procedure, procedural radiation exposure, amount of contrast agent and reasons for port device removal.

RESULTS

Percutaneous TIVAP placement under sonographic guidance was technically successful in 34 of 35 procedures (97.1%). Procedure-related complications did not occur. During the follow-up, 13,684 catheter days were analyzed, revealing 11 complications (0.8 per 1,000 catheter-duration days), Of these 11 complications, 7 were major and 10 occurred late. In seven cases, the port device had to be removed; removal-related complications did not occur.

CONCLUSION

Peripheral TIVAP placement in the forearms of children is a feasible, effective and safe technique with good midterm outcome. As results are comparable with standard access routes, this technique may be offered as an alternative when intermittent venous access is required.

Infections of Port Access Catheters in Children

Background: The most important complication of port access catheters (PAC) compared to peripheral lines is a higher incidence of infections. Objectives: This study investigated the frequency of catheter infection and related factors in Dr. Sheikh Children Hospital (SCH). Methods: This is a retrospective descriptive study at Sheikh children’s hospital, Mashhad, Iran. The data of children with an operation for PAC surgery were gathered from hospital files and completed by calling the parents. The definition of PAC infection was based on clinical signs of catheter infection and any positive blood culture (peripheral or catheter sample) or the resolution of signs of infection after the extraction of the catheter in the absence of positive blood cultures. Results: During six years, 70 children received PAC, all of whom (except five) were followed by telephone calls. Forty percent of them were younger than two years, and 71.4% had malignant disease. Catheter infection occurred in 16 (22.8%) cases. Signs of catheter infection were fever and cellulitis over the port in nine (56%) cases (pocket infection), chills and fever during catheter usage (without port infection) in six (37.5%) cases, and persistent fever in one patient (6.2%). Blood culture was positive in 75% (12 cases) of catheter infections, and the responsible organisms were Gram-negative bacilli (five cases), Coagulase-negative staphylococci (three cases), Candida (three cases), and group B streptococci (GBS). The success rate for “medical therapy per se” was 68% in catheter infections. The catheter was removed in 22 (31.4%) patients, which was due to infection in half of them. The mean time to removal was 15.3 months. Conclusions: The incidence of catheter infection, especially pocket infection, is high in this population, which necessities revision in all procedures of catheter implantation and care.

Early central line-associated blood stream infections in children with cancer pose a risk for premature catheter removal

AIM

This study examined the clinical characteristics of central line-associated blood stream infections occurring within 30 days after insertion versus later infections in paediatric cancer patients and the subsequent risk for premature catheter removal.

METHODS

This was a retrospective study of children aged 0-18 years who were diagnosed with cancer from 2013 to 2014 at the Astrid Lindgren Children Hospital, Sweden. Clinical and microbiology data for each patient were collected for 365 days after the central venous catheter (CVC) was inserted.

RESULTS

During the study period, 154 children received a CVC. The overall incidence of central line associated blood stream infections was 2.0 per 1000 catheter days. A total of 108 infectious episodes were identified in 44/154 (29%) patients. Of those, 15/44 children (29%) had an early infection within 30 days and alpha-haemolytic Streptococci and coagulase-negative Staphylococci dominated. Children with early infections were more likely to have a haematological malignancy and to need premature removal of the CVC due to repeated infections.

CONCLUSION

We observed a high prevalence of early CVC associated blood stream infection mainly in patients with haematological malignancies. Our study highlights the importance of preventive measures in reducing infections in paediatric cancer patients.

Experience in totally implantable venous port catheter: Analysis of 3,000 patients in 12 years

Background

This study aims to present our experience with patients who were performed totally implantable venous port catheter.

Methods

Demographics-clinical features, surgical results and complications of 3,000 patients (1,824 males, 1,176 females; mean age 61.04±11.5 years; range, 18 to 88 years) who were performed totally implantable venous port catheter between March 2005 and March 2017 were evaluated retrospectively. Totally implantable venous port catheter indications, complications, catheter duration of stay, reasons for catheter removal and statistical analysis information were reported in detail by reviewing patient records.

Results

Of the cases, the Seldinger method was used in 98%, 1% (n=36) had the catheter inserted with superficial Doppler ultrasonography, while the veins were not found in 1% (n=29) and these patients were excluded from the study. Totally implantable venous port catheter was inserted via right internal jugular vein in 2,095 patients (70%), via right subclavian vein in 470 patients (16%), via left internal jugular vein in 290 patients (10%), and via left subclavian vein in 106 patients (3%). Mean duration of stay for totally implantable venous port catheter was 46.7 months (range, 1 to 78 months). Complications were detected in a total of 288 patients (9.6%), 153 (5.1%) being early and 135 (4.5%) being late. The most common oncologic indication was colorectal cancer. The rate of port removal was 298/3,000 (9.9%) and the main reasons were infection, thrombosis, pain, and end of treatment. Totally implantable venous port catheter was required to be inserted twice in 33 patients (1%) and thrice in 14 patients (0.5%). Totally implantable venous port catheter had malposition in eight patients and all were revised successfully with over the guide method.

Conclusion

Totally implantable venous port catheter may increase the quality of life in cancer patients. Despite possible complications, totally implantable venous port catheter is safe and comfortable for long-term intravenous treatment. Possible complications may be prevented or managed when totally implantable venous port catheter is performed by surgeons with adequate experience.

Dislocation of central venous catheters in pediatric patients

Children have limited venous access possibilities; therefore, when long-term therapy is necessary, it is better to place a catheter in a central vein. The Port catheter, totally implanted, is less exposed to the risk of infection and permits a normal life. However, there is the possibility of the displacement or fragmentation of the catheter that can be diagnosed initially only by clinical symptoms and later by a chest X-ray. We report a case of disconnection between the Port catheter and the reservoir resulting in catheter migration to the left pulmonary artery.

Cohort Study: Central Venous Catheter-Related Complications in Children with Hematologic Diseases at a Single Center

Objective:

This study aims to document and analyze the central venous catheter (CVC)-related complications in children with hematological diseases who were treated within a single institution.

Materials and Methods:

A retrospective investigation was conducted in 106 pediatric patients in whom 203 CVCs were inserted. A total of 175 catheter-related complications occurred in 5 years.

Results:

The rates of clinical catheter infections, local catheter infections, venous thromboembolism, bleeding, and mechanical complications were 2.6, 1.1, 0.2, 0.2, and 0.2 per 1000 catheter days. Methicillin-resistant Staphylococcus epidermidis was the predominant infectious organism in blood and catheter cultures. The children with leukemia had a significantly higher frequency of clinical catheter infections (p=0.046). The children who underwent bone marrow transplantation had a significantly lower frequency of clinical catheter infections (p=0.043) and higher frequency of local catheter infections (p=0.003). The children with implanted catheters had a significantly lower frequency of clinical catheter infections (p=0.048). The children with thrombocytopenia had significantly fewer local catheter infections and significantly more clinical catheter infections and catheter-related bleeding (respectively p=0.001, p=0.042, and p=0.024).

Conclusion:

Leukemia, bone marrow transplantation, and thrombocytopenia are risk factors for CVC-associated complications. The relatively higher number of interventions performed via permanent catheters may be responsible for the significantly increased incidence of systemic infections and mechanical injury.

Complications of chemoport in children with cancer: Experience of 54,100 catheter days from a tertiary cancer center of Southern India

BACKGROUND

Chemoport is an essential part of the management of children with cancer and provides long-term venous access. There are few studies from resource poor countries reporting complications of chemoport.

AIMS

This study was aimed at describing the complications of chemoport in patients with cancer.

MATERIALS AND METHODS

This retrospective observational study analyzed 200 patients <15 years of age who underwent chemoport insertion. The medical records of these patients were reviewed for the patient characteristics, diagnosis, nature of port use, port-related complications and their management.

RESULTS

A total of 209 ports were implanted in 200 patients and 24 ports were removed due to port-related complications. There were 122 boys and 78 girls whose ages ranged from 4 months to 13 years (median age 2.5 years). About72% of patients were <2 years old. The cumulative duration of catheterization was 54,100 days. Of 209 ports, there were 36 complications that led to the removal of 21 ports. Port-related infection was the most common infection observed in our study (0.66/1000 catheter days and 11.9%). Mechanical complications were seen in 9 patients. Venous thrombosis and skin necrosis occurred in one patient each.

CONCLUSIONS

Use of chemoport is safe and is a boon for children with cancer in developing countries with incidence of complications similar to Western countries. Although use of chemoport is associated with complications, they are easily managed. With stringent catheter care by trained personnel, some complications can be prevented.

Catheter-Related Complications in Children With Cancer Receiving Parenteral Nutrition: Change in Risk Is Moderated by Catheter Type

BACKGROUND

Although central venous catheters (CVCs) are essential to pediatric cancer care, complications are common (eg, occlusion, central line-associated bloodstream infection [CLABSI]). Parenteral nutrition (PN) and external CVCs are associated with an increased complication risk, but their interaction is unknown.

METHODS

A retrospective matched cohort study of pediatric oncology patients who received PN through subcutaneous ports or external CVCs. Complication rates were compared between CVC types during PN and non-PN periods (log-negative binomial model).

RESULTS

Risk of CLABSI was higher during PN for children with ports (relative risk [RR] = 39.6; 95% confidence interval, 5.0-309) or external CVCs (RR = 2.9; 95% confidence interval, 1.1-7.4). This increased risk during PN was greater for ports than for external CVCs (ratio of relative risks = 13.6). Occlusion risk was higher during PN in both groups (RR = 10.0 for ports; RR = 2.0 for external CVCs), and the increase was significantly greater in ports (ratio of relative risks, 4.9). Overall, complication rates for ports were much lower than for external CVCs during the non-PN period but similar during the PN period.

CONCLUSION

Children with cancer who receive PN have increased risk of CLABSI and occlusion. The risk increase is greatest in children with ports: a 40- and 10-fold increase in infection risk and occlusion, respectively, resulting in similar complication rates during PN regardless of CVC type and negating the usual benefits of ports. Children with cancer who will require PN should have primary insertion of external CVCs where possible.

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.

Ultrasonography-guided central venous port placement with subclavian vein access in pediatric oncology patients

BACKGROUND/PURPOSE

To evaluate the technical success and complications of image-guided central venous port (CVP) placement with subclavian vein (SCV) access in pediatric oncology population.

MATERIALS AND METHODS

Ninety-two children (52 boys, 40 girls; mean age, 8.5 years) underwent CVP implantation under local anesthesia with conscious sedation. SCV access was firstly attempted under ultrasonographic guidance and CVP implantation was performed under fluoroscopic guidance. Technical success, peri-procedural (<24h) complication, and post-procedural (>24h) complication were assessed.

RESULTS

In total, 102 CVPs were implanted in 92 children with a mean catheter time of 364 days (total, 38,224 days; range, 14-1911 days). In three small children, conversion of SCV access to internal jugular vein access yielded a primary technical success rate of 97.1% and overall technical success rate of 100%. Three minor peri-procedural complications were observed (2.9%) and seven post-procedural infectious complications occurred (infection rate, 6.7%; 0.18/1000 catheter days). No pneumothorax, catheter malposition, venous thrombosis, or mortality occurred.

CONCLUSION

Image-guided CVP placement with SCV access in a pediatric population was performed with high technical success and low complication rate without general anesthesia. This procedure can be taken into account as a choice of procedure when internal jugular venous access is not possible.

Invasive bacterial and fungal infections in paediatric patients with cancer: incidence, risk factors, aetiology and outcomes in a UK regional cohort 2009-2011

BACKGROUND

Cancer is the second most common cause of childhood deaths in the United Kingdom and infection contributes to a quarter of all cancer-related deaths. This study aimed to estimate the risk, aetiology and outcome of bloodstream bacterial and fungal infections in children with cancer within a geographically defined region in South-West London over a 3-year period.

METHODS

Web-based questionnaires were completed using case records of children with positive blood cultures admitted to five London hospitals during 2009-2011.

RESULTS

A total of 112 children with a median age of 5.4 (IQR 3.6-11.2) years had 266 significant blood cultures during 149 infection episodes. Haematological malignancy affected 68 patients (60.7%) and solid tumours 44 (39.3%). The overall bloodstream infection rate was 1.5 episodes per 1,000 days-at-risk (95% CI, 1.2-1.8) and was similar for those with haematological malignancies and solid tumours. Most episodes were attributed to central venous catheter infection (120/149, 80.5%). Coagulase-negative staphylococci were isolated in almost half the bloodstream infections (127/266; 47.7%), while Gram-negative organisms accounted for a further quarter (64/266; 24.1%). Fungal isolates from blood were uncommon (8/112 children, 7.1%) but significantly associated with neutropenia (18/149 [12.1%] vs. 1/114 [0.9%], P = 0.0004). Six children (5.4%) died, including three (2.7%; 95% CI, 0.6-7.6%) whose deaths were infection-related.

CONCLUSIONS

This study provides an updated risk estimate for bloodstream infections in children with cancer and adds to the framework for developing evidence-based guidance for management of suspected infections in this highly vulnerable group.

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.

Port-a-cath-related thrombosis and postthrombotic syndrome in pediatric oncology patients

OBJECTIVE

To investigate Port-A-Cath (PAC)-related thrombosis and postthrombotic syndrome (PTS) in children with cancer.

STUDY DESIGN

The study population was a consecutive cohort of children diagnosed with cancer and a PAC implanted at diagnosis. Children were evaluated for the presence of PAC-related thrombosis by magnetic resonance venography and the presence of congenital prothrombotic risk factors and PTS.

RESULTS

A total of 114 children (median age, 6.04 years) were included. Of these children, 48 (42%) were treated for solid tumors and 66 (58%) were treated for hematopoietic tumors, including 38 for acute lymphoblastic leukemia. At the time of magnetic resonance venography, 42 children (37%) had the PAC still in place, and 72 (63%) had the PAC removed. Overall, PACs were in place for a total of 324.92 PAC-years. PAC-related thrombosis was detected in 45 children (39.5%) with a current or previous PAC. Of these, 21 (47%) had a solid tumor, 14 (31%) had acute lymphoblastic leukemia, and 10 (22%) had another hematopoietic tumor. Younger age at diagnosis, female sex, duration of PAC use, and left-side PAC placement were independently associated with an increased risk of thrombosis, whereas asparaginase therapy and the presence of inherited prothrombotic risk factors were not. Mild PTS (ie, presence of prominent collateral vessels in the skin) was present in 5.6% of the children.

CONCLUSION

PAC-related thrombosis is common in pediatric oncology patients. In some children, thrombotic complications can lead to the development of PTS.

Low rate of bacteremia with a subcutaneously implanted central venous access device

PURPOSE

Patients at long-term acute care hospitals (LTACs) are medically complex with multiple comorbidities and high rates of antibiotic and device use. The objective of the study was to analyze the incidence and rate of central line-associated bloodstream infections (CLABSI) and the critical factors for patient care, management, placement and maintenance of the implanted central venous access device at this LTAC.

METHODS

A 13-year retrospective chart review was performed comprising 191 medically complex patients with multiple comorbidities who had an implanted central line port. Information analyzed included (1) number of catheters; (2) number of patients; (3) number of catheter line days; (4) patient demographics; (5) port location; (6) admission diagnoses; (7) type, incidence and rate of catheter-related complications.

RESULTS

The total number of catheter days was over 183,183 with a mean of 959 catheter days per patient. The mean rate of CLABSI was 0.087 per 1,000 days; incidence was less than 8% of patients with catheters.

CONCLUSIONS

The study found a markedly lower rate of CLABSI than reported for other LTACs as well as intensive care units, over 14- to 100-fold lower than other LTACs. The authors propose that standardized catheter placement with implementation of rigorous, prospective catheter care plans and a team approach to management were responsible for extremely low complication rates. These results can be extrapolated to different settings across the healthcare continuum.

Port-a-Cath complicated by infection or migration not removed by manual traction: usefulness of cardiac pacing leads extraction techniques

BACKGROUND

Long-term use of Port-a-Caths (PACs) is related to device-related delayed complications. The aim of this study is to describe the high success rate and safety of cardiac pacing lead extraction techniques used for PACs complicated by infection or migration and not removed by manual traction.

METHODS

During a 13-year period (1997-2010), 19 consecutive PAC recipients (54.1±13 years, 11 females) were referred to our hospital for PAC-related delayed complications and PACs not removable by manual traction (mean dwelling time 29.3±31 months).

RESULTS

PAC implantation indications included gastrointestinal cancer (21%), breast cancer (15.7%), other malignant diseases (52.6%), and nonmalignant diseases (10.5%). PAC removal indications were breakdown due to subclavian crush (63.1%), breakdown due to unsuccessful previous removal attempt (21%), sepsis (10.5%), or malfunction (5.3%). Removal of fractured free-floating catheters (16) migrated toward the venous blood course was attempted by tool-guided traction in all cases except 1 in whom mechanical dilation was necessary. For the 3 intact ones (2 infected and one malfunctioning) we used tool-guided traction and single-sheath mechanical dilation, depending on the vascular/cardiac-catheter setting. By using multiple venous approaches we removed 18 catheters completely and 1 partially, achieving clinical success in all of the patients. The most commonly used venous approach was transfemoral (TFA; 73.6%), followed by the original venous entry site approach (VEA; 15.7%) and internal transjugular approach (ITA; 10.5%). No major or minor complications were observed.

CONCLUSIONS

In experienced centers, cardiac pacing lead extraction techniques may be considered as an additional, efficacious, safe option for extraction of otherwise nonremovable entrapped PACs before surgery.

Totally implantable venous access device in children with cancer lead to disfiguring scar

BACKGROUND

In pediatric cancer patients scars of totally implantable venous access devices (TIVAD) are often widened and hypertrophic. This study report on the prevalence and deviation of abnormal scarring in children with a TIVAD and to describe the influencing factors for this abnormal scarring.

METHODS

In a cross-sectional study scars of 122 childhood cancer patients (age 1-21 years) were evaluated; 72 patients had a TIVAD in-situ and in 50 the TIVAD had been removed. Outcome parameters were hypertrophy (modified Vancouver Scar Scale (mVSS), scar surface area, pain, and itching. Scar abnormality was defined as mVSS of >2, or scar width >3 mm.

RESULTS

Abnormal TIVAD scars were found in 107 participants. The mVSS score was higher in patients ≤45 months after removal and the widest >45 months after TIVAD removal. Multivariable analyses showed that the mVSS score was positively related with scar width (mm) and children being ≤45 months after TIVAD removal. Furthermore, TIVAD scar width was positively related with age at last TIVAD surgery, and associated with suture material. In conclusion, there was a high incidence of abnormal TIVAD scars with some pain and itching complaints. However, no typical cancer related influencing factors were associated with increasing abnormalities.

Impact of hydrochloric acid instillation on salvage of infected central venous catheters in children with acute lymphoblastic leukaemia

BACKGROUND

Bacteraemia associated with indwelling central venous catheters (CVC) causes significant morbidity in children with cancer. Hydrochloric acid (HCl) instillations have been reported to salvage CVCs with antibiotic-refractory infection. We implemented this treatment in 2002. The impact on the survival of CVCs has been evaluated in a retrospective cohort study of children with acute lymphoblastic leukaemia (ALL).

METHODS

Children with newly diagnosed ALL during 1999-2005 having their first CVC inserted before (n = 16) and after (n = 24) the introduction of the procedure were studied. All bacteraemic episodes were reviewed, recording bacteriological findings and treatment, and the time to premature or planned removal of the CVC was determined.

RESULTS

In the comparison cohort, 31.0% (9/29) of bacteraemic episodes led to removal of the CVC, compared to 5.5% (2/36) in the intervention cohort (p = 0.01). Thus, the rate of catheter loss due to infection fell from 56.3% (9/16) to 8.3% (2/24) after introducing HCl treatment (p = 0.0025). Overall, the premature catheter removal rate fell from 75.0% (12/16) to 45.8% (11/24) (p = 0.10). Analysed in a CUSUM plot the reduced frequency of premature CVC removal evidently coincided with the introduction of the procedure. In a subgroup analysis of 21 monobacterial infections with coagulase-negative staphylococci, a decrease in systemic and lock antibiotic therapy was found. No adverse events were noted.

CONCLUSIONS

HCl instillations significantly reduced the need to remove and replace CVCs. The procedure is practical, appears to be safe, and may reduce the consumption of antibiotics.

Central venous catheter-associated bloodstream infections

BACKGROUND

To investigate the epidemiologic and microbiological aspects of long-term central vein catheter (CVC)-associated bloodstream infections (CABSI) in children <18 years old treated at the hemato-oncology unit during 1998-2008.

PATIENTS AND METHODS

The two long-term access devices used were Hickman and Port-A-Cath catheters. Information retrieved included demographic data, baseline pathologies, methods of insertion, anatomical insertion sites, duration of use, microbiological, and antibiotic susceptibility data and outcome.

RESULTS

There were 178 CABSI episodes; average number of episodes/1,000 catheter days was 4.7. More CABSI episodes were recorded among patients with Hickman catheter than in patients with Port-A-Cath catheter (5.05 vs. 3.57/1,000 catheter days, P = 0.059). The CVC was removed due to BSI in 52/178 (29.2%) episodes. Overall, 243 pathogens were isolated (144 Gram-negative, 92 Gram-positive, and 7 Candida spp). More Enterobacteriaceae spp. were isolated in CABSI in patients with Hickman catheters than in patients with Port-A-Cath catheters (35/103, 34%, vs. 10/65, 15%, P = 0.008); more coagulase-negative staphylococci were isolated in patients with Port-A-Cath catheters than in patients with Hickman catheters (25/65, 38.5%, vs. 23/103, 22.3%, P = 0.02). No differences in pathogen distribution were found between CABSI recorded for jugular versus subclavian veins, open versus close inserted-CVC or for CVC requiring removal versus those treated conservatively. No fatalities directly related to CABSI were recorded.

CONCLUSIONS

CABSI rates were higher in patients with Hickman catheters compared with those with Port-A-Cath catheters; Gram-negative organisms were the dominant etiologic agents of CABSI; CABSI in patients with Hickman catheters had different etiologies compared with patients with Port-A-Cath catheters.

Catheter-related infections in pediatric patients with cancer

Central venous catheters (CVCs) are essential in the management of pediatric patients receiving antineoplastic therapy or bone marrow transplants, and have significantly improved their quality of life, but CVC-related infectious complications are a major source of morbidity. It has been estimated that 14-51 % of the CVCs implanted in children with malignancies may be complicated by bacteremia, and that the incidence of infections is 1.4-1.9 episodes per 1,000 CVC days. However, there are few recent data concerning the epidemiology of CVC-related infections, the prevalence of antimicrobial resistance in their etiology, or the main factors associated with an increased risk of infection by type of catheter, patient age, the type of cancer, or the presence of neutropenia. Moreover, although various new strategies have been proposed in an attempt to reduce the risk of CVC-related infections, such as catheters impregnated with antiseptics/antibiotics, lock antibiotic prophylaxis, the use of ointments at the exit site, and antithrombotic prophylaxis, their real efficacy in children has not yet been demonstrated. The management of CVC-related infections remains difficult, mainly because of the number of still open questions (including the choice of optimal antimicrobial therapy because of the increasing isolation of multiresistant bacterial strains, treatment duration, whether catheters should be removed or not, the feasibility of guidewire exchange, and the usefulness of antibiotic lock therapy) and the lack of studies of children with cancer. Only well-designed, prospective clinical trials involving pediatric cancer patients can clarify optimal prevention and treatment strategies for CVC-related infections in this population.

Catheter fracture of intravenous ports and its management

BACKGROUND

Intravenous ports are widely used for oncology patients. However, catheter fractures may lead to the need for re-intervention. We aimed to identify the risk factors associated with catheter fractures.

METHODS

Between January 1 and December 31, 2006, we retrospectively reviewed the clinical data and plain chest films of 1,505 patients implanted with an intravenous port at Chang Gung Memorial Hospital. Different vascular sites were compared using the chi-square or Fisher's exact test for categorical variables, and the t test was used for continuous variables with normal distribution; P < 0.05 was considered statistically significant.

RESULTS

There were 59 and 1,448 procedures in the fracture and non-fracture groups, respectively. Monovariate analysis revealed that the risk factors for catheter fracture were as follows: large angle (P < 0.0001), female gender (P < 0.0008), subclavian route (P < 0.0001), and port type Arrow French (Fr.) 8.1 (P < 0.0001). Because these risk factors showed no interaction effects, they were all considered independent risk factors. When all factors were considered together, all risk factors, except angle and age, retained their statistical significance.

CONCLUSIONS

Most catheter fractures were caused by material weakness. If catheter fracture is confirmed, further intervention for port and catheter removal is recommended. Female gender, intravenous port implantation via the subclavian route, and the Arrow Fr. 8.1 port were found to be risk factors. Patients with these risk factors should be monitored closely to avoid catheter fractures.

Long-term complications in totally implantable venous access devices: randomized study comparing subclavian and internal jugular vein puncture

BACKGROUND

This prospective randomized study evaluated complications related to long-term totally implantable catheters in oncologic children and adolescents by comparing venopunction performed either in the jugular or subclavian vein.

METHODS

A total of 83 catheters were implanted from January 2004 to April 2006 and followed-up until March 2008. Patients were randomly allocated to the subclavian or jugular vein group. The endpoint was complications that led to catheter revision or catheter removal.

RESULTS

Six patients were excluded, 43 had the catheter implanted in the subclavian and 34 in the jugular vein. Subclavian catheters were used for up to 12.6 months, while jugular catheters were kept in place for up to 14.8 months (P = 0.38). No statistical differences were found between the groups concerning age, sex, leukocyte count, platelet count, type of admission (in or outpatient), or previous chemotherapy regimens. When analyzed individually, long-term complications did not present statistically significant differences either. Infection occurred in 20 and 11% (P = 0.44), while catheter embolism took place in 23 and 8% (P = 0.11) of patients with subclavian and jugular catheters, respectively. A statistical difference was seen in the total number of complications, which occurred in 48 and 23% (P = 0.02) of patients in the subclavian and in the jugular groups, respectively.

CONCLUSIONS

Catheters implanted by puncture in the subclavian vein were more prone to late complications than those implanted in the jugular vein.

Catheter-related bloodstream infection with removal of catheter in pediatric oncology patients: a 10-year experience in Taiwan

BACKGROUND

Long-term central venous catheter (CVC) implantation has become more affordable in Taiwan since 1995. Surgical removal of the catheter may be the essential treatment for catheter-related bloodstream infections (CRBSI). The aim of this study was to evaluate the clinical features and microbial isolates in pediatric cancer patients with removal of CVC for CRBSI.

PROCEDURE

The records of positive blood culture from hospitalized pediatric oncology patients between 1995 and 2004 were reviewed. One hundred and forty-three patients implanted with a long-term CVC were further identified.

RESULTS

Seventeen catheters in 16 patients developed catheter-related bacteremia that needed catheter removal. The rate of catheter removal was 11.9%. The median device life was 7.7 months. Six catheters were removed within 3 months of insertion. Nine of the 17 catheters were removed from patient younger than 2 years. Eight infections occurred during severe neutropenia, and 6 patients had refractory or relapsed underlying disease. The cultural isolates were Gram-negative bacilli in 7, Gram-positive in 5, fungi in 5, and atypical mycobacterium in 1. The frequency of catheter removal for infection control was significantly higher in the first 5 years (1994-1999) compared to the last 5 years (2000-2004) (30.9 vs. 4.0%, p = 2.3 × 10(-4)).

CONCLUSIONS

Factors such as microbiological isolates, age of infection, the status of malignancy, and neutropenia are related to catheter outcome. The reduction in patients with positive cultures needing removal of the catheters can be related to improved nursing care and more aggressive antibiotic therapy.

Severe neutropenia at time of port insertion is not a risk factor for catheter-associated infections in children with acute lymphoblastic leukemia

BACKGROUND

The objective of this study was to determine whether severe neutropenia on the day of port-a-catheter (PORT) insertion was a risk factor for catheter-associated infection (CAI) in children with acute lymphoblastic leukemia (ALL).

METHODS

This was a retrospective study of children with ALL who had a PORT insertion between January 2005 and August 2008. Early (≤ 30 days) and late (>30 days) postprocedure complications were reviewed. The length of follow-up ranged between 7 months and 42 months.

RESULTS

In total, 192 PORTs were inserted in 179 children. There were 43 CAIs (22%), and the infection rate was 0.35 per 1000 catheter-days. The CAI rate (15%) in children who had severe neutropenia on the day of the procedure did not differ statistically from the CAI rate (24%) in children who did not have severe neutropenia (P = .137). Conversely, patients with severe neutropenia who had a CAI were more likely to have their PORT removed (P = .019). The most common organisms to cause catheter removal were coagulase-negative Staphylococcus and Staphylococcus aureus. Patients with high-risk ALL had a statistically significant higher incidence of late CAI than patients with standard-risk ALL (P = .012). Age (P = .272), positive blood culture preprocedure (P = 1.0), and dexamethasone use (P = .201) were not risk factors for CAI. Patients who had an early CAI did not have a greater chance of having a late CAI. The catheter infection-free survival rate at 1 year was 88.6%.

CONCLUSIONS

The current results indicated that severe neutropenia on the day of PORT insertion does not increase the risk of CAI in children with ALL.

Groshong catheter-related complications in children with cancer

BACKGROUND

Children with cancer undergo intensive treatments requiring reliable vascular access. Central venous catheters (CVCs) reduce discomfort due to venipuncture and the risks of extravasations from chemotherapy administration. The aim of our retrospective study was to assess safety and complications of Groshong devices in children with cancer.

PATIENTS AND METHODS

One hundred ninety Groshong CVCs were placed in 166 children over a 5-year period. Early complications, and infectious and mechanical events were collected.

RESULTS

The mean period of permanence of the CVCs was 330 days per patient (range 7-1,037). Of the febrile episodes, 36 (34.6%) were CVC-related, with an incidence rate of 0.56 per 1,000 CVC days. Severe neutropenia conditions most of all complicated CVC-related infectious events (94.4%) and Gram-negative bacteria were those most often isolated (55%). Twenty CVCs were affected by mechanical or thrombotic complications, with an incidence of 0.33 episodes per 1,000 CVC days. Mechanical complications led to CVC removal in 6 (3.1%) cases, while CVC-related infective episodes were responsible for 10 (5.2%) CVC removals.

CONCLUSIONS

The long in situ duration of this device allowed it to be safely employed from the beginning to the end of the treatment period in most children.

Infections in pediatric patients with hematologic malignancies

Despite significant advances in supportive care, infection remains second only to malignancy as a cause of death in pediatric oncology patients, and infection accounts for a large fraction of treatment-related costs. Multiple risk factors contribute to infection-related morbidity, chief among them the immunosuppressive effects of leukemia itself and of cytotoxic chemotherapy, prolonged hospitalization and antibiotic use, and loss of barrier integrity associated with mucositis and the need for indwelling central access. While viruses are the most common causes of infection, bacteria are responsible for most life-threatening complications. Gram-negative bacilli are a concern for all patients undergoing treatment, while a subset of gram-positive organisms, particularly viridans streptococci, become significant pathogens in children receiving profoundly immunosuppressive therapy. Invasive fungal infections are also a serious risk for morbidity and mortality in this population. Availability of new antimicrobial agents has made it possible to treat infectious complications more effectively, but their availability is also leading to an increased prevalence of highly resistant pathogens. Future work in pediatric oncology will need to include measures to reduce the immunosuppressive effects of anti-cancer therapy, provide targeted treatment for infections, and better identify groups of patients at high risk for infectious complications, who may benefit from antimicrobial prophylaxis or more aggressive empirical therapy.

Suspected infections in children treated for ALL

AIM

The aim of our study was to get epidemiological information on bacterial infections in children treated for ALL and to analyse which patients have an enhanced infection risk.

METHODS

Episodes of suspected or confirmed infections were evaluated during the first 12 months of treatment for childhood acute lymphoblastic leukaemia (ALL).

RESULTS

The number of patients was 73 (43 boys). The median age was 4.6 years. A total of 179 episodes occurred, varying from none in six patients to eight in one. Bacteria were cultured in 57 episodes (31.8%), the most common being coagulase-negative staphylococci. The number of episodes fell significantly with increasing age for suspected and confirmed infections (p < 0.001 and p = 0.03). The proportion of confirmed infections was significantly higher (p < 0.001) in the first episodes. The average number of suspected infections was higher in girls than in boys (p = 0.03), but confirmed infections were not.

CONCLUSION

Most of the serious infections occur early in the treatment and the number of suspected and confirmed infections falls with age. Suspicion of infection is more likely in girls, but the number of confirmed infections is equal in both sexes. Coagulase-negative staphylococcus was most commonly isolated, highlighting the importance of careful handling of central venous devices.

Interventions using foreign material to treat congenital heart disease in children increase the risk for infective endocarditis

BACKGROUND

Congenital heart disease (CHD) is a risk factor for infective endocarditis (IE). We aimed to assess the impact of cardiac interventions on the frequency and microbial profile of IE in children with CHD.

METHODS

Episodes of IE were analyzed in children aged < or =18 years with CHD between 1995 and 2005 with respect to cardiac surgery or catheter interventions with or without implantation of foreign material.

RESULTS

Diagnosis of IE was made in 14 (0.36%) of 3826 children with CHD including native IE in 6 and postinterventional IE in 8 patients. During the period 3029 cardiac interventions (1944 surgeries; 1085 catheters) were performed; foreign material was implanted in 1360 interventions (1139 surgeries; 221 catheters) including all 8 patients with postinterventional IE. Cardiac intervention by itself did not change the risk for IE compared with no intervention. The risk of IE after implantation of foreign material was higher than following intervention without implantation (odds ratio, 21.0; 95% confidence interval, 1.2-365; P < 0.05). Pacemaker implantation was associated with the highest risk for IE (odds ratio, 11.0; 95% confidence interval, 2.6-46.5; P < 0.001). Staphylococci were the most frequently isolated organisms in foreign material-associated IE.

CONCLUSIONS

Cardiac intervention in children with CHD does not increase the risk for IE. Postinterventional IE in children with CHD is strongly linked to implantation of foreign material, especially of pacemaker.

Complete caval thrombosis secondary to an implanted venous port--a case study

HISTORY AND CLINICAL FINDINGS

We report the case of a woman who presented to the medical emergency room with upper thoracic inlet syndrome six months after being treated for cancer of the left breast with surgery, radiation, and chemotherapy. A port-related occlusion of the superior vena cava was diagnosed on the basis of the history, physical findings, and diagnostic images.

METHODS

The local standards for the handling of port systems are presented.

DISCUSSION

Implanted port systems facilitate the treatment of the chronically ill by enabling easy and safe venous access. As the number of patients with such systems is growing, there is an increased need for optimized handling and care, awareness of the risks (such as catheter occlusion, thrombosis, and infection), and recognition of complications when they arise.

Skin and soft tissue complications in pediatric leukemia patients with and without central venous catheters

We aimed to retrospectively evaluate the skin and soft tissue complications secondary to procedures in acute leukemia patients with and without catheters. Eighty-seven acute leukemia patients (75 acute lymphoblastic leukemia, 12 acute myeloid leukemia ) were included. There were 30 patients with 37 catheter use (6 port, 31 Hickman catheter) and 57 patients without catheter. In patients with catheters, skin and soft tissue complications were seen in 20 (66%) children. The most frequent complication was cellulitis (55%). In the patients without catheter, skin and soft tissue complications were seen in 37 (65%) patients. Cellulitis (37.8%) and extravasation (37.8%) were the most frequent causes. When the frequency of skin and soft tissue complications in patients with and without catheters were compared with each other, there was statistically no significant difference (P=0.792). The duration of chemotherapy was significantly longer in patients who developed skin and soft tissue complications with or without catheters when compared with the duration of the therapy in patients without any skin and soft tissue complications (259.2+/-36.3 and 218.3+/-58.3 d, respectively; P<0.0001). In pediatric leukemia patients, with or without catheters, skin and soft tissue complications are common and these complications may prolong the duration of chemotherapy.

Use of totally implantable catheters for peripheral blood stem cell apheresis

Collection of PBSC by leukapheresis requires one venous access (VA) for inflow and one for outflow. The use of implantable venous access devices (IVAD) has never been reported in this setting. We retrospectively analyzed the use of IVAD for performing apheresis. The study was conducted between January 2000 and June 2005 on 64 patients (41 children) requiring intensification for treatment of a solid tumor. Mean body weight was 26 kg (range 8-91 kg) for a median age of 8.5 years (range 0.7-66 years). A total of 121 aphereses were performed (mean 1.89 apheresis/patient). The second VA was in a cubital vein in 84 procedures and was a temporary central VA in 31. Mean duration of apheresis was 3 h (range 30-274 min). Mean flow rate was 41.3 ml/min (range 12-85 ml/min). Mean collection rate was 59.2% for CD34+ cells and 70% for mononuclear cells. The total number of CD34+ cells collected was 2.5 x 10(6)/kg per apheresis, and 5.9 x 10(6)/kg per patient. Several complications occurred: one catheter-related sepsis (0.86%), four catheter occlusions (3.47%) and eight hemodynamic instabilities related to extracorporeal volume. Weight <10 kg is a risk factor for complication (P=0.0006). IVAD are effective and safe for PBSC collection. Placement of a second central VA (requiring general anesthesia for children) could be avoided.

Port-A-Cath insertions in acute leukemia: does thrombocytopenia affect morbidity?

BACKGROUND

Unnecessary delay of insertion of Port-A-Cath indwelling venous catheters in thrombocytopenic patients may result from fear of potential morbidity. This study sought to compare the morbidity of Port-A-Cath insertions in acute leukemic patients with platelet counts below and above 50 x 10(9)/L.

METHOD

Incidence and profile of catheter-related bloodstream infections (CRBSIs) and other complications were determined in 80 consecutive Port-A-Cath insertions in pediatric patients with acute leukemia from January 2002 to December 2004. Subgroup analysis was performed for patients with platelet levels below and above the recommended safe level of 50 x 10(9)/L.

RESULTS

Twenty-two (27.5%) patients had insertions performed at platelet levels below the recommended level (median, 35.3; range, 10-49 x 10(9)/L); postoperative counts were correspondingly higher (median, 66.0; range, 20-207 x 10(9)/L) with perioperative platelet transfusion. Catheter-related bloodstream infection incidence was similar in patients with platelets less than and greater than the recommended threshold (18.2% vs 17.2%, respectively), and likewise for CRBSIs encountered in the immediate 30 postoperative days (4.6% and 5.2%, respectively). Only 2 episodes of postoperative bleeding occurred, both in the group with platelet counts greater than 50 x 10(9)/L, with an equally low incidence of other local and mechanical complications in both subgroups. Patient demographics and other preoperative blood parameters did not differ significantly.

CONCLUSION

Preoperative thrombocytopenia was not associated with increased incidence of postoperative complications for Port-A-Cath insertions in acute leukemic children.

Port-A-Cath Insertions in Acute Leukaemia and Childhood Malignancies

OBJECTIVE

This retrospective case series sought to determine the incidence and profile of catheter-related complications associated with Port-A-Cath insertions in paediatric cancer patients, as well as predictive factors for infection-related port removals.

METHODS

Between January 2002 and December 2004, 175 consecutive Port-A-Cath insertions were followed for a total of 75,000 days (median, 407; range, 6-1,074). Incidence of catheter-related bloodstream infections (CRBSIs), other complications and CRBSI-related port removals were analysed for cases with acute leukaemia versus other malignancies.

RESULTS

A total of 33 CRBSIs were encountered in 26 cases (18.9%), an infection rate of 0.44 episodes per 1,000 catheter days. While mean preoperative platelet count was 125.34 x 10(9)/L in children with acute leukaemia and 392.11 x 10(9)/L in those with other malignancies (p < 0.01), the incidence of all complications were similar between both subgroups. Staphylococcus epidermidis (23.1%) and Klebsiella spp. (19.2%) were most commonly isolated from infected ports. Median patient age and duration of implantation in CRBSI-related port removals was 1.5 years and 111 days respectively, and 10.0 years and 414 days respectively in CRBSIs without port removal.

CONCLUSION

Minimal complications are associated with Port-A-Cath insertions, even in thrombocytopaenic leukaemic patients. The dominance of Gram-negative organisms in CRBSIs parallels the changing trend of nosocomial infectious agents involved in catheter-related infections.

Totally implantable central venous access devices in children with hemato-oncologic malignancies: evaluation of complications and comparison of incidence of febrile episodes with similar patients without central venous access devices

The incidence of mechanical and infectious complications of totally implantable central venous access devices (TIDs) must be related to underlying disease, intensity of the chemotherapy, and frequency of manipulations. Records of the patients hospitalized from January 2002 to May 2005 were evaluated. Patients with TIDs were matched with patients without TIDs having the same malignancy and the same anti-neoplastic chemotherapy. Catheter-related complications were documented and corresponding phases of the chemotherapy in matched pairs were compared with regard to infections. TIDs were inserted in 31 patients with a median age of 4.3 years (22 acute leukemia, 1 NHL, and 8 solid tumors). Total number of catheter days was 5268, with a median catheter life of 174 days (range 9-493 days). Nine catheters (29%) were removed due to mechanical and infectious complications. There was 13 catheter-related infections with a rate of 2.46/1000 catheter days. Total number of mechanical complications was 5 and overall rate of complications was 3.41/1000 catheter days. The rate of febrile episodes was 54 and 41 in the TID and no TID group, respectively (p: .11). Duration of neutropenia was 9.6 and 7.4 days and duration of fever per febrile attack was 5.6 and 4.4 days in the TID and no TID group, respectively (p: .047 and .56). Although most of the patients in this study had hematological malignancy and required frequent manipulation, the results were similar to those in developed countries. TIDs are essential for management of chemotherapy in pediatric malignancies with acceptable complications.