Central venous catheter infections

Central venous access devices in patients with hemophilia

Hemophilia is a hereditary disorder in which the major clinical manifestation is bleeding into the joints, muscles, internal organs and the CNS, often without any obvious trauma. Bleeding can be fatal as in the case of CNS hemorrhage, or severely debilitating following repeated bleeding into joints that results in crippling arthritis. Treatment for hemophilia includes the intravenous administration of clotting factor concentrates to replace the missing or defective protein. Venous access is therefore critical to the treatment of hemophilia and the prevention of complications due to bleeding. According to the US Centers for Disease Control and Prevention, approximately half of patients less than 16 years of age and one-third of all patients with hemophilia receive regular prophylactic injections of clotting factor concentrates. Prophylaxis, or the regular scheduled administration of antihemophilic factor concentrate, is effective in preventing bleeding. Among those patients with severe disease, in the absence of prophylaxis, approximately 13 bleeds, including nine joint hemorrhages, occur annually. In contrast, when prophylaxis is administered, the annual number of total and joint bleeds decreases to five and three, respectively. One of the major barriers to the more wide-spread use of prophylaxis is venous access. While peripheral venipuncture remains the first choice for venous access, central venous access devices are frequently used to facilitate repeated and/or urgent administration of clotting factor concentrates. The advantages of central venous access devices are well recognized in certain treatment regimens such as prophylaxis and immune tolerance therapy, as well as certain patient groups such as young children in whom venipuncture is often difficult and traumatic, and adults with scarred veins. Central venous access devices also allow earlier commencement of both home treatment and prophylaxis. The goal of this review is to discuss the different types of central venous access devices and their role in the management of hemophilia to provide practitioners that care for patients with hemophilia with the necessary information to make sound therapeutic recommendations to their patients.

Spectrum of external catheter-related infections in children with acute leukemia-Single-center experience

BACKGROUND

External catheters (ECs) are commonly used in children who are receiving treatment for acute leukemia.

AIMS

To study the spectrum of microorganisms and to compare the rates of infection.

METHODS

A total of 42 ECs were inserted, including 28 Port-A-Caths, 11 CVC lines and 3 Hickman lines. Single ECs were required for 19 patients (45.2%), whereas 2, 3 and 4 ECs were required in 8, 1 and 1 patients, respectively.

RESULTS

Overall, 37 culture-documented infections were present in 18 (62%) patients who had ECs. Gram-positive microorganisms were identified in 20 cases, Gram-negative microorganisms in 14 cases and fungal infections in 3 cases. Of the 42 devices implanted, 10 out of 28 Port-A-Caths (35.7%), 2 out of 3 Hickman catheters (66.7%) and 9 out of 11 central venous catheters (81.8%) required removal due to infection. The average length of working life for the ports was 330.6 days (range: 40-1043 days). The median rate of complications due to infection was 2.84 infections per 1000 catheter days (interquartile range: -1.55 to 5.8), and the number of infections was correlated with the number of ports (Pearson's r=0.51; p<0.05).

Catheter-associated bloodstream infections in pediatric hematology-oncology patients

Catheter-associated bloodstream infections (CABSIs) are common complications encountered with cancer treatment. The aims of this study were to analyze the factors associated with recurrent infection and catheter removal in pediatric hematology-oncology patients. All cases of CABSIs in patients attending the Department of Pediatric Hematology-Oncology between January 2008 and December 2010 were reviewed. A total of 44 episodes of CABSIs, including multiple episodes involving the same catheter, were identified in 31 children with cancer. The overall CABSIs rate was 7.4 infections per 1000 central venous catheter (CVC) days. The most frequent organism isolated was coagulase-negative Staphylococcus (CONS). The CVC was removed in nine (20.4%) episodes. We found that hypotension, persistent bacteremia, Candida infection, exit-side infection, neutropenia, and prolonged duration of neutropenia were the factors for catheter removal. There were 23 (52.2%) episodes of recurrence or reinfection. Mortality rate was found to be 9.6% in children with CABSIs. In this study, we found that CABSIs rate was 7.4 infections per 1000 catheter-days. CABSIs rates in our hematology-oncology patients are comparable to prior reports. Because CONS is the most common isolated microorganism in CABSIs, vancomycin can be considered part of the initial empirical regimen.

Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections

Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices.Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria.The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use of suitable antiseptics in combination with medical devices may further support reduction and prevention of such infections. In addition to reducing the adverse clinical outcomes related with these infections, such reduction may substantially decrease the economic burden caused by device-related infection for health care systems.

Tsukamurella catheter-related bloodstream infection in a pediatric patient with pulmonary hypertension

Catheter-related bloodstream infections (CR-BSI) are important complications in patients with long-term indwelling central venous catheters. In this report, we present the case of a 14-year-old male with pulmonary hypertension treated with continuous treprostinil infusion, who presented with a CR-BSI caused by a Tsukamurella species. This case highlights the potential for this unusual organism to cause infection in immunocompetent patients.

Side-effects and venous access issues with immune tolerance therapy

Immune tolerance therapy (ITT) is the most effective approach to eradicate inhibitors in patients with haemophilia who develop high-titre inhibitors. Yet ITT is associated with many adverse side-effects. Rarely, adverse side-effects arise from the various factor concentrates that patients on ITT receive or from adjuvant immunosuppressive agents used during ITT. Most adverse side-effects of ITT are related to the need for frequent and repetitive venous access, which often results in the need for central venous access devices (CVAD). These devices greatly facilitate the ability to give repeated doses of factor concentrates to patients and are particularly useful in young children who often have small and poorly functioning peripheral veins. These devices can become infected, can malfunction or can lead to venous thrombosis. These complications, although rarely causing mortality, may lead to significant morbidity including the need to have the devices removed and new ones inserted. As well, such CVAD complications may lead to reduced effectiveness of ITT through interruptions in ITT.

Closed-hub systems with protected connections and the reduction of risk of catheter-related bloodstream infection in pediatric patients receiving intravenous prostanoid therapy for pulmonary hypertension

BACKGROUND

Intravenous prostanoids (epoprostenol and treprostinil) are effective therapies for pulmonary arterial hypertension but carry a risk of catheter-related bloodstream infection (CR-BSI). Prevention of CR-BSI during long-term use of indwelling central venous catheters is important.

OBJECTIVE

To evaluate whether using a closed-hub system and waterproofing catheter hub connections reduces the rate of CR-BSI per 1,000 catheter-days.

DESIGN

Single-center open observational study (January 2003-December 2008).

PATIENTS

Pediatric patients with pulmonary arterial hypertension who received intravenous prostanoids.

METHODS

In July 2007, CR-BSI preventive measures were implemented, including the use of a closed-hub system and the waterproofing of catheter hub connections during showering. Rates of CR-BSI before and after implementing preventive measures were compared with respect to medication administered and type of bacterial infection.

RESULTS

Fifty patients received intravenous prostanoid therapy for a total of 41,840 catheter-days. The rate of CR-BSI during the study period was 0.51 infections per 1,000 catheter-days for epoprostenol and 1.38 infections per 1,000 catheter-days for treprostinil, which differed significantly (P < .01). CR-BSIs caused by gram-negative pathogens occurred more frequently with treprostinil than with epoprostenol (0.91 infections per 1,000 catheter-days vs 0.08 infections per 1,000 catheter-days; P < .01). Patients treated with treprostinil after the implemented changes had a significant decrease in CR-BSI rate (1.95 infections per 1,000 catheter-days vs 0.19 infections per 1,000 catheter-days; P < .01).

CONCLUSION

The closed-hub system and the maintenance of dry catheter hub connections significantly reduced the incidence of CR-BSI (particularly infections caused by gram-negative pathogens) in patients receiving intravenous treprostinil.

Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America

These updated guidelines replace the previous management guidelines published in 2001. The guidelines are intended for use by health care providers who care for patients who either have these infections or may be at risk for them.

The morbidity and mortality of pediatric oncology patients presenting to the intensive care unit with septic shock

BACKGROUND

Children with an underlying diagnosis of malignancy are at high risk for developing serious infections. Previous studies, although very limited in number, suggest a particularly poor outcome for these patients if admitted to an intensive care unit with septic shock.

PROCEDURE

A review of all oncology patients admitted to the pediatric intensive care unit (PICU) at a tertiary care Children's Hospital over an 11-year period with a diagnosis of septic shock was performed. Patients were age and gender-matched with non-oncology patients also admitted to the PICU with septic shock during the same time period. Mortality and morbidity rates were compared, and risk factors for poor outcome were examined.

RESULTS

The charts of 69 oncology patients and 69 control patients were reviewed. Mortality rate at PICU discharge was not significantly different between the two groups (15.9% in the oncology group, versus 11.6% in the control group, P = 0.607). Organ dysfunction was higher in the oncology group (P = 0.005), although length of PICU stay was shorter (P = 0.036). There was no difference in ventilator days or vasopressor use.

CONCLUSION

This review found that the survival of oncology patients admitted to the PICU with septic shock was not significantly different from control patients, and was significantly higher than previous reports. Aggressive management of these children is warranted as their long term prognosis may be much more favorable than originally thought.

Risk determinants for catheter-associated blood stream infections in children and young adults with cancer

BACKGROUND

Catheter-associated blood stream infections (CABSI) are frequent complications encountered with cancer treatment. In order to understand which factors might predispose to CABSIs in children and young adults, we evaluated risk for infection in association with tumor type, catheter type, and setting of occurrence.

METHODS

All pediatric oncology patients having a central venous catheter (CVC) with a tunneled external (TE) or totally implantable design (TID) were prospectively followed for the occurrence of a CABSI for 12 months. CABSIs were defined in accordance with the guidelines published by the Centers for Disease Control, and were quantified as the number of occurrences per 1,000 device days. Rates of CABSIs were stratified by tumor histology, type of catheter design, and setting of occurrence. Statistical comparisons were made using the Mantel-Haenzel statistic and the Cox proportional hazard model.

RESULTS

A total of 58 CABSIs were identified in 139 patients over a period of 35,935 CVC days. The overall CABSI rate was 1.6 infections per 1,000 CVC days (95% CI 1.2, 2.1). Stratified analysis demonstrated increased risk for CABSIs in hospitalized patients having TEs, and while patients with solid tumors were also at higher risk; this association was not supported by the Cox proportional hazard model.

CONCLUSION

While our baseline CABSI rate was comparatively lower than for other institutions, subset analyses identified that hospitalized cancer patients having TEs are at the highest risk for developing CABSIs. Our findings may help to guide improved methods of anticipating and controlling infections in immunocompromised patients.

Prevention of catheter-related infections using a closed hub system in patients with pulmonary arterial hypertension

BACKGROUND

Most of the patients with pulmonary arterial hypertension (PAH) receiving intravenous epoprostenol have experienced catheter-related infections during long-term treatment. Catheter hub was reported to be the most important source of catheter-related infections. To prevent the catheter-related infections, we have introduced a closed hub system and compared the incidence of catheter-related infections with that in patients using a non-closed hub system.

METHODS AND RESULTS

We evaluated the results obtained on 24 occasions in 20 patients with PAH between June 1999 and December 2005. On 11 occasions, a non-closed hub system was used and on 13 cases a closed hub system. We classified the catheter-related infection into a catheter-related bloodstream infection (CRBSI) group or a tunnel infection group based on the pathway of bacteria. The CRBSI rate was 0.89 per 1,000 catheter days in the non-closed hub system group vs 0.10 per 1,000 catheter days in the closed hub system group. Kaplan-Meier analysis showed that the risk of CRBSI significantly decreased in the closed hub system group. None of the patients died as a direct consequence of catheter-related infection during the study period.

CONCLUSIONS

We successfully prevented CRBSI by using a closed hub system.

Central Venous Lines in Children With Lesser Risk Acute Lymphoblastic Leukemia: Optimal Type and Timing of Placement

Purpose

In pediatric patients with acute lymphoblastic leukemia (ALL), the optimal time for central venous line (CVL) insertion and the optimal type of CVL (internal v external) is unclear. This study was undertaken to compare complication rates between early versus late line insertion, and between internal versus external lines in children with lesser risk ALL.

Patients and Methods

We performed a retrospective analysis of patients enrolled onto Pediatric Oncology Group (POG) protocol 9201. Data regarding demographics, CVL types and insertion dates, blood counts, and complications were reviewed through week 25 of therapy.

Results

Of 697 patients enrolled onto POG protocol 9201, 362 patients had sufficient data for analysis. When compared to late line placement (> day 15 of induction), early CVL placement (≤ day 15 of induction) was associated with an increased risk of having a positive blood culture (odds ratio, 2.2; 95% CI, 1.0 to 5.0; P = .05). When compared with internal CVLs (“ports”), external CVLs were associated with a positive blood culture (odds ratio, 3.1; 95% CI, 1.3 to 7.5; P = .01), thrombosis (odds ratio, 3.9; 95% CI, 1.5 to 10.3; P = .006), and CVL removal (odds ratio, 5.6; 95% CI, 2.7 to 11.6; P < .001).

Conclusion

In pediatric patients with lesser risk ALL, internal lines (ports) should be the preferred CVL type due to a lower risk of infectious and thrombotic complications. In addition, CVLs placed early in induction are associated with a higher risk of positive blood culture than those placed later in induction.

Catheter-related infections in children treated with hemodialysis

Infectious complications of the central venous catheter (CVC) are a major source of morbidity among children treated with hemodialysis (HD), with catheter-related bloodstream infections (CRBSI) being the most important clinical manifestations. As only a few studies of children on HD have been published, the management of CVC-related infections in this population is mainly based on data derived from adults or occasionally from children not affected by end-stage renal disease (ESRD). The aim of this review is to discuss current knowledge concerning the epidemiology, prevention, and treatment of catheter-related infections in children on HD. Catheters impregnated with antibiotics/antiseptics, lock antibiotic prophylaxis, nasal mupirocin, and the application of ointments at the exit-site have all been proposed as means of reducing the risk of CVC infections, but their real efficacy in the pediatric population has not yet been demonstrated. Furthermore, it is not clear how long antibiotic therapy should be continued, and there is still debate as to whether the catheter has to be removed. We propose some practical guidelines for the management of CRBSI in children with percutaneously inserted and surgically implanted HD catheters, but a number of unresolved clinical issues still remain, which will require prospective clinical trials specifically performed in pediatric patients with ESRD.

Consensus recommendations for use of central venous access devices in haemophilia

Venous access is essential for delivery of haemophilia factor concentrate. Wherever possible, peripheral veins remain the route of choice, and the use of central venous access devices (CVADs) should be limited to cases of clear need in patients with caregivers able to exercise diligence in CVAD care and should continue no longer than necessary. CVADs are of recognized value for repeated administration of coagulation factors in haemophilia, particularly for prophylaxis and immune tolerance therapy and in young children. Evidence to guide best practices has been fragmentary, and standardized methods for CVAD usage have yet to be established. We have developed management recommendations based upon available published evidence as well as extensive clinical experience. These recommendations address patient and CVAD selection; CVAD placement, care and removal; caregiver/patient guidance; and complications, including infection and thrombosis. In the absence of inhibitors, ports are recommended, primarily because of fewer associated infections than with external catheters. For patients with inhibitors, ports also appear to be associated with fewer infections. Infection is the most frequent complication, and recommendations to prevent and treat infections are supported by extensive clinical data and experience. Strict adherence to handwashing and aseptic technique are essential elements of catheter care. Evidence-based data regarding the detection and treatment of CVAD-related thrombotic complications are limited. Caregiver education is an integral part of CVAD use and the procedural practices of users should be regularly re-assessed. These recommendations provide a basis for sound current CVAD practice and are expected to undergo further refinements as new evidence is compiled and clinical experience is gained.

Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective randomized clinical trial

PURPOSE

To evaluate the efficacy of long-term nontunneled silicone catheters impregnated with minocycline and rifampin (M-R) in reducing catheter-related bloodstream infections.

PATIENTS AND METHODS

This prospective, randomized, double-blind clinical trial was conducted at M.D. Anderson Cancer Center, a tertiary care hospital in Houston, TX. All patients in the trial had a malignancy.

RESULTS

Between September 1999 and May 2002, 356 assessable catheters were used: 182 M-R and 174 nonimpregnated. The patients' characteristics were comparable between the two study groups. The mean (+/- standard deviation) duration of catheterization with M-R catheters was comparable to that of nonimpregnated catheters (66.21 +/- 30.88 v 63.01 +/- 30.80 days). A total of 17 catheter-related bloodstream infections occurred during the course of the study. Three were associated with the use of M-R catheters and 14 were associated with the nonimpregnated catheters, with a rate of catheter-related bloodstream infection of 0.25 and 1.28/1,000 catheter-days, respectively (P = .003). Gram-positive cocci accounted for the majority of the organisms causing the infections. There were no allergic reactions associated with M-R catheters.

CONCLUSION

Long-term nontunneled central venous catheters impregnated with minocycline and rifampin are efficacious and safe in reducing catheter-related bloodstream infections in cancer patients.

Micrococcus-associated central venous catheter infection in patients with pulmonary arterial hypertension

STUDY OBJECTIVES

To determine the incidence of catheter-related infection in patients with pulmonary arterial hypertension (PAH) receiving epoprostenol (EPO), and to note an etiologic role for Micrococcus spp, which is rarely reported as a pathogen in the medical literature.

DESIGN

Observational study.

SETTING

Two PAH specialty treatment centers, Harbor-UCLA Medical Center (Torrance, CA), and the College of Physicians and Surgeons, Columbia University (New York, NY).

PATIENTS

A total of 192 patients with PAH receiving continuous therapy with IV EPO.

INTERVENTIONS

From 1987 to 2000, 192 patients with PAH received infusions of EPO via central venous catheter. Catheter care included regular dressing changes with dry gauze using a sterile procedure, without the use of flushes. Patients were asked to report on known infections and treatments, and symptoms. All infections were verified by a telephone call to the patient, care provider, and microbiology laboratory whenever possible.

MEASUREMENTS AND RESULTS

There were 335,285 catheter days (mean +/- SD, 1,325 +/- 974 catheter days). There were 88 clinical catheter infections with 51 blood culture-positive infections, necessitating catheter removal in 38 instances. The following pathogens were isolated: Staphylococcus aureus (25); Micrococcus spp (14); mixed flora (3); coagulase-negative Staphylococcus spp (2); Corynebacterium spp (2); Serratia marcessens (1); Enterobacter spp (1); Pseudomonas aeruginosa (1); enterococci (1); and unidentified Gram-positive cocci (1). The catheter infection rate was 0.26 per 1,000 catheter days.

CONCLUSIONS

The use of long-term therapy with continuous EPO appears to be associated with a low incidence of catheter-related infections. Micrococcus spp were the second most common etiologic agent. Caregivers managing patients with PAH must be aware of the risk of catheter infection, as it may contribute to the morbidity and mortality associated with the use of EPO. When isolated, Micrococcus spp should not be viewed as a contaminant, but rather as a true pathogen that may require therapeutic intervention.

Catheter-related bloodstream infection in adult haematology patients: catheter removal practice and outcome

The aim of the present study was to describe the practice of central venous catheter (CVC) removal and outcomes of catheter-related bloodstream infection (CR-BSI) in adult haematology patients. Patients were identified retrospectively according to diagnosis coding of inpatient episodes and evaluated when, on examination of medical records, there had been evidence of sepsis with strong clinical suspicion that the source was the CVC. Demographic and bacteriological data, as well as therapeutic measures and clinical outcomes, were recorded. One hundred and three patient episodes were evaluated. The most frequent type of CVC was the Hickman catheter and the most frequently isolated pathogen was coagulase-negative staphylococci. Twenty-five percent of episodes were managed with catheter removal. Treatment failure, defined as recurrence of infection within 90 days or mortality attributed to sepsis within 30 days, occurred significantly more frequently in the group managed without catheter removal (52.5% versus 4%, P < 0.05). Specifically, 90-day recurrence was more common when the catheter was retained (46% versus 0%). However the difference in 30-day attributable mortality (7% versus 4%) was not significantly different. Notably, no significant difference between the two groups emerged in respect of other measured characteristics that had been considered as potential determinants of outcome. More frequent CVC removal for CR-BSI, in this population, should be considered. Management of CR-BSI without catheter removal is associated with treatment failure, morbidity and carries significant resource implications.

Purging iron from the heart

Methods are now available to measure the magnitude of iron accumulation in the heart. Their validation currently relies on indirect evidence and not on chemical estimation in cardiac biopsies. All patients with symptomatic heart disease appear to have abnormal T2* values, but many patients without symptomatic heart disease also have evidence of increased myocardial iron. Although there is no proof to date that increased myocardial iron, as evidenced by abnormal magnetic resonance imaging, carries an adverse prognosis, it is likely that such new information will affect the chelating programme of patients. In these cases, there are a number of options available: (i) ongoing treatment with either desferrioxamine (DFO) or deferiprone may be intensified; (ii) the patient may be switched to the alternative chelator or (iii) combined chelation with both DFO and deferiprone may be started, which is more effective than using either chelator alone. For patients with symptomatic heart disease, continuous intravenous DFO with, or without deferiprone, remains the currently recommended treatment, in view of its documented ability to salvage these patients.

Factors influencing central line infections in children with acute lymphoblastic leukemia: results of a single institutional study

BACKGROUND

We compared the rates of infection in external catheters (ECs) and totally implantable devices (TIDs) and the effect of timing of insertion in children with acute lymphoblastic leukemia (ALL).

PROCEDURE

Central line data was collected on all children with ALL referred to the National Guard Hospital, Jeddah. Data was collected retrospectively from 1996 to September 1999 and prospectively thereafter. Only ECs were inserted prior to 1999 subsequently TIDs were preferred.

RESULTS

One hundred forty eight children with ALL, mean age 5.1 years had 129 ECs and 70 TIDs inserted for a total of 41,382 catheter days. The overall rate of infective episodes (infections/1,000 catheter days) was 3.43. Of the initial 148 lines 100 developed complications of which 76 (51%) were secondary to an infective episode. Only young age and treatment protocol were risk factors for first line infections (P < 0.05). There was weak evidence that ECs had an earlier time to infection compared to TIDs (P = 0.056).

CONCLUSIONS

In this study, population central lines were associated with a high rate of infection. Treatment protocol and age were the only significant risk factors when only first lines were considered. Delaying catheter insertion for more than 3 weeks from diagnosis did not reduce the risk of infection.

Central venous access devices in haemophilia

Central venous access devices (CVADs) can facilitate repeated and/or urgent administration of coagulation factors in haemophilic patients. We conducted a systematic review and meta-analysis of complication rates and risk factors for poor outcome. Forty-eight studies with a total of 2704 patients and 2973 CVADs were included. The primary indications for CVADs were immune tolerance therapy (34.9% of patients), difficult venous access (31.8%) and prophylaxis (29.1%). Fully implanted CVADs were employed in 77.4% of cases and external CVADs in 22.6%. A total of 1190 infections were reported, and the pooled incidence of infection was 0.66 per 1000 CVAD days [confidence interval (CI), 0.44-0.97 per 1000 CVAD days]. Among patients developing infection, the pooled time to first infection was 295 days (CI, 181-479 days). Presence of inhibitors was an independent risk factor for infection with an incidence rate ratio (IRR) of 1.67 (CI, 1.15-2.43). Infection was less likely in patients >6 years of age (IRR, 0.46; CI, 0.27-0.79) and recipients of fully implanted CVADs (IRR, 0.31; CI, 0.12-0.86). Available information on thrombosis was limited, with only 55 cases being reported. Eventually, 31.3% of CVADs were removed, and infection was the reason for removal in 69.9% of cases and thrombosis in 4.1%. The pooled time period CVADs remained indwelling prior to removal or the expiration of the study observation period was 578 days per CVAD (CI, 456-733 days per CVAD). CVADs can confer major benefits in patients with haemophilia requiring long-term venous access, and serious complications are rare.

Reversal of cardiac complications in thalassemia major by long-term intermittent daily intensive iron chelation

OBJECTIVES

In patients with thalassemia major (TM) who are non-compliant with long-term deferoxamine (DFO) chelation, survival is limited mainly because of cardiac complications of transfusional siderosis. It was recently shown in a small group of TM patients with established cardiac damage that continuous 24-h DFO infusion via an indwelling intravenous (i.v.) catheter is effective in reversing cardiac toxicity. The aim of the present study was to evaluate the results with intermittent daily (8-10 h) i.v. DFO.

PATIENTS

Eight TM patients with cardiac complications treated with intensive intermittent DFO were retrospectively evaluated by the mean annual serum ferritin, radionucleated ventriculography and 24-h electrocardiography recordings.

RESULTS

The median age at diagnosis of cardiac disease was 17.5 yr (range 14-21), and the median follow-up time was 84 months (range, 36-120). In the majority of patients (seven of eight) high-dose DFO (mean 95 +/- 18.3 mg/kg/d) was administered via a central venous line. During follow-up, there was a significant decrease in the mean ferritin levels (5828 +/- 2016 ng/mL to 1585 +/- 1849 ng/mL, P < 0.001). Both cardiac failure (mean ejection fraction 32 +/- 5) and cardiac arrhythmias were resolved in four of five patients. One non-compliant patient died during the follow-up. Following discontinuation of the i.v. therapy, compliance with conventional DFO therapy improved. The complications of this regimen, mainly catheter-related infections and catheter-related thrombosis, were similar to those described earlier.

CONCLUSIONS

These results with the longest follow-up period in the literature suggest that i.v. high-dose DFO for 8-10 h daily may be as effective as continuous 24-h infusion for the reversal of established cardiac disease in TM.

Prognostic value of quantitative blood cultures for the outcome of central venous catheters in children

Quantitative blood cultures have been used in order to define catheter-related bloodstream infection (CRBI) in pediatric patients with malignancy and central venous catheters (CVCs). We prospectively followed 32 patients with a total of 38 CVCs for a period of 4 y (14,068 catheter-days). Of a total of 35 cases of bacteremia, 9 were considered to be CRBI (25%). The incidence of bacteremia in our study was 2.48 episodes/1,000 catheter-days and 20/38 CVCs (52%) were affected by bacteremia. The incidence of CRBI was 0.63 episodes/1,000 catheter-days and it was detected in 9/38 CVCs (23%). The catheter salvage rate in cases of bacteremia, irrespective of etiology, was 30/35 (85%). The catheter salvage rate in cases of CRBI was only 4/9 (44%), whereas all the catheters (26/26) in non-catheter-related cases of bacteremia were salvaged. We suggest that the use of quantitative blood cultures is a useful tool for the evaluation of bacteremia in patients with CVCs and is of prognostic value.

Complications of central venous access devices in paediatric haemophilia patients

We conducted a retrospective survey of our experience with central venous access devices (CVADs) implanted in children with haemophilia seen at the Vanderbilt Hemostasis-Thrombosis Clinic from 1986 to 2000. Following discussion with parents on the merits and risks associated with the use of CVADs for immune tolerance induction or factor prophylaxis, catheters were inserted under sterile technique in the operating room. One nurse provided demonstration and teaching about catheter care and access. Thirty central venous catheters were inserted in 22 children. Our survey revealed that the two most common complications associated with central venous catheters were bacteraemia and thrombosis. We found a sepsis rate of 0.30/1000 catheter-days or one episode of bacteraemia for every 3346 days of catheter use. The thrombosis rate of our cohort was 0.13/1000 catheter-days or one episode of thrombosis for every 7529 days of catheter use. Uncomplicated venous access is essential in children with severe haemophilia who require prophylaxis or immune tolerance induction. While infection was the most common complication observed in our series, we experienced a lower overall infection rate than several reported series. Catheter thrombosis and subsequent obstruction may occur as a result of intraluminal fibrin deposits. We conclude that the use of implantable central venous catheters is an effective method for accessing children with haemophilia. We accept that the benefits of CVADs in the treatment of paediatric haemophilia patients outweigh the previously documented risks. Future prospective studies should be designed to define all associated risks and to determine effective strategies to reduce them.

The pediatrician and medical care of the child with cancer

The child's pediatrician is an important resource for families regarding a host of issues such as infections, complications and side effects of chemotherapy, school issues, and psychosocial stressors that are common in families of children with life-threatening illness. This article provides guidance for caring for children with malignancies in the primary care setting.

Are femoral Broviac catheters effective and safe? A prospective comparison of femoral and jugular venous broviac catheters in newborn infants

STUDY OBJECTIVES

Patients with femoral venous catheters are commonly believed to be at higher risk of infectious complications as compared to patients with jugular catheters. Although reports have suggested that femoral venous Broviac catheters (Davol; Cranston, RI) are safe, no comparisons with jugular catheters were presented. Thus, we compared our efficacy and complications of femoral and jugular venous Broviac catheters in newborns.

METHODS

We prospectively recorded demographic data, cannulation requirements, duration of catheter use, and complications.

SETTING

Special-care nursery.

PATIENTS

Newborns.

INTERVENTIONS

Insertion of tunneled single-lumen Broviac catheters into vessels of the femoral triangle or the internal jugular, external jugular, or facial veins by surgical cutdown.

MEASUREMENTS AND RESULTS

Sixty infants had 2,503 catheter-days with 111 catheters. Twenty-six infants had 47 femoral catheters, and 34 infants had 64 jugular catheters. All insertion attempts were successful. The median durations of catheter use were 24.0 days and 17.0 days for femoral and jugular catheters, respectively (p = 0.021). Group characteristics, insertion variables, incidences of complications, and deaths were not significantly different between groups.

CONCLUSIONS

We conclude that compared to jugular catheters, femoral venous Broviac catheters are an effective means to vascular access, with similar incidences of complications in newborn infants.

Central venous catheter-associated bloodstream infections in pediatric oncology home care

Fifty-two pediatric oncology patients with central venous catheters (CVCs) who received home care services were studied. Gram-negative organisms were responsible for a greater proportion of CVC-associated bloodstream infections in pediatric oncology patients receiving home care than in hospitalized pediatric oncology patients.

Wireless Replacement of the “Lost” Central Venous Line in Children

Although the achievement of central venous access in children is often difficult maintenance of access is often frustrated by the tendency of the small-caliber central venous line (CVL) to thrombose despite adequate heparinization or—worse yet—be inadvertently removed. Traditional replacement over wire (Seldinger technique) is often not an option for these “lost” CVLs. Over the past 7 years we have used a wireless technique of CVL replacement to re-establish central access in children. The charts of 125 children who underwent wireless CVL replacement at various institutions between January 1995 and July 2000 were retrospectively reviewed. The wireless technique involves replacement of CVL by direct insertion through the previous catheter tract marked by the old puncture site. Plain film was used to confirm the line position postprocedure. The technique was applied predominantly to percutaneously placed 3- to 4-F CVLs with distal port thrombosis or those that had been inadvertently removed. Successful replacement was defined as re-establishment of previous line position and the ability to flush/draw blood through all ports. Wireless replacement was successful in 120 of 125 cases (96.0%). Recannulization was successful in CVLs as new as 3 days old and those removed for as long as 24 hours. Of the five unsuccessful cases, however, two CVLs were >3 weeks old, but >6 hours had elapsed since removal. The remaining three cases were CVLs that were <3 days old. There were no intra- or postoperative complications, notably air embolism. We conclude that wireless CVL replacement in children can be performed safely and successfully in children who have lost central access not amenable to replacement via the traditional Seldinger technique. The often difficult chore of re-establishing central access at a new site in small children can thus be avoided.

Simultaneous Placement of Long-Term Central Venous Catheters and Surgical Debridement for Treatment of Osteomyelitis

Nonhealing wounds with underlying osteomyelitis require surgical debridement and a course of intravenous antibiotics usually via long-term venous catheter. Fear of catheter infection resulting from bacteremia or direct cross-contamination has traditionally led to staged procedures. A protocol for simultaneous placement of a long-term central venous catheter (Hickman) for antibiotic therapy and surgical debridement of chronic wounds with osteomyelitis does not result in elevated catheter-related infections. We conducted a prospective consecutive trial at a community-based tertiary-care training hospital. From October 1995 through June 1997 100 consecutive patients received 105 central venous catheters and surgical debridement for treatment of chronic wounds with underlying osteomyelitis at the same operative setting. Four catheters required removal because of infectious complications. There was no correlation between the bacteria cultured from the central venous line or blood cultures and the wound cultures. Combining placement of long-term central venous catheters and surgical debridement of chronic wounds with osteomyelitis at one operative setting results in an acceptably low catheter infection rate.

Guidelines for the management of intravascular catheter-related infections

These guidelines from the Infectious Diseases Society of America (IDSA), the American College of Critical Care Medicine (for the Society of Critical Care Medicine), and the Society for Healthcare Epidemiology of America contain recommendations for the management of adults and children with, and diagnosis of infections related to, peripheral and nontunneled central venous catheters (CVCs), pulmonary artery catheters, tunneled central catheters, and implantable devices. The guidelines, written for clinicians, contain IDSA evidence-based recommendations for assessment of the quality and strength of the data. Recommendations are presented according to the type of catheter, the infecting organism, and the associated complications.

Intravascular catheter-related infections are a major cause of morbidity and mortality in the United States. Coagulase-negative staphylococci,Staphylococcus aureus, aerobic gram-negative bacilli, andCandida albicansmost commonly cause catheter-related bloodstream infection. Management of catheter-related infection varies according to the type of catheter involved. After appropriate cultures of blood and catheter samples are done, empirical iv antimicrobial therapy should be initiated on the basis of clinical clues, the severity of the patient's acute illness, underlying disease, and the potential pathogen (s) involved. In most cases of nontunneled CVC-related bacteremia and fungemia, the CVC should be removed.

Management of complications associated with totally implantable ports in patients with AIDS

Morbidity associated with totally implantable ports is common in patients with acquired immune deficiency syndrome (AIDS). More than half of the implanted devices will have at least one complication before its removal or the patient's death. Infectious complications are the most frequent. Two patients are reported here in whom staphylococcal infection of the totally implantable port occurred; one of the devices could be saved through the antibiotic lock technique. Infectious complications of totally implantable ports occur more commonly in patients who are neutropenic or who have low CD4 cell counts (<25 cells per microliter). When patients have chamber infection (the most frequent infectious complication) with or without secondary bacteremia, the antibiotic lock technique has proven useful for device sterilization.

Prevention of central venous catheter-related infections and thrombotic events in immunocompromised children by the use of vancomycin/ciprofloxacin/heparin flush solution: A randomized, multicenter, double-blind trial

PURPOSE

To determine whether an antibiotic flush solution containing vancomycin, heparin, and ciprofloxacin (VHC) can prevent the majority of line infections.

PATIENTS AND METHODS

A prospective double-blind study was performed comparing VHC to vancomycin and heparin (VH) to heparin alone in 126 pediatric oncology patients.

RESULTS

The 153 assessable lines resulted in 36,944 line days studied. There were 58 blood stream infections (43 gram-positive, 14 gram-negative, and one fungal). Forty were defined as line infections (31 heparin, three VH, six VHC). The time to develop a line infection was significantly increased using either antibiotic flush (VH, P =.011; VHC, P =.036). The rate of total line infections (VH, P =.004; VHC, P =.005), gram-positive line infections (VH, P =. 028; VHC, P =.022), and gram-negative line infections (VH, P =.006; VHC, P =.003) was significantly reduced by either VH or VHC. Sixty-two (41%) of the lines developed 119 occlusion episodes (heparin, 3.99 per 1,000 line days; VHC, 1.75 per 1,000 line days; P =.0005). Neither antibiotic could be detected after flushing, and no adverse events were detected, including increased incidence of vancomycin-resistant Enterococcus colonization or disease.

CONCLUSION

The use of either VH or VHC flush solution significantly decreased the complications associated with the use of tunneled central venous lines in immunocompromised children and would save significant health care resources.

Success rates and cost-effectiveness of antibiotic combinations for initial treatment of central-venous-line infections during total parenteral nutrition

BACKGROUND

Central-venous-line infections can be successfully treated with appropriate antibiotics, thus avoiding the need for catheter removal. Based on our experience, vancomycin, gentamicin, piperacillin, ceftazidime, and amphotericin, alone or in combination, are usually administered, pending sensitivity results. This empirical list, however, has never been verified against actual sensitivity results nor has it been tested for cost or efficacy.

METHODS

Medical records of inpatients on hyperalimentation over 1 year were reviewed. Success rate, therapy duration, and drug acquisition cost and charge were assessed for central-venous-line infections. Antibiotics then were paired and evaluated in terms of charge and efficacy against all microorganisms as determined by sensitivity results.

RESULTS

In 500 inpatients receiving hyperalimentation for 9,698 patient-days, 8.4 central-venous-line infections/1,000 patient-days occurred. Staphylococcus non-aureus, Candida species, Enterococcus faecium, and Staphylococcus aureus predominantly were isolated. Of the infections, 51 (67%) were sensitive to one or more of the initial antibiotics. A 2-week course of antibiotics successfully treated 50 (66%) catheter infections without line removal. Appropriate initial therapy on average reduced treatment duration by 8 to 10 days and drug charges by $400 to $700.

CONCLUSIONS

Amikacin-vancomycin appears to be the most cost-effective selection for presumed central-venous-line infections, pending sensitivity results, followed by valid alternatives. Lower failure rates are well worth the extra cost in pharmaceutical charges.

Long-term outcome of continuous 24-hour deferoxamine infusion via indwelling intravenous catheters in high-risk β-thalassemia

The optimal regimen of intravenous deferoxamine for iron overload in high-risk homozygous β-thalassemia is unknown because only short-term follow-up has been described in small patient groups. We report the outcome over a 16-year period of a continuous 24-hour deferoxamine regimen, with dose adjustment for serum ferritin, delivered via 25 indwelling intravenous lines for 17 patients. Treatment indications were cardiac arrhythmias, left ventricular dysfunction, gross iron overload, and intolerability of subcutaneous deferoxamine. Cardiac arrhythmias were reversed in 6 of 6 patients, and the left ventricular ejection fraction improved in 7 of 9 patients from a mean (± SEM) of 36 ± 2% to 49 ± 3% (P = .002, n = 9). The serum ferritin fell in a biphasic manner from a pretherapy mean of 6281 ± 562 μg/L to 3736 ± 466 μg/L (P = .001), falling rapidly and proportionally to the pretreatment ferritin (r2 = 0.99) for values &gt;3000 μg/L but falling less rapidly below this value (at 133 ± 22 μg/L/mo). The principal catheter-related complications were infection and thromboembolism (1.15 and 0.48 per 1000 catheter days, respectively), rates similar to other patient groups. Only one case of reversible deferoxamine toxicity was observed (retinal) when the therapeutic index was briefly exceeded. An actuarial survival of 61% at 13 years with no treatment-related mortality provides evidence of the value of this protocol.

Stability of antibiotics used for antibiotic-lock treatment of infections of implantable venous devices (ports)

Antibiotic-lock is a treatment for catheter-related bloodstream infections in which a solution containing heparin and an antibiotic dwells in the lumen of the catheter or port. We tested the stability of vancomycin, cefazolin, ticarcillin-clavulanic acid, ceftazidime, or ciprofloxacin combined with heparin after incubation in vitro at 25 or 37 degrees C for intervals of up to 10 days by bioassay. All the antibiotic solutions except ceftazidime retained >/=90% activity at both 25 and 37 degrees C. Thus, studies of antibiotic-heparin lock solutions with dwell times of up to 10 days are feasible.

Right atrial catheter-related complications in pediatric oncology patients: the situation in a developing country

The complications of right atrial catheters (RACs) in pediatric oncology patients are unknown for centers in developing countries. This study examined the complications of RACs at Ankara University Medical School, Turkey. A total of 90 RACs were placed in 61 children for long-term chemotherapy with a total experience of 15,536 catheter days. The rate of catheter-related sepsis was 4.9 episodes per 1000 catheter days. Coagulase-negative staphylococci and Candida species were the most common organisms, accounting for 25.0 and 13.1% of all organisms, respectively. The most common reasons for the removal of the RACs were infection (42.4%) and dislodgement (32.2%). The rates of complications were significantly higher in this study than in western studies. This increase could be explained by the differences in catheter care practices in the Turkish center. In conclusion, the use of RACs in a developing country necessitates an appraisal of the benefits and risks for each patient and improvement of catheter care procedures.