Central venous catheter exchange by guidewire for treatment of catheter-related bacteraemia in patients undergoing BMT or intensive chemotherapy

Guidewire Catheter Exchange in Pediatric Oncology: Indications, Postoperative Complications, and Outcomes

BACKGROUND

Maintaining long-term central venous catheters (CVCs) in children undergoing chemotherapy can be challenging. Guidewire catheter exchange (GCE) replaces a CVC without repeat venipuncture. This study evaluated the indications, success rate, and complications of GCE in a large cohort of pediatric cancer patients.

PROCEDURE

Medical records of pediatric cancer patients who underwent GCE at our institution between 2003 and 2013 were retrospectively reviewed. Variables analyzed included gender, age at GCE, primary cancer diagnosis, indication for GCE, absolute neutrophil count (ANC) at GCE, vein used, success rate, and postoperative complications (<30 days after exchange).

RESULTS

A total of 435 GCEs performed in 407 patients (230 males and 177 females) were reviewed. Median age at GCE was 8 years (range, 0.2-24). Acute lymphoblastic leukemia was the most common diagnosis (50.6%). The primary indication for GCE was the desire to have an alternative type of CVC (71%). Other indications included catheter displacement (17%), catheter malfunction (11%), and catheter infection (1%). Median ANC at GCE was 2,581/mm(3) (range, 0-43,400). Left subclavian vein was more commonly used (57.7%). The success rate of GCE was 93.4% (406 of 435 procedures, 95% confidence interval: 91.0-97.5%). A total of 33 (7.5%) postoperative complications occurred including central line associated bloodstream infection (CLABSI) (n = 20, 4.5%), catheter dislodgement (n = 6, 1.4%), and catheter malfunction (n = 7, 1.6%).

CONCLUSIONS

We conclude that GCE in pediatric cancer patients is associated with a high success rate and a low risk of complications. The most common postoperative complication, CLABSI, occurred at a rate significantly lower than following de novo CVC placement.

Prevention and management of infectious complications of percutaneous interventions

Infectious complications following interventional radiology (IR) procedures can cause significant patient morbidity and, potentially, mortality. As the number and breadth of IR procedures grow, it becomes increasingly evident that interventional radiologists must possess a thorough understanding of these potential infectious complications. Furthermore, given the increasing incidence of antibiotic-resistant bacteria, emphasis on cost containment, and attention to quality of care, it is critical to have infection control strategies to maximize patient safety. This article reviews infectious complications associated with percutaneous ablation of liver tumors, transarterial embolization of liver tumors, uterine fibroid embolization, percutaneous nephrostomy, percutaneous biliary interventions, central venous catheters, and intravascular stents. Emphasis is placed on incidence, risk factors, prevention, and management. With the use of these strategies, IR procedures can be performed with reduced risk of infectious complications.

Novel approach using antimicrobial catheters to improve the management of central line-associated bloodstream infections in cancer patients

BACKGROUND

Central venous catheter (CVC) removal has often been recommended for the treatment of central line-associated bloodstream infections (CLABSIs). However, CVC removal is not always practical in patients with cancer, and changing CVCs with noncoated CVCs over guidewire may result in cross-infection of the new CVC. Therefore, the current matched retrospective cohort study was conducted to evaluate the effectiveness of exchanging infected CVCs for minocycline- and rifampin (MR)-coated CVCs in cancer patients with CLABSIs.

METHODS

The authors identified all cancer patients with CLABSIs who had undergone either CVC exchange with MR-coated CVCs or CVC removal at the study institution. All patients were treated with appropriate systemic antibiotics. The exchange group was matched in a 1:2 ratio with the removal group by organism, underlying disease, and neutropenia. The demographics, clinical characteristics, and outcome were compared. Overall response was defined as the resolution of clinical signs and symptoms and eradication of bacteremia within 72 hours after CVC exchange or removal, without disease recurrence or infection-related death.

RESULTS

A total of 120 cancer patients were included (40 in the exchange group and 80 in the removal group). Overall response rates were 95% in the exchange group and 76% in the removal group (P = .011). No disease recurrences or infection-related deaths occurred in the exchange group; 8 disease recurrences or deaths (11%) occurred in the removal group (P = .05). Patients in the exchange group also experienced lower rates of mechanical failure (3% vs 15%; P = .049).

CONCLUSIONS

Exchanging CVCs for MR-coated CVCs in cancer patients with CLABSIs may improve the overall response rate and decrease the risk of mechanical failure, disease recurrence, and infection-related mortality.

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.

Central venous catheterization

OBJECTIVE

To provide current information related to central venous catheterization.

DESIGN

Review of literature relevant to central venous catheterization and its indications, insertion techniques, and prevention of complications.

RESULTS

Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%. Operator experience, familiarity with the advantages and disadvantages of the various catheterization sites, and strict attention to detail during insertion help in reducing mechanical complications associated with catheterization. Strict aseptic technique and proper catheter maintenance decrease the frequency of catheter-related infections.

CONCLUSIONS

Appropriate catheter and site selection, sufficient operator experience, careful technique, and proper catheter maintenance with removal as soon as possible are associated with optimal outcome.

Infectious Complications of Cancer Therapy

Advances in the management of cancer, particularly the development of new chemotherapeutic agents, have greatly improved the survival and outcome of patients with hematologic malignancies and solid tumors; overall 5-year survival rates in cancer patients have improved from 39% in the 1960s to 60% in the 1990s.1 However, infection, caused by both the underlying malignancy and cancer chemotherapy, particularly myelosuppressive chemotherapy, remains a persistent challenge.

Infections associated with medical devices: pathogenesis, management and prophylaxis

The insertion or implantation of foreign bodies has become an indispensable part in almost all fields of medicine. However, medical devices are associated with a definitive risk of bacterial and fungal infections. Foreign body-related infections (FBRIs), particularly catheter-related infections, significantly contribute to the increasing problem of nosocomial infections. While a variety of micro-organisms may be involved as pathogens, staphylococci account for the majority of FBRIs. Their ability to adhere to materials and to promote formation of a biofilm is the most important feature of their pathogenicity. This biofilm on the surface of colonised foreign bodies is regarded as the biological correlative for the clinical experience with FBRI, that is, that the host defence mechanisms often seem to be unable to handle the infection and, in particular, to eliminate the micro-organisms from the infected device. Since antibacterial chemotherapy is also frequently not able to cure these infections despite the use of antibacterials with proven in vitro activity, removal of implanted devices is often inevitable and has been standard clinical practice. However, in specific circumstances, such as infections of implanted medical devices with coagulase-negative staphylococci, a trial of salvage of the device may be justified. All FBRIs should be treated with antibacterials to which the pathogens have been shown to be susceptible. In addition to systemic antibacterial therapy, an intraluminal application of antibacterial agents, referred to as the 'antibiotic-lock' technique, should be considered to circumvent the need for removal, especially in patients with implanted long-term catheters. To reduce the incidence of intravascular catheter-related bloodstream infections, specific guidelines comprising both technological and nontechnological strategies for prevention have been established. Quality assurance, continuing education, choice of the catheter insertion site, hand hygiene and aseptic techniques are aspects of particular interest. Furthermore, all steps in the pathogenesis of biofilm formation may represent targets against which prevention strategies may be directed. Alteration of the foreign body material surface may lead to a change in specific and nonspecific interactions with micro-organisms and, thus, to a reduced microbial adherence. Medical devices made out of a material that would be antiadhesive or at least colonisation resistant would be the most suitable candidates to avoid colonisation and subsequent infection. Another concept for the prevention of FBRIs involves the impregnation of devices with various substances such as antibacterials, antiseptics and/or metals. Finally, further studies are needed to translate the knowledge on the mechanisms of biofilm formation into applicable therapeutic and preventive strategies.

Faut-il faire des changements de cathéters sur guide ?

Two types of catheter replacement with the help of wire introducer are reported: systematic scheduled replacement and replacement in case of suspicion of catheter related infection. Guidelines do not recommend systematic scheduled replacement of the catheters. In case of suspicion of catheter infection, French consensus guidelines allow the use of wire introducer in the absence of local risk and of signs of severity. The American guidelines do not recommend the catheter change over guidewire in this setting.

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.

Diagnosis and Management of Long-term Central Venous Catheter Infections

The pathogenesis, diagnosis, and management of central venous catheter infections differ between short-term and long-term catheters. This review summarizes available data regarding the diagnosis and management of catheter-related bloodstream infections (CRBSIs) associated with long-term catheters. A review of various diagnostic modalities is provided, including methods of CRBSI diagnosis for catheters that are retained. Management of CRBSIs for long-term catheters is also addressed, with an emphasis on differentiating infections that require catheter removal from those that may allow catheter salvage. Data regarding catheter salvage with use of antibiotic lock therapy are also reviewed.

Conversion of indwelling chest port catheters to tunneled central venous catheters

PURPOSE

To determine the safety and efficacy of the conversion of subcutaneous chest wall infusion ports to tunneled central venous catheters.

MATERIALS AND METHODS

During a period of 34 months, 67 patients were referred for conversion of indwelling subcutaneous chest wall ports to tunneled central venous catheters as part of a bone marrow transplant protocol. Six patients were deemed unacceptable for conversion and the remaining 61 underwent successful conversion. All patients had functioning surgically placed single-lumen (n = 50) or double-lumen (n = 11) chest ports, which were removed to maintain the original venous access sites for placement of a tunneled central venous catheter, incorporating the chest wall pocket for tunneling, in 46 patients (75%). A new tunnel was created in the other 15 patients. There were no immediate complications and all patients were followed until catheter removal or patient demise with the catheter in place.

RESULTS

57 of 61 (93%) catheters were used without evidence of infection for 23-164 days (mean, 57 d) after placement. Two (3%) were removed (both at 26 days) because of persistent neutropenic fever without physical signs or laboratory evidence of catheter infection, and two (3%) were removed (at 11 and 77 days) because of proven catheter infection, yielding an overall infection rate of 1.2 per 1,000 catheter days. Two catheters required exchange and two required stripping because of decreased function, resulting in an overall catheter-related complication rate of 2.4 per 1,000 catheter days.

CONCLUSIONS

Indwelling subcutaneous chest wall infusion ports can be safely converted to tunneled central venous catheters, even in an immunocompromised patient population, with a low risk of complications such as infection.

Diagnostic tests: distinguishing good tests from bad and even ugly ones

This article focuses on the selection and interpretation of diagnostic tests, emphasizing the importance of understanding how their mathematical parameters affect the information they provide in various settings. The utility and limitations of sensitivity, specificity, predictive value, and receiver operating characteristic (ROC) curves are discussed using catheter-related bloodstream infections as an example. ROC curves have been used for selecting optimal cutoff values for a positive result and for selecting among several alternative diagnostic tests. For example, 16 different tests have been proposed for diagnosis of catheter-related bloodstream infection; ROC analysis provides an effective way to determine which test offers the best overall performance.

Catheter-Related Bloodstream Infection

Central venous catheters are associated with the vast majority of nosocomial, catheter-related bloodstream infections (CR-BSI). Despite identification of multiple effective methods for preventing CR-BSI, it remains an important clinical problem. Catheters coated with anti-infective substances, such as chlorhexidine and silver sulfadiazine or rifampin and minocycline, have shown promising results in recent clinical trials, but confirmatory studies by different investigators are still needed. Concern has also been raised about widespread use of clinically important antibiotics on catheter surfaces, which may promote the development of antibiotic resistance. More accurate and cost-effective methods of diagnosing CR-BSI are desirable. Recent studies have evaluated endoluminal brush sampling and differential blood culture growth rates, which may provide acceptable accuracy without requiring removal of long-dwelling catheters, but the accuracy of these techniques needs to be confirmed in other studies.