Management of Hickman catheter sepsis

Vancomycin-loaded electrospun polycaprolactone/nano-hydroxyapatite membrane for the treatment of blood infections

Nowadays, because of the resistance of bacteria to antibiotics, researchers are trying to make new antibiotics or sometimes even bring them back into the treatment cycle so that they could eliminate the bacteria's resistance. On the other hand, the use of nanofibers has become widespread in many fields for their unique properties and convenient design. The present study focuses on the production of hydrophobic nanofibers to absorb the bacteria and their toxins from the bloodstream that contains the infection. Many bacterial surfaces have hydrophobic surfactant properties due to hydrophobic surface protein. According to the principle of binding two hydrophobic molecules to each other in an aqueous medium, the nanofibers are designed to physically absorb the bacteria. The use of antibiotics in the study can remove some unattached bacteria. In addition, using nanofiber manufacturing techniques can reduce the resistance of bacteria to antibiotics. The construction of the desired membrane can be used in subsequent studies as a replacement membrane for dialysis filters.

Guideline for Prevention of Intravascular-Device–Related Infections

The “Guideline for Prevention of Intravascular Device-Related Infections” is designed to reduce the incidence of intravascular device-related infections by providing an over view of the evidence for recommendations considered prudent by consensus of Hospital Infection Control Practices Advisor y Committee (HICPAC) members. This two-part document updates and replaces the previously published Centers for Disease Control's (CDC) Guideline for Intravascular Infections (Am J Infect Control1983;11:183-199). Part I, “Intravascular Device-Related Infections: An Over view” discusses many of the issues and controversies in intravascular-device use and maintenance. These issues include definitions and diagnosis of catheter-related infection, appropriate barrier precautions during catheter insertion, inter vals for replacement of catheters, intravenous (IV) fluids and administration sets, catheter-site care, the role of specialized IV personnel, and the use of prophylactic antimi-crobials, flush solutions, and anticoagulants. Part II, “Recommendations for Prevention of Intravascular Device-Related Infections” provides consensus recommendations of the HICPAC for the prevention and control of intravascular device-related infections. A working draft of this document also was reviewed by experts in hospital infection control, internal medicine, pediatrics, and intravenous therapy. However, all recommendations contained in the guideline may not reflect the opinion of all reviewers.

Catheter-related and infusion-related sepsis

This article focuses on the pathogenesis, diagnosis, prevention, and management of infectious complications of intravascular cannulation and fluid infusion. Although continuous vascular access is one of the most essential modalities in modern-day medicine, there is a substantial and underappreciated potential for producing iatrogenic complications, the most important of which is blood-borne infection. Clinicians often fail to consider the diagnosis of infusion-related sepsis because clinical signs and symptoms are indistinguishable from bloodstream infections arising from other sites. Understanding and consideration of the risk factors predisposing patients to infusion-related infections may guide the development and implementation of control measures for prevention.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Catheter-related sepsis in long-term parenteral nutrition with Broviac catheters. An evaluation of different disinfectants

From April 1976 to January 1988, 58 patients received home parenteral nutrition for 2-138 months, median 36 months, corresponding to a total treatment period of 233 patient years. Before 1980 and after 1985, 0.5-2% iodine tincture or 0.5% chlorhexidine in 70% ethyl alcohol were used to disinfect the exit site of the catheter and the connections of the infusion line. In these periods the sepsis incidence was 0.25-0.28 per catheter year, corresponding to one episode of sepsis per 3.6-4.0 catheter years. In the period 1980 to 1985, 10% povidone-iodine (Isobetadine) was used, and the incidence in this period was 0.58, corresponding to one episode of sepsis per 1.7 catheter year. This suggests that 10% povidone-iodine may be inferior to iodine-tincture and chlorhexidine alcohol in this type of catheter care. The incidence of catheter sepsis was 0.32 per catheter year when the catheter was placed on the chest and 0.86 per catheter year with the catheter on the thigh. Klebsiella pneumoniae was the most common microorganism grown when the catheter was placed on the thigh, while coagulase-negative staphylococci were most common when the catheter was placed on the chest.

Clinical outcome of long-term home parenteral nutrition in non-oncological patients: a report from two specialised centres

OBJECTIVE AND METHODS

Forty-one (20 m, 21 f) non-oncological home parenteral nutrition (HPN) patients (52.0+/-16.6 years, BMI 20.2+/-4.0 kg/m(2)), enrolled from 1995 to 2005, underwent a clinical and biochemical follow-up at 3 months, 1 and 3 years.

RESULTS

At admittance the Karnofsky Index ranged between 40 and 50 in 13 (31.7%) and 60 and 80 in 28 (68.3%) patients; the most frequent underlying disease was mesenteric infarction (11 patients, 27%). All had a central venous access. Mean catheterization days were 864+/-992, while mean HPN days were 630+/-668. At the 3-month follow-up, all patients were on HPN, at 1 year 24 (58.5%) and at 3 years 11 (27%). At 3 months, 1 and 3 years there was a significant increase in BMI (p=0.001), body weight (p=0.001) and Karnofsky Index (p=0.001), as well as an improvement of several biochemical parameters. Survival rate of HPN patients was 90.2% at 1 year, 87.8% at 3 years and 82.9% at 5 years. As to HPN-related complications, there was a central venous catheter (CVC) obstruction in 8 patients (19.5%) and 47 CVC infections in 24 (58.5%) patients. The infection rate was 1.32/(00) days of catheterization (1.8/(00) from 1995 to 1998 and 1.0/(00) from 1999 to 2005). Hospitalisation was necessary in over 50% of patients, and death occurred in 8, always as a consequence of the primary disease.

CONCLUSIONS

The experience of the nutritional team and careful patient and caregiver training reduce CVC infection rate and the overall risk of complications possibly due to HPN.

epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were commissioned by the Department of Health (DH) and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were published in January 2001. These guidelines describe the precautions healthcare workers should take in three areas: standard principles for preventing HCAI, which include hospital environmental hygiene, hand hygiene, the use of personal protective equipment, and the safe use and disposal of sharps; preventing infections associated with the use of short-term indwelling urethral catheters; and preventing infections associated with central venous catheters. The evidence for these guidelines was identified by multiple systematic reviews of experimental and non-experimental research and expert opinion as reflected in systematically identified professional, national and international guidelines, which were formally assessed by a validated appraisal process. In 2003, we developed complementary national guidelines for preventing HCAI in primary and community care on behalf of the National Collaborating Centre for Nursing and Supportive Care (National Institute for Healthand Clinical Excellence). A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective in preventing HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. Consequently, the DH commissioned a review of new evidence published following the last systematic reviews. We have now updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the original epic guidelines published in 2001 remain robust, relevant and appropriate but that adjustments need to be made to some guideline recommendations following a synopsis of the evidence underpinning the guidelines. These updated national guidelines (epic2) provide comprehensive recommendations for preventing HCAI in hospitals and other acute care settings based on the best currently available evidence. Because this is not always the best possible evidence, we have included a suggested agenda for further research in each section of the guidelines. National evidence-based guidelines are broad principles of best practice which need to be integrated into local practice guidelines. To monitor implementation, we have suggested key audit criteria for each section of recommendations. Clinically effective infection prevention and control practice is an essential feature of protecting patients. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of healthcare in NHS hospitals in England can be minimised.

Diagnosis of central venous catheter related infection in adult patients

Intravascular catheters are one of the main causes of bacteraemia and septicaemia in hospitalised patients and continue to be associated with a significant morbidity and mortality. Two main types of infections occur, they can be either localised at the catheter insertion site of systemic with a septicaemia. The clinical parameters related to these infections are presented. The laboratory diagnosis of these infections is also extensively reviewed and recommendations are made as to the most appropriate diagnostic method to be used.

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.

Home parenteral nutrition registry: a five-year retrospective evaluation of outcomes of patients receiving home parenteral nutrition support

OBJECTIVE

Few data are currently reported on home parenteral nutrition (HPN) patient outcomes, which makes evaluating comparative outcomes in HPN difficult. This study describes outcomes of consecutive HPN patients collected retrospectively over a 5-y period by one HPN support provider.

METHODS

Retrospective data from the HPN support provider was aggregated yearly from 1997 to 2001. Length of therapy, demographics, diagnosis, rehospitalizations, catheter infection rate, catheter occlusion rate, and mechanical complication rate data were reported.

RESULTS

The mean age of HPN patients ranged from 42 y to 45 y. The average length of HPN therapy was 100 d. There were more female than male HPN patients. Nutritional deficiency and malabsorption were the most common International Classification of Diseases, Ninth Revision codes for HPN use and reflects a focus on nutritional diagnosis rather than on disease state as the criterion for HPN use. Catheter infection rates ranged from 0.44 to 0.84 per 1000 catheter days, a lower than anticipated number. Mean catheter occlusion rates were lower than 7% and mean mechanical complication rates were approximately 5%. Known termination of therapy was secondary to completion of therapy (50% to 56%) or death (17.3% to 22%).

CONCLUSIONS

Overall, time on HPN therapy in the United States has increased. Nutritional diagnoses are currently used to justify HPN. Catheter infection and occlusion rates, in general, are low. Termination of therapy and death are the most common reasons for HPN discontinuation. Standardization of HPN data collection is necessary to obtain a historical snapshot of the efficacy and safety of patients treated outside the hospital with nutritional support.

The antibiotic-lock technique for therapy of 'highly needed' infected catheters

Catheter-related bacteremia is a major complication in patients with long-term surgically implanted central venous catheters, which are difficult and expensive to remove. Conventional treatment fails in a significant number of cases, resulting in removal of the device. The antibiotic-lock technique involves instilling a high concentration of antibiotic into the catheter lumen, and allowing it to remain for a period of time. Results of several open studies, mainly involving patients receiving home parenteral nutrition, indicate that this method may be regarded as an alternative to the conservative treatment of noncomplicated intraluminal catheter-related bacteremia, in which infection may be treated without catheter removal. However, many questions about this therapeutic method remain to be resolved, including appropriate concentration of antibiotics, duration of treatment, and whether or not concomitant systemic antibiotic therapy is necessary. Prospective studies comparing the antibiotic-lock technique with conventional treatment are needed.

Diagnosis of catheter-related bacteraemia: a prospective comparison of the time to positivity of hub-blood versus peripheral-blood cultures

BACKGROUND

A method of diagnosing catheter-related infection (CRI) without removing the catheter would be useful. An earlier positivity of central compared with peripheral venous-blood cultures may be associated with catheter-related bacteraemia. We evaluated prospectively the differential time to positivity (DTP) of paired blood cultures drawn simultaneously via the catheter hub and from a peripheral venous site.

METHODS

Over a 14-month period in an intensive-care unit of a cancer referral centre, simultaneous hub-blood and peripheral-blood cultures (a mean of two per patient) were obtained from patients with a suspected CRI. According to clinical criteria and quantitative culture of the catheter tip, cases were classified as CRI or sepsis of other origin. At least one pair of hub-blood and peripheral-blood cultures was obtained within 48 h before catheter removal, and we recorded the DTP between hub-blood and peripheral-blood cultures with an automatic device for detection of blood culture positivity.

FINDINGS

We analysed 93 catheters removed because of suspicion of CRI. In 28 episodes, the same micro-organisms were found in both hub-blood and peripheral-blood cultures. A diagnosis of definite bacteraemic CRI was made in 16 of the 17 patients in whom a positive hub-blood culture was detected at least 2 hours earlier than peripheral-blood culture. About half (9/17) of these episodes occurred in long-term (>30 days) devices. CRI was excluded in ten of the 11 patients with a DTP lower than 2 h. The DTP of paired blood cultures was significantly greater in patients with CRI than in others (p<10(-4)). A cut-off DTP value of 120 min had 91% specificity and 94% sensitivity for the diagnosis of CRI. Three of 17 episodes with only hub-blood culture positive were associated with CRI.

INTERPRETATION

This prospective study suggests that measurement of the differential time to positivity between hub-blood and peripheral-blood cultures is a simple and reliable tool for in-situ diagnosis of catheter-related sepsis in cancer patients. Further studies are needed to confirm these data for short-term catheters.

Challenge of supportive surgical care in pediatric oncology

The advent of aggressive treatment protocols and the development of new techniques and procedures now require that the pediatric surgeon be an integral part of all aspects of pediatric oncology care. Supportive care issues, rather than primary tumor management decisions, now dominate the pediatric surgeon's experience and range from managing the different types of vascular access devices and their complications to assessing the surgical implications of the toxic complications of current chemotherapy protocols. New treatments such as bone marrow transplantation have presented new challenges to the pediatric surgeon, while new techniques such as minimally invasive surgery have dramatically improved our ability to render compassionate and more effective care to our patients as they undergo these potentially toxic treatment regimens.

A prospective randomized trial of urokinase as an adjuvant in the treatment of proven Hickman catheter sepsis

BACKGROUND/PURPOSE

Chronic vascular access catheters have become an important adjunct to the treatment of children with complex medical diseases, particularly malignancy. One of the major complications of chronic venous access devices is bacterial infection of the catheter site and bloodstream. Infusion of systemic antibiotics directly into the catheter has been the standard initial therapy with failure leading to catheter removal and replacement. It has been suggested by a number of investigators that the addition of urokinase as a thrombolytic agent to lyse any accumulated thrombus or fibrin would increase the successful catheter clearance by antibiotics. This study was designed as a prospective, randomized trial to compare treatment of children with positive catheter blood cultures with either antibiotics alone or in combination with urokinase 5,000 U boluses 12 and 24 hours after study entry.

METHODS

A total of 63 patients were entered in the study. Thirty-three received antibiotics and urokinase, and 30 received antibiotics alone.

RESULTS

A total of 45 catheters (71%) were cleared of infection and salvaged. Treatment failures leading to catheter removal occurred in 9 of 33 in the experimental group and 9 of 30 in the control population (no significant difference).

CONCLUSIONS

Urokinase could not be shown to act as an adjuvant in the clearance of infection from chronic central venous access catheters that had no evidence of clot or thrombus. This study required the performance of a dye study and excluded any patient with a known thrombus. This conclusion must therefore be limited to patients with no evidence of a clot or fibrin sheath.

Infection versus colonization in the critical care unit

Serious infections in the critical care unit are commonplace. However, distinguishing true infection from mere colonization is a difficult and often uncertain process that has been shown to result in both over- and under-treatment of patients. Antimicrobial agents used in the CCU setting are expensive and not without toxicities. This article discusses methods to differentiate colonization from infection.

Earlier positivity of central-venous- versus peripheral-blood cultures is highly predictive of catheter-related sepsis

To diagnose catheter-related sepsis without removing the catheter, we evaluated the differential positivity times of cultures of blood drawn simultaneously from central venous catheter and peripheral sites. In a 450-bed cancer reference center, simultaneous central- and peripheral-blood cultures were prospectively performed for patients with suspicion of catheter-related sepsis over an 18-month period. Data for 64 patients for whom the same microorganisms were found when central- and peripheral-blood samples were cultured were retrospectively reviewed by two independent physicians blinded to the differential positivity time values in order to establish or refute the diagnosis of catheter-related sepsis. The diagnosis was established in 28 cases, refuted in 14, and indeterminate in the remaining 22. The differential positivity time was significantly greater for patients with catheter-related sepsis (P < 10(-4)). A cutoff limit of +120 min had 100% specificity and 96.4% sensitivity for the diagnosis of catheter-related sepsis. These results strongly suggest that measurement of the differential positivity time might be a reliable tool facilitating the diagnosis of catheter-related sepsis in patients with an indwelling catheter.

A review of 560 Hickman catheter insertions

Indwelling, cuffed, tunnelled, central venous (Hickman) catheters are increasingly being used for venous access and the administration of chemotherapy for oncological patients. This paper reviews the technical problems associated with the percutaneous insertion of these catheters and the complications arising from their use. Five hundred and sixty catheters were inserted; 31.3% had complications at insertion, most commonly precipitation of an arrhythmia (13.9%). Arterial puncture occurred in 3.8% and pneumothorax in 1.6%. Catheters remained in place for a median period of 91 days. Forty percent of catheters were removed electively on completion of treatment; 30.2% required removal because of complications, which included sepsis, migration, thrombosis and blockage. Twenty percent of patients died with their catheter in place, 8.5% were still in situ and 1.6% were removed because of patient non compliance. Sepsis remains the commonest, long term complication, with staphylococcus epidermidis being the organism isolated most frequently. There were no catheter-related deaths.

Urokinase in the treatment of bacteremia and candidemia in patients with right atrial catheters

BACKGROUND

Urokinase plasminogen activator was used in combination with antibiotic therapy given through the catheter to improve the treatment of right atrial catheter infections.

METHODS

One hundred fifty-four episodes of bacteremia and candidemia occurring in 97 children with malignant or hematologic conditions were treated. After 24 hours of antibiotic therapy, 1 ml urokinase (5000 units/ml) was instilled, dwelling 1 hour, and then removed; this was repeated within 24 hours. Antibiotic therapy was continued for then removed; this was repeated within 24 hours. Antibiotic therapy was continued for 10 to 35 days. Administration of urokinase was repeated once if infection recurred within 8 weeks of initial treatment.

RESULTS

There were no adverse affects from administration of urokinase. Bacteremia clearance failed after initial administration of urokinase in 12 episodes; this failure was mostly associated with the presence of gram-positive organisms. Blood culture results remained positive in three cases after repeat therapy. Bacteremia recurred in 15 of 125 episodes; in three cases bacteremia did not clear after repeat administration of urokinase or recurred again. Recurrence was lowest for gram-negative organisms and Candida sp. Less than 5% of catheters were removed as a result of treatment failure.

CONCLUSIONS

Administration of urokinase combined with antibiotic therapy is safe and may be effective in treating bacteremia and candidemia in patients with right atrial catheters. Use of urokinase may improve treatment of organisms that are otherwise difficult to control and may prevent recurrence of infection.

A study of the influence of biphase calcium phosphate ceramics on bacterial strains: in vitro approach

An in vitro study of the influence of Biphase Calcium Phosphate Ceramics (BCPCs) on bacterial strains is presented. The test procedures were carried out in saline test solution to which different quantities (2,4,50,100, and 200 mg) of BCPCs(samples A and B) were added. The influence of BCPCs on standard bacterial strains has been determined by measuring bacterial contamination using the plate count method. The testing method was validated with membrane filtration and direct inoculation in culture media of sediment and supernatant. The test demonstrated reduction of the bacterial cell population in from 1 to 24 h in all experiments. The antibacterial effect revealed the specific inherent properties of the BCPCs under investigation.

Comparison of diagnostic specimens and methods to evaluate infected venous access ports

BACKGROUND

Implanted venous access port infection can be difficult to diagnose and treat. If device removal is necessary, confirming port infection is problematic.

MATERIALS AND METHODS

Culture specimens from three sites, catheter tip (Tip), port pocket, and the material within the reservoir (Inside), were sent from ports removed for potential infection. The results of these cultures were compared to preremoval peripheral and central blood cultures.

RESULTS

Forty-five ports were removed for suspected infection. Confirmed port infection was defined as positive culture(s) from one or more experimental specimen(s). In 29 evaluable cases, the Inside specimens were completely predictive. Tip specimens were less accurate, even with a lower diagnostic threshold. In 7 of 19 confirmed infections, only the Inside culture was diagnostic.

CONCLUSION

The most predictive culture specimen in a potentially infected port is the thrombotic material inside the reservoir.

A prospective randomized double-blind trial of bolus urokinase in the treatment of established Hickman catheter sepsis in children

BACKGROUND

The incidence of Hickman catheter sepsis is 10% to 40%, with resultant catheter loss in one third of infections. Urokinase causes dissolution of colonized intracatheter fibrin thrombi and may improve salvage.

STUDY AIMS

To evaluate the efficacy of 12-hour-interval slow-push urokinase infusion in addition to standard antibiotic therapy in the treatment of catheter sepsis in a pediatric oncology population.

METHODS

A two-arm randomized double-blind trial was undertaken, with catheter salvage rate as the end point. Patients with Hickman catheter sepsis were randomized after culture data confirmed the diagnosis. The study drug was administered by a slow intravenous push and given at 12-hour intervals for a total of four doses. The catheters were aspirated after 1 hour.

RESULTS AND CONCLUSIONS

The trial was stopped after 41 patients were entered into the study; 18 patients received a placebo, and 23 received the urokinase. In the placebo group, six catheters were lost; in the urokinase group, eight were lost. The rate of bacterial clearance was equivalent for both. After administration of the study drug, each group had three episodes of fever and chills; two of these resulted in hypotension (one in each group). The authors conclude that slow-push urokinase infusion during established Hickman catheter sepsis does not result in improved catheter salvage or bacterial clearance. Slow intravenous push infusions in this setting may provoke hemodynamic instability even after initiation of antibiotics.

Venous access in pediatric oncology patients

Long-term central venous access is an integral part of the management of many, but not all children with cancer. The proper selection of those children who require this access and which access device (external vs. totally implanted) is best suited to that child is important to minimize complications and obtain optimal results. Although most of these devices can be expected to last the duration of the treatment protocol or the patient's life, complications (infection, occlusion, dislodgment) occur with higher than desired frequency, infection being the most common. No measures are clearly beneficial in preventing infection, but most infections can be treated successfully without device removal. Premature removal or dislodgement occurs more frequently with external catheters and may be minimized by techniques used at insertion. Occlusion, detected early, can be successfully managed by clot lysis in most children.

Chronic venous access in patients with cancer. Selective use of the saphenous vein

BACKGROUND

Dependable chronic venous access is an important aspect of supportive care for patients requiring chemotherapy or other long-term therapy because it enables such patients to be treated on an outpatient basis.

METHODS

The authors studied 56 patients with cancer requiring chronic venous access who had an infusion catheter placed into the inferior vena cava (IVC) through open saphenous venotomy, most commonly because superior vena cava (SVC) occlusion, severe chest wall infection, or chest wall malignancy precluded standard subclavian or jugular cannulation.

RESULTS

The 56 catheters were in place for 12-550 days. The overall complication rate was 0.30 complications per 100 catheter-days. Thirty-six patients (64%) had no complications. Among the remaining 20 patients, 8 (14.3%) had a local infection, 2 (3.6%) had systemic bacteremia, and 10 had lower extremity edema, including 9 patients (16.1%) in whom the IVC was thrombosed. Twelve of the 20 complications were treated successfully without catheter removal. Thus, in 86% (48 of 56) of patients, the catheter was effective for as long as infusion therapy was required.

CONCLUSION

Venous cannulation through the saphenous vein is a useful method of achieving and maintaining chronic venous access in patients in whom the subclavian or jugular veins are unavailable.

Prospective analysis of urokinase in the treatment of catheter sepsis in pediatric hematology-oncology patients

Use of right atrial catheters (RACs) in children with cancer improves the comfort and efficacy of therapy. However, catheter-related infections are responsible for significant morbidity leading to the removal of approximately 20% of implanted RACs. Sepsis has been linked to thrombus and fibrin sheath formation within the RAC. Gram-negative and fungal infections appear to be particularly resistant to antibiotic therapy alone and most of these infections have required catheter removal. Urokinase has been effectively used for reopening thrombus occluded RACs. Theoretically, thrombolytic agents could improve the treatment of catheter-related infections by removing luminal sites of bacterial/fungal colonization. We prospectively monitored the use of urokinase and antibiotics for catheter-related sepsis in our pediatric hematology/oncology population from 1985 to 1991. Sepsis episodes were treated with 2 doses of urokinase and antibiotics (10 to 42 days) infused through the RAC. One to 2 mL of urokinase (5,000 U/mL) was instilled in the RAC for 1 hour, then removed and repeated 24 hours later. During the study, 224 RACs were placed in 177 children. RACs were in place for a total of 71,134 days (median, 274 days). There were 67 blood culture-positive sepsis episodes occurring in 50 RACs. Fifty-nine sepsis episodes were treated with urokinase and antibiotics and all responded by clearance of organisms from the blood. Three patients (5.1% of urokinase treated) had recurrent sepsis with the same organism within 2 months, were considered treatment failures and had RACs removed. Only 1 of 16 episodes of multiple organism/Candida sepsis led to RAC removal due to inability to cure the infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term central venous catheters: issues for care

Long-term central venous catheters allow the safe administration of chemotherapy, blood and blood products, total parenteral nutrition, fluids, and other medications. Despite their benefits, the risk of certain complications (e.g., fibrin sleeve and mural thrombus formation, infection, catheter occlusion, extravasation, and catheter malposition) exist for every person who has a catheter. Thus, preventative measures, recognition of early signs and symptoms of complications, and adequate care of utmost importance.

Comparison of infections in Hickman and implanted port catheters in adult solid tumor patients

Long-term therapy of oncology patients has been facilitated by permanent indwelling central venous catheters, but catheter-related infections remain a serious complication of their use. Using a retrospective matched cohort design, we compared the risk of catheter-related infection in 47 adult solid tumor patients with right atrial Hickman catheters and 94 patients with totally implanted port catheters. Patients were matched for primary solid tumor, presence of metastases, age, gender, and date of catheter insertion. Seven of 47 patients with Hickman catheters developed catheter-related infection (1.8 infections/1,000 catheter days at risk) compared with 10 of 94 patients with implanted port catheters (0.4/1000 catheter days, P less than 0.0002). Hickman catheters were used more often for terminally ill patients than were port catheters which was a potential source of bias, but results were unchanged after stratifying patients on lifespan. Our study suggests that there are fewer infections in port than in Hickman catheters in adult patients with solid tumors, but prospective randomized studies are needed.

Venous access. Preoperative, operative, and postoperative dilemmas

The past two decades have seen a tremendous increase in the use of central venous catheters and its associated complications. The increased sophistication that physicians now have with regard to nutritional and metabolic needs has escalated the use of central venous catheters. As the acquired immunodeficiency syndrome epidemic grows, so too will the number of patients with infections and metabolic complications, many of whom will have conditions severe enough to benefit from the use of central venous catheters to deliver antimicrobial drugs and other supportive intravenous therapy. Our ability to sustain patients with short-bowel syndrome also relies critically on central venous access. Likewise, treatment of patients with leukemias and certain solid tumors frequently requires placement of these catheters. Central venous catheters are essential for bone marrow transplantation. Efforts to minimize the risks associated with placement of a central venous catheter by more frequent use of catheter exchange rather than another venipuncture should be encouraged when possible. Techniques to prevent arrhythmia during overinsertion of guide wires are also important. Vigilant searches for, and prompt treatment of, catheter-related sepsis and central vein thrombosis are critical. Better prophylaxis against the development of catheter-related sepsis and catheter-related thrombosis is also needed. Further prospective investigations should be performed, however, to define precisely cost-effective methods of detection and duration of therapy for patients with both catheter-related sepsis and catheter-related thrombosis. Further advances in the technology and management of catheters need to continue to meet these ongoing challenges.

The insertion of chronic indwelling central venous catheters (Hickman lines) in interventional radiology suites

The insertion of Hickman central venous catheters for chronic venous access is a procedure usually conducted in the operating theatre under local or general anaesthesia. In a prospective study over a one year period we have assessed the feasibility of radiologists inserting central venous catheters for long term access. A subclavicular approach to the subclavian vein with prior digital subtraction angiography or video imaging of the vein was the technique of choice. Thirty-one Hickman catheters were inserted in 21 patients. All but two patients had a haematological malignancy. Ages ranged from 19 to 77 years. The mean time for insertion was 43 min (range 20-80 min). The catheters remained in situ for between 2 days and 242 days with a mean of 86 days. There was one documented line infection; nine patients had episodes of septicaemia with identified organisms, and a further six had pyrexias of unknown origin during the line indwelling period. There were four documented line and or ipsilateral subclavian vein thromboses, and one death occurred within 36 hours of the procedure. We conclude that radiological placement is an excellent alternative to 'blind' surgical placement. Screening during insertion provides immediate facilities for correction of malposition and monitoring of immediate complications. The time taken for catheter insertion did not impede the usual patient throughout in the interventional radiology suite.

Staphylococcus aureus bacteremia in patients with Hickman catheters

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

A century of home parenteral nutrition for Crohn's disease

During an 11-year period, 41 patients with Crohn's disease were placed on home parenteral nutrition (HPN) for a mean of 1,083 days (range: 33 to 3,258 days). Data were retrospectively analyzed to determine whether HPN had an effect on the course of their disease, i.e., on the number of operative procedures performed and the intensity of required medical therapy. Data represented information obtained during a total of 121 patient-years of HPN for Crohn's disease. The main indications for HPN were short bowel syndrome (66%) and high stoma output. Twenty-four of 41 patients (59%) underwent surgery for Crohn's disease during the course of HPN. There was no significant difference between the number of procedures performed per patient per year of Crohn's disease during pre-HPN and HPN periods (p greater than 0.25). Although there was no significant change in body weight, both serum albumin and transferrin levels increased during HPN (p less than 0.01 and p less than 0.01, respectively). Twenty-nine percent of patients were taking prednisone while on HPN, compared with 54% of patients during the pre-HPN period (p less than 0.01). HPN appeared to result in a significant improvement in the numerically assessed quality of life. During the HPN period, 24 patients had 1 or more HPN-related complications that required 1 to 13 hospital admissions (mean: 1.8). These complications included catheter sepsis in 19 patients, blocked or damaged catheters in 15 patients, and dehydration and/or electrolyte imbalance in 5 patients. Eight patients died, with 7% of deaths secondary to catheter-related sepsis. Although permanent HPN is associated with an identifiable morbidity and mortality and is not associated with a reduction in the frequency of surgery for Crohn's disease, benefits include a decrease in the intensity of medical therapy, an improvement in patients' nutritional state, and a significant perceived improvement in patients' quality of life. Without HPN, we believe all patients would have died secondary to malnutrition and/or dehydration.

Continuous venous access in children with urological diseases

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

Value of semiquantitative cultures of blood drawn through catheter hubs for estimating the risk of catheter tip colonization in cancer patients

Colonization of central catheter tips has been associated with catheter-related infections. This colonization is defined as the presence of over 15 CFU in a semiquantitative catheter tip culture performed after catheter removal. Using a simple pour-plate technique, we determined the microbial concentrations in samples of blood collected via the hubs of 205 central catheters while they were in position in 179 cancer patients. All catheters were removed within three days of blood collection via the hub and cultured semiquantitatively. We then compared the results for the hub blood cultures and catheter tip cultures. Cultures from 18% of the hub samples and 29% of the tips were positive. When a cutoff limit of 1,000 CFU/ml was used for the blood cultures, the sensitivity was 20% and the specificity was 99% for estimating catheter tip colonization. These values did not seem to be related to the underlying disease, the site of catheter insertion, or the antibiotic treatment administered at catheter removal. We conclude that, if positive, cultures of blood sampled via the catheter hub can be useful in assessing the risk of catheter colonization in cancer patients.

Inhibitory effect of disodium EDTA upon the growth of Staphylococcus epidermidis in vitro: relation to infection prophylaxis of Hickman catheters

Granulocytopenic patients with an intravascular catheter are at increased risk for infection with Staphylococcus epidermidis. During the intervals when the catheters are not being used for infusions, it is customary to maintain patency of the catheter lumen with a solution containing heparin. We show that heparin does not inhibit the growth of S. epidermidis isolated from the catheter of an infected patient. A 20-mg/ml solution of disodium EDTA, a chelating agent which effectively anticoagulates blood at this concentration, was shown to be bactericidal for an initial inoculum of 10(3) CFU of staphylococci per ml in 24 h. Vancomycin, an antibiotic which is often employed to treat Staphylococcus infections, was also bactericidal for initial inocula of 10(3) CFU/ml at doses of 6.7 micrograms/ml, a drug concentration in the therapeutic range. When 10(3) staphylococci per ml were cultured in the presence of catheter segments and disodium EDTA or vancomycin, subcultures of the catheters showed minimal or no growth, respectively. In contrast, when cultured with heparin alone, subcultures showed abundant growth. In view of its low cost, effectiveness as an anticoagulant, and bactericidal activity, EDTA should be studied as a replacement for heparin solutions for the maintenance of intravenous catheters in granulocytopenic patients.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Central venous catheter infections

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

Vascular-access infections in hospitalized patients

Vascular catheters are a common source of nosocomial infections, although many of these infections are potentially preventable. A long duration of catheterization, multiple catheter manipulations, the inexperience of some inserters, use of transparent plastic dressings, violations of aseptic technique, the use of multilumen catheters, and inadequate sterilization of reusable pressure transducers all increase the risk of these infections. The only interventions that have been proved to reduce the risk are standardized insertion and maintenance technique by an intravenous-therapy team, preinsertion skin preparation with chlorhexidine gluconate, and the use of topical antibiotics at the insertion site. The goal of the physician should be to prevent catheter infection, because the treatment of established infection can be difficult and costly. Treatment must be individualized for each patient on the basis of the clinical presentation and the causative organism.

Implantable injection port for long-term venous access

In recent times, totally implantable devices using a Silastic right atrial catheter connected to a subcutaneous injection chamber have been introduced for long-term venous access. This study reports the experience of 39 patients in whom 41 such devices have been implanted. It totals 9697 patient days so far. There has been no incidence of major vein or catheter thrombosis and an infection rate of 0.41 per 1000 catheter days has been achieved. Catheter related complications have occurred in 20% of the cases after a mean duration of usage of 237 days. It is concluded that implantable injection ports provide a safe and reliable method of prolonged venous access.

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

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

Broviac catheter insertion: operating room or neonatal intensive care unit

We reviewed the records of all infants hospitalized in the neonatal intensive care unit (NICU) who underwent insertion of a Broviac catheter from July 1, 1984 through August 30, 1985. Eighty-six catheters were inserted in 81 patients. Thirty-one catheters were inserted in the NICU and the remainder were inserted in the operating room (OR). The patient's average weight at the time of catheter insertion was the same in both groups. Fifty-two of the 55 OR catheters (95%) were inserted in the external or internal jugular vein while only 68% of the NICU catheters were placed in the jugular veins. Six of the NICU catheters (19%) and 11 of the OR catheters (20%) developed catheter-associated sepsis with positive blood cultures. The infection rate per catheter day was similar in both groups as was the incidence of catheter occlusion. The NICU catheters were in place for an average of 51 days, and there was an average 46 day lifespan for the OR inserted catheters. Broviac catheter insertion can safely be performed in the NICU without an increase in morbidity. Broviac catheter insertion in the NICU is less costly and saves transportation of the sick neonate to the operating room.

A key to the literature of total parenteral nutrition: update 1987

This comprehensive bibliography is intended to enhance the education of the practitioner, student, and academician in the area of parenteral nutrition. This bibliography is not all-inclusive but serves as an update from the original published in 1983. Of particular note in this work is the addition of topics that reflect a growing interest in medical specialties with regard to patient nutritional status and support.