Recombinant tissue plasminogen activator may reduce frequency of central venous access device infection in hemophilia patients undergoing immune tolerance therapy

Recombinant tissue plasminogen activator to restore catheter patency: efficacy and safety analysis from a multihospital NICU system

OBJECTIVE

In 2001, the US Food and Drug Administration approved recombinant tissue plasminogen activator (alteplase, Cathflo Activase) to reestablish patency of central catheters occluded, presumably, by a fibrin clot. We conducted a multicenter quality improvement study to determine the value of this procedure in our Neonatal Intensive Care Unit (NICUs), including analyses of efficacy, safety and costs.

STUDY DESIGN

We conducted a retrospective quality analysis of neonates in level III NICUs, who received alteplase for the purpose of reestablishing patency of occluded central catheters.

RESULTS

Alteplase was administered to 169 neonates, each given one to four doses, totaling 205 episodes of administration. The most common type of catheter where alteplase was used was percutaneously inserted central catheter (PICC) lines (78% of uses), 8% were umbilical venous catheters (UVCs), 6% arterial lines, 5% chest tubes and 3% other catheters. Postnatal age at first dose ranged from 0 to 132 days (median, 12); dosed patients were 22 to 41 weeks gestation at birth (median, 31). Fifty-eight percentage of administrations restored catheter function. Success was more likely at younger postnatal age (10±2 days old in successful vs 14±1 days in unsuccessful treatments; P=0.023). Seventy-two percentage of the re-canalized catheters remained functional until they were no longer needed (2 to 30 days later). Nine percentage of episodes were treated with a second dose 1 to 17 days later for re-occlusion and 50% of those were successful. Bleeding consequences were identified in only one case, where three separate lines were treated (chest tube, PICC and UVC) within a 6-h period. Costs to the health system of doses, minus savings to the system by not needing to replace lines, averaged a net of $34 per dose.

CONCLUSIONS

The apparent safety and favorable value analysis prompted us to develop a consistent approach to alteplase usage in the Intermountain Healthcare NICUs, using the data in this report to standardize the guidelines across our health system.

Patient and central venous catheter related risk factors for blood stream infections in children receiving chemotherapy

BACKGROUND

The use of central venous catheters (CVCs) has greatly improved the quality of care in children receiving chemotherapy, yet these catheters may cause serious infectious complications. The aim of this prospective registry study was to assess the host and CVC-related risk factors for blood stream infections (BSIs).

PROCEDURE

Patients undergoing CVC insertion for chemotherapy were followed prospectively for CVC complications. At the time of enrollment demographic-, clinical- and CVC-related data were collected. Survival and Cox-regression analysis were performed.

RESULTS

A total of 423 CVCs were inserted into 262 patients for a total of 76,540 catheter-days. The incidence of BSIs was 1.95 per 1,000 patient-days (95% CI 1.66-2.29). Myeloid leukemia and younger age were associated with higher risk for BSI. At least one BSI occurred in 187 CVCs with an incidence of 2.84 per 1,000 catheter-days (95% CI 2.47-3.24). Externalized CVCs, that is, tunneled externalized catheters and peripheral inserted central catheters, were associated with higher risk for BSI in the group of diseases with relatively lower rate of infection. However, in diseases with high rate of infection no such association was found. The type of BSI was associated with the diagnosis and the CVC type. CVC occlusion was associated with higher risk for recurrent BSI and for coagulase negative staph BSI.

CONCLUSIONS

Both patient and CVC-related factors are associated with higher risk of BSI in children receiving chemotherapy. The results of this study could be used in developing studies aiming to reduce the rate of BSIs in children with cancer.

Antibiotic and other lock treatments for tunnelled central venous catheter-related infections in children with cancer

BACKGROUND

The risk of developing a tunnelled central venous catheter (CVC)-related infection ranges between 0.1 and 2.3 per 1000 catheter days for children with cancer. These infections are difficult to treat with systemic antibiotics (salvage rate 24% - 66%) due to biofilm formation in the CVC. Lock treatments can achieve 100 - 1000 times higher concentrations locally without exposure to high systemic concentrations.

OBJECTIVES

Our objective was to investigate the efficacy of antibiotic and other lock treatments in the treatment of CVC-related infections in children with cancer compared to a control intervention. We also assessed adverse events of lock treatments.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, issue 3, 2011), MEDLINE/PubMed (1945 to August 2011) and EMBASE/Ovid (1980 to August 2011). In addition we searched reference lists from relevant articles and the conference proceedings of the International Society for Paediatric Oncology (SIOP) (from 2006 to 2010), American Society of Clinical Oncology (ASCO) (from 2006 to 2010), the Multinational Association of Supportive Care in Cancer (MASCC) (from 2006 to 2011), the American Society of Hematology (ASH) (from 2006 to 2010) and the International Society of Thrombosis and Haematology (ISTH) (from 2006 to 2011). We scanned the ISRCTN Register and the National Institute of Health Register for ongoing trials (www.controlled-trials.com) (August 2011).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing an antibiotic lock or other lock treatment (with or without concomitant systemic antibiotics) with a control intervention (other lock treatment with or without concomitant systemic antibiotics or systemic antibiotics alone) for the treatment of CVC-related infections in children with cancer. For the description of adverse events, cohort studies were also eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies, extracted data and performed 'Risk of bias' assessments of included studies. Analyses were performed according to the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

Two RCTs evaluated urokinase lock treatment with concomitant systemic antibiotics (n = 56) versus systemic antibiotics alone (n = 48), and one CCT evaluated ethanol lock treatment with concomitant systemic antibiotics (n = 15) versus systemic antibiotics alone (n = 13). No RCTs or CCTs evaluating antibiotic lock treatments were identified. All studies had methodological limitations and clinical heterogeneity between studies was present. We found no evidence of significant difference between ethanol or urokinase lock treatments with concomitant systemic antibiotics and systemic antibiotics alone regarding the number of participants cured, the number of recurrent CVC-related infections, the number of days until the first negative blood culture, the number of CVCs prematurely removed, ICU admission and sepsis. Not all studies were included in all analyses. No adverse events occurred in the five publications of cohort studies (one cohort was included in two publications) assessing this outcome; CVC malfunctioning occurred in three out of five publications of cohort studies assessing this outcome.

AUTHORS' CONCLUSIONS

No significant effect of urokinase or ethanol lock in addition to systemic antibiotics was found. However, this could be due to low power or a too-short follow-up. The cohort studies identified no adverse events; some cohort studies reported CVC malfunctioning. No RCTs or CCTs were published on antibiotic lock treatment alone. More well-designed RCTs are needed to further explore the effect of antibiotic or other lock treatments in the treatment of CVC-related infections in children with cancer.

Alteplase use for malfunctioning central venous catheters correlates with catheter-associated bloodstream infections

OBJECTIVES

A catheter thrombosis and the presence of a catheter-associated bloodstream infection (CBSI) often occur simultaneously, but it is unclear if or to what degree the two complications relate. Several animal and adult studies indicate a relationship between fibrin sheaths and thrombi in the development of CBSIs. To date, there has been limited human investigation in the pediatric population to determine a clear link between the presence of a thrombus and bacteremia. The use of alteplase for malfunctioning central venous catheter may indicate the formation of intraluminal thrombus or fibrin sheath. A catheter that requires alteplase is at higher risk of a CBSI.

DESIGN

A retrospective chart review from July 2008 to December 2010.

SETTING

PICU.

PATIENTS

All patients with central catheters admitted to the PICU.

INTERVENTIONS

No interventions performed with the retrospective study.

MEASUREMENTS

Number of total central venous catheters, number of central venous catheters that received treatment with alteplase, and number of CBSIs.

MAIN RESULTS

Preliminary data during the study period identified 3,289 central venous catheters. Twelve percent of these catheters required at least one dose of alteplase. There were 40 CBSIs during this same time period of which 28% received alteplase during the 5 days preceding the positive blood culture. The odds ratio for getting a CBSI when alteplase is administered is 2.87 (confidence interval 1.42-5.80; p = 0.002). The average age of the central venous catheters at time of infection was not statistically different, 16.1 days in the alteplase catheters compared with 25.6 days for the catheters that did not receive alteplase (p = 0.6).

CONCLUSIONS

There is a positive correlation between the use of alteplase for malfunctioning central venous catheters and the development of a CASBI. This is likely associated with the presence of an intraluminal fibrin sheath or thrombus. This study adds evidence linking thrombus formation to CBSI.

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.