To determine risk factors for infection of hyperalimentation catheters, we prospectively studied 169 catheter systems (88 patients) by using a semiquantitative culture technique. Infection occurred in 24 (14%) catheters (16 patients), was inversely proportional to the number of previous catheters inserted by the operator (P less than .02), and was proportional to the interval between admission and catheter insertion (P less than .0005). Catheter replacement over a guidewire was no more likely to be associated with infection than was a de novo percutaneous insertion at another site (P = .6). Using a proportional hazards model, we estimated the risk of infection per day to be 1.3 times greater for a catheter if the patient had been hospitalized 50 days instead of seven days, and 3.8 times greater if the patient had a Swan-Ganz catheter at the time of insertion.
To identify predictors of infection in catheters used for total parenteral nutrition (TPN), clinical and microbiological data were prospectively collected on 169 catheter systems (88 patients). Based on semiquantitative catheter cultures, infection was associated with a positive insertion site skin culture taken close to the time of catheter removal (relative risk [RR] = 4.50), especially one yielding greater than or equal to 50 colonies of an organism other than coagulase-negative staphylococci. Infection was also associated with erythema at the insertion site greater than 4 mm in diameter (RR = 2.93). In a subset of 67 catheters for which blood cultures were obtained, infection was also associated with a positive peripheral venous blood culture (RR = 5.90) and a positive central venous blood culture obtained through the catheter (RR = 5.44). Based on a logistic regression model, periodic cultures of the insertion site should be useful in evaluating subsequent fever in stable patients with indwelling central venous catheters. Another source of fever is likely if inflammation is absent and there is either no colonization or there is colonization by less than 50 colonies of coagulase-negative staphylococci at the insertion site. Conversely, the catheter should be removed and cultured semiquantitatively if the site is colonized by an organism other than coagulase-negative staphylococci. We suggest that blood culture results add little to the risk estimate in these situations.
Since a percutaneous catheter insertion into the subclavian vein can be tedious, time consuming, and risky, we have compared the morbidity of 137 de novo subclavian catheter insertions to that of 93 reinsertions over guidewire. Mechanical complications were significantly higher (p less than 0.03) in those with catheter insertions (8.8%) than in those with the guidewire insertions (2.2%). These included pneumothorax (4), arterial puncture (4), catheter-size bleed (3), and hemothorax (1) in the catheter insertion group and local bleeding (1) and hydrothorax (1) in the guidewire insertion group. The difference in complications between methods is probably inherent in the techniques. Operator experience was not a factor: 55% of the physicians in each group had previously done less than 26 subclavian venous catheterizations. Preliminary analysis indicates that the infection rate, as determined by semiquantitative, cultures, is the same in each group. When considering the equal potential for infection, we conclude that change over a guidewire is an acceptable alternative to contralateral de novo percutaneous subclavian venipuncture for feeding catheter insertion. In view of fewer mechanical complications and greater ease of insertion, change of subclavian feeding catheters by guidewire is probably the method of choice.
Sequential outbreaks of infection due to gentamicin-resistant Klebsiella pneumoniae (GRKP) types 30 and 19 occurred in the neonatal intensive care unit (NICU) at the Medical College of Virginia in 1977 and 1978. The extensive epidemiologic investigation carried out included a case-control study, careful review of aseptic technique, and cultures from nursery staff and environment. The gastrointestinal (GI) tracts of the patients were the reservoirs for GRKP, and the epidemic strain was transmitted by hands of personnel. The case-control study showed a significant relationship between acquisition of GRKP by patients and oropharyngeal and GI instrumentation, including use of bag resuscitation, oropharyngeal suctioning, and use of nasogastric feeding tubes. The findings of the case-control study were supported by observation of the patient care techniques practiced by NICU staff. Institution of control measures based on results of the epidemiologic investigation of the first outbreak rapidly brought the second outbreak under control, even though cohorting or use of routine isolation was not possible. Whereas GI colonization and hand transmission have been described previously in outbreaks of K. pneumoniae infections in NICUs, this study is the first to document the mode of inoculation of patients' GI tracts by contaminated hands of personnel.
The present study was undertaken to assess the impact of acute discontinuation (AD) of total parenteral nutrition (TPN) on serum glucose, insulin, and glucagon levels and on the generation of symptomatic hypoglycemia. Fifty studies were performed in 48 patients. In none of the 30 studies of 1 hour duration nor in the 20 studies of 8 hours duration was there a single episode of symptomatic hypoglycemia. One patient had a glucose below normal (60 mg/dl) during the first hour after AD. Glucose and insulin concentrations were elevated at the start of TPN discontinuation but returned to normal values within 60 minutes and remained there during the successive 7 hours of study. Although glucagon levels were slightly elevated at zero time, no significant decrease occurred. There was no evidence for counter-regulation based on the patterns of glucose and hormone levels. With some restrictions, acute discontinuation is a safe, rapid method of ending a prolonged TPN infusion.
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