Central Venous Catheter Management in High-risk Children With Bloodstream Infections

Abstract

Background: National guidelines recommend removal of central venous catheters (CVCs) for central line–associated bloodstream infections (CLABSIs) caused by Staphylococcus aureus, Pseudomonas aeruginosa, and fungi. Data regarding guideline compliance and rates of associated treatment failures in pediatric patients with attempted CVC salvage are limited. Methods: We performed a retrospective analysis of high-risk children (age ≤ 21 years) hospitalized from 1/2009 to 12/2015 with a long-term CVC and CLABSI due to S. aureus, Pseudomonas spp., and Candida spp. Enterococcus spp. was included given differing management recommendations between short and long-term CVCs. Compliance with national guideline recommendations, as well as treatment failures including infection relapse, recurrence, and death were evaluated in relation to CVC retention or removal. Multivariate logistic regression modeling was performed to account for confounders impacting treatment failure. Results: Fifty-three children had 108 CLABSI episodes requiring 84 hospitalizations. CVCs were removed in 36 (33%) CLABSI episodes per guideline recommendations. Optimal antimicrobial management, including targeted agent and adequate duration was provided in 54 (50%) of 106 treated episodes; no significant difference in treatment failure rates were noted compared with episodes with suboptimal management. The treatment failure rate was significantly higher in patients with CVC retention compared those with CVC removal within 7 days of the first positive blood culture (31% vs. 6%, P = 0.003). Conclusions: Despite pathogen-specific guideline recommendations for CVC removal, compliance with national guidelines was poor. CVC salvage was attempted in the majority of CLABSI episodes in our cohort and resulted in a significantly higher treatment failure rate.

Central Venous Catheter-related Bloodstream Infections Caused by Enterobacterales in Pediatric Oncology Patients: Catheter Salvage or Removal

“…The cumulative incidence estimated in this study is higher than the 1 expected by clinicians based on the scarce previously published literature. 12–20 Differences with previous literature can be explained by multiple reasons. First, successful salvage was defined taking into account the clinical status of the patient and not solely CVC removal or reinfections as done by previous studies.…”

Clinical and Microbiological Characteristics of Neonates with Candidemia and Impacts of Therapeutic Strategies on the Outcomes

“…However, in cases when the catheter is not the source of sepsis, it deserves a prospective, randomized controlled trial to document whether prompt catheter removal contributes significantly to the outcomes as it is often difficult to reinsert the CVC during the critically ill period. Because of different study designs, cohort selections, and perhaps the bias of illness severity, previous studies failed to have undebatable conclusions [ 31 , 32 , 33 , 36 ]. Nevertheless, we suggest that CVC removal at earliest stage of sepsis should be considered for neonates with candidemia, based on our study result and the current guidelines [ 37 ].…”

“A salvage technique using a fibrous sheath to avoid the loss of the central veins in cases of pediatric intestinal failure”

“…Hecht et al reported real-world data showing that the compliance rate was poor, and attempted CVCs salvage resulted in a high treatment failure rate for high-risk children with bloodstream infections (BSI), although the guideline recommends CVC removal for CLABSI [5]. This is understandable, as clinicians must decide between risking CVCs infection and CVC salvage or allowing CV retention, as CVC removal can result in remnant CV loss and directly lead to a poor prognosis in high-risk patients.…”