Central venous catheter-related blood stream infections in patients receiving intravenous iloprost for pulmonary hypertension

Sammut, D.; Elliot, Charles; Kiely, David G.; Armstrong, Iain; Martin, L E; Wilkinson, Joanne; Sephton, Paul; Jones, John E.; Hamilton, Neil; Hurdman, Judith; McLellan, Elizabeth; Sabroe, Ian; Condliffe, Robin

doi:10.1007/s10096-013-1822-z

Cited by 16 publications

(20 citation statements)

References 14 publications

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“…While studies have documented the CLABSI rates among PH patients receiving IV prostanoids, 8 – 12 , 14 , 15 few studies have analyzed pediatric PH populations. 17 This study examines not only the types of infections and infection rates in children receiving IV prostanoid drugs, but also the effect of line management strategies on reinfection.…”

Section: Discussionmentioning

confidence: 99%

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Central line replacement following infection does not improve reinfection rates in pediatric pulmonary hypertension patients receiving intravenous prostanoid therapy

Ef¹,

Ogawa

Hopper

et al. 2018

Pulm. circ.

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Treatment of pediatric pulmonary hypertension (PH) with IV prostanoids has greatly improved outcomes but requires a central line, posing inherent infection risk. This study examines the types of infections, infection rates, and importantly the effect of line management strategies on reinfection in children receiving IV prostanoids for PH. This study is a retrospective review of all pediatric PH patients receiving intravenous epoprostenol (EPO) or treprostinil (TRE) at one academic tertiary care center between 2000 and 2014. No patients declined participation in the study or were otherwise excluded. Infectious complications were characterized by organism(s), infection rates, time to next infection, and line management decisions (salvage vs. replace). Of the 40 patients followed, 13 sustained 38 infections involving 49 pathogens, with a predominance of gram-positive (GP) organisms (n = 35). The pooled infection rate was 1.06 per 1000 prostanoid days with no difference between EPO and TRE. No significant difference in reinfection rate was observed when comparing line salvage to replacement, regardless of organism type. Both overall and organism-type comparisons suggest longer time between line infections following line salvage compared with line replacement (732 vs. 410 days overall; 793 vs. 363 days for GP; 611 vs. 581 days for gram-negative [GN]; P > 0.05 for all comparisons). Central line replacement following blood stream infections in pediatric PH patients does not improve subsequent infection rates or time to next infection, and may lead to unnecessary risks associated with line replacement, including potential loss of vascular access. A revised approach to central line infections in pediatric PH is proposed.

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Section: Discussionmentioning

confidence: 99%

“…This rate is comparable to or better when compared with previous PH studies and is a relatively low infection rate compared to other studies documenting CLABSI rates for children who depend on central lines for survival. 8 – 15 , 17 , 20 …”

Section: Discussionmentioning

confidence: 99%

Central line replacement following infection does not improve reinfection rates in pediatric pulmonary hypertension patients receiving intravenous prostanoid therapy

Ef¹,

Ogawa

Hopper

et al. 2018

Pulm. circ.

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“…2 The incidence of CVL-BSI among adults treated with PGI 2 analogues is 0.1-1.13 cases per 1,000 catheter-days. 5,12 The REVEAL registry report is the largest, with 1,063 patients >18 years old with at least 5 years of follow-up (the number of CVL-days was not given). 2 As noted above, the overall rate of CVL-BSI was 0.20 cases per 1,000 line-days (epoprostanol ¼ 0:12, treprostinil ¼ 0:36), with more gram-negative infections associated with the latter analogue.…”

Section: Discussionmentioning

confidence: 99%

Central Venous Line Complications with Chronic Ambulatory Infusion of Prostacyclin Analogues in Pediatric Patients with Pulmonary Arterial Hypertension

et al. 2015

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Chronic infusion of prostacyclin (PGI 2 ) via a Broviac central venous line (CVL) is attended by risk of CVL-related complications, but we know of only one report regarding CVL-associated bloodstream infection (BSI) with PGI 2 in children and none regarding other complications. We conducted a retrospective cohort study involving pediatric patients with pulmonary hypertension treated with chronic intravenous infusion of PGI 2 at Boston Children's Hospital and determined the rate (per 1,000 line-days) of various CVL-related complications. We also determined how often complications necessitated line replacement and hospitalization, time to replacement of CVLs, and interpatient variability in the incidence of complications. From 1999 until 2014, 26 patients meeting follow-up criteria had PGI 2 infusion, representing 43,855 line-days; mean follow-up was 56 months (range, 1.4-161 months). The CVL complication rates (per 1,000 linedays) were as follows: CVL-BSI, 0.25; superficial line infection, 0.48; impaired integrity, 0.59; occlusion, 0.09; and malposition, 0.32. The total complication rate was 1.73 cases per 1,000 line-days. All CVL-BSI and malposition cases were treated with CVL removal and replacement. Of CVLs with impaired integrity, 23 could be repaired and 3 required replacement. Six of 21 superficial CVL infections required replacement of the CVL. Three of 4 occluded CVLs were replaced. CVL complications occasioned 65 hospitalizations. There was marked interpatient variability in the rate of complications, much but not all of which appeared to be related to duration of CVL placement. We conclude that non-BSI complications are very significant and that efforts to teach and emphasize other aspects of line care are therefore very important. Chronic intravenous infusion of the prostacyclin (PGI 2 ) analogues epoprostanol and treprostinil, usually through a Broviac central venous line (CVL), has been the most effective therapy for severe pulmonary arterial hypertension (PAH) since 1996, 1 but it is attended with the risk of CVL-related complications. There are multiple reports focused on CVL-related bloodstream infections (BSIs) in adults 2-5 but only a single report regarding CVL-BSI with PGI 2 infusion in mostly pediatric patients (although the age of the patients is not given), 6 and we know of no information regarding the incidence of other complications (e.g., CVL superficial infection, fracture, displacement, and occlusion) in this setting. Children may be at different risk than adults for CVL complications owing to high activity levels, being less mindful of the need for CVL protection, and possibly other factors. Noninfectious complications are also important, as they frequently require hospital visit, admission, or CVL replacement, and their rate of occurrence may substantially exceed that of CVL-BSI. 7,8 A better understanding of non-BSI complications associated with CVLs in pediatric patients receiving PGI 2 analogues could lead to strategies to reduce such events. Also, an alternative means o...

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“…prostanoid are at risk of developing a catheter-related bloodstream infection (CRBSI). 12 Patients with a CRBSI will often have no external signs of line infection and may present with non-specific worsening of breathlessness. An elevated, unexplained, CRP in such patients should lead to exclusion of a line infection with peripheral and central blood cultures and antibiotic therapy to cover gram-positive and gram-negative organisms while cultures are pending.…”

Section: Treatment Of Underlying Cause For Deteriorationmentioning

confidence: 99%

Critical care management of pulmonary hypertension

Condliffe¹,

Kiely²

2017

BJA Education

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Patients with pulmonary hypertension (PH) can be extremely challenging to manage in the critical care setting. In this article we review the classification, diagnosis, and chronic management of PH. An approach to the management of the critically unwell PH patient is discussed. Initial management involves treating underlying precipitants of deterioration and optimizing right ventricular (RV) preload. Reduction of RV afterload with pulmonary vasodilators is also required. Augmentation of cardiac function and perfusion pressures with inotropes and vasopressors may additionally be needed. Advanced renal and respiratory support may be appropriate depending on the clinical context. Patients with known PH who have undergone major surgery or who are in the immediate postpartum period are also at significant risk of deterioration and require management in the critical care setting. Although pulmonary vasodilators are associated with improvements in pulmonary haemodynamics and oxygenation in patients with acute respiratory distress syndrome or after cardiac surgery, there is currently no evidence demonstrating improved outcomes. Key points • Current classification of pulmonary hypertension comprised five diagnostic groups based on shared pathophysiology. • Diagnostic approach includes echocardiography, the exclusion of thromboembolic disease, and right heart catheterization. • The majority of evidence for the use of pulmonary vasodilators is in patients with pulmonary arterial hypertension. • Critical care management of the acutely unwell patient should involve: a. treating precipitating factors. b. optimizing right ventricular preload and afterload. c. maintaining perfusion pressures. d. increasing right ventricular contractility.

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Central venous catheter-related blood stream infections in patients receiving intravenous iloprost for pulmonary hypertension

Cited by 16 publications

References 14 publications

Central line replacement following infection does not improve reinfection rates in pediatric pulmonary hypertension patients receiving intravenous prostanoid therapy

Central line replacement following infection does not improve reinfection rates in pediatric pulmonary hypertension patients receiving intravenous prostanoid therapy

Central Venous Line Complications with Chronic Ambulatory Infusion of Prostacyclin Analogues in Pediatric Patients with Pulmonary Arterial Hypertension

Critical care management of pulmonary hypertension

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