Central Venous Catheter Salvage in Ambulatory Central Line–Associated Bloodstream Infections

Abstract

BACKGROUND Guidelines for treatment of central line–associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. METHODS This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. RESULTS A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CONCLUSIONS CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.

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

“…The issue of whether the CVC should be removed as early as possible after the occurrence of sepsis has been the topic of debate as most critically ill patients need the CVC for antibiotic administration and fluid supplementation. Although there have been multicenter studies that did not reach a conclusion on the importance of early CVC removal to the outcomes [ 31 , 32 , 33 ], we did find that delayed CVC removal in neonates with candidemia was independently associated with final in-hospital mortality. This can probably be explained by these patients being more likely to have persistent candidemia and/or breakthrough candidemia, which is associated with final adverse outcomes [ 34 , 35 ].…”

“…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 ].…”

Catheter salvage from central line‐related bloodstream infections in pediatric intestinal failure

“…Ford et al found no difference in the rate of salvage attempts for those with fungal infections versus other infection types. Similar to our patient population, they had a significantly lower rate of successful salvage for patients with fungal infections (11%) compared to other infection types (77.3%) 10 . The use of ethanol locks may help increase the success of line salvage in the setting of fungal infections 17 .…”

“…Our relatively homogenous patient population of patients with IF may also have contributed to our higher successful salvage rate compared to other studies. 10,13 The types of infections treated also likely contributes to the salvage rates, as many studies looked at just one infection type such as Staphylococcus aureus. 11,12 The IDSA suggests removal for all infections with S. aureus, Pseudomonas aeruginosa, Mycobacterium, polymicrobial infections, and Candida and that line salvage should only be attempted in "extenuating circumstances."…”

“…Other studies with different methods and patient populations found successful salvage rates for S. aureus of 67%-83% with one study demonstrating a 10% recurrence rate within 60 days. [10][11][12][13]15 The differing rates of salvage success for S. aureus infections likely are related to the patient population studied, treatment differences, and definition of line salvage failure as in some studies salvage failure was defined only in the immediate period while for other studies failure was defined as any reoccurrence up to 60 days after antibiotic treatment.…”