Should Central Venous Catheters Be Removed as Soon as Candidemia Is Detected in Neonates?

Abstract

ABSTRACT. Background. Controversy exists regarding the most appropriate acute management of central venous catheters (CVCs) in neonates with candidemia, with up to two thirds of neonatologists preferring to attempt antifungal therapy without removing CVCs.Objective. To determine whether CVCs should be removed as soon as candidemia is detected in neonates.Methods. A cohort study of candidemia and CVC was conducted in infants in a neonatal intensive care unit (NICU) over a 5-year period (1994 -1998).Results. Fifty infants had early-removal CVC (ER-CVC) within 3 days and 54 infants had late-removal CVC (LR-CVC) >3 days after the first positive blood culture for Candida species. All infants were treated with amphotericin B. There was no significant difference between infants in the ER-CVC and LR-CVC groups in terms of gender, ethnicity, birth weight, gestational age, age at candidemia, severity-of-illness scores, distribution of types of CVC, or in the distribution of Candida species causing candidemia. The ER-CVC group had significantly shorter duration of candidemia (median: 3 days; range: 1-14 days), compared with the LR-CVC group (median: 6 days; range: 1-24 days). The case fatality rate of Candida albicans candidemia was significantly affected by the timing of CVC removal: 0 of 21 (95% confidence interval [CI]: 0 -14) infants died in the ER-CVC group in contrast to 9 of 23 (39%; 95% CI: 19 -59) in the LR-CVC group.Conclusion. Failure to remove CVC as soon as candidemia was detected in neonates was associated with significantly increased mortality in C albicans candidemia and prolonged duration of candidemia regardless of Candida species. The 1996 International Consensus Conference on the Management of Severe Candidal Infections strongly suggested that all intravascular catheters in patients with systemic candidal infections be removed, although the focus of the Consensus Conference was primarily adult patients. 4 Edwards and Baker 5 unequivocally stated that identification of candidemia in neonates "mandates removal of all intravascular devices," but no citation from the neonatal literature was given to support this recommendation. In fact, 2 case series have recently suggested that bloodstream infections in neonates, including candidemia, can resolve with antimicrobial therapy without removing CVC. 6,7 Therefore, it is not surprising that a recent survey by the Neonatal Candidiasis Study Group reported that only 35% neonatologists and 53% infectious disease specialists would immediately remove a CVC from a neonate with the first positive blood culture for Candida species. 8 In our institution, the attitude toward removal of CVC at the time of diagnosis of candidemia varied among pediatric specialists, leaving the dilemma unresolved. Because we have extensive experience with candidemia in neonates, we sought to address this controversy by determining: 1) whether candidemia was prolonged when CVCs were not removed immediately; 2) whether the case fatality rate of candidemia was increased if CVCs were not removed...

Accuracy of bacterial DNA testing for central venous catheter-associated bloodstream infection in children with cancer

“…From the 38 potentially eligible studies (see Figure 5), we found one systematic review 43 and eight retrospective cohort studies in children. [45][46][47][48][49][50][51][52] We excluded seven retrospective cohort studies in adults. 41,42,[53][54][55][56][57] We excluded one further study in children with cancer, 52 as none of the required outcomes was reported in children with CVC removal and retention.…”

“…The systematic review by Nucci and Anaissie 43 reported 14 cohort studies, four of which were in children, 48,51,58,59 that compared CVC removal with retention in patients with candidaemia. We included only two studies 48,51 that were discussed in that review 43 as they involved children and were published after 1994.…”

“…We included only two studies 48,51 that were discussed in that review 43 as they involved children and were published after 1994. However, their review elucidates the critical source of bias inherent in observation studies of CVC removal: the timing of removal depends on the patient's condition.…”

“…[45][46][47][48][49][50][51] The studies involved different patient groups (four studies were confined to neonates) [47][48][49][50] and different types of bloodstream infection (five studies were restricted to specific organisms), 45,[47][48][49]51 making it difficult to assess consistency of results. None of the studies presented results adjusted for severity of illness, but three studies, one of bloodstream infection due to Enterobacteriaceae, 47 one in neonates with coagulase-negative staphylococcal bloodstream infection 49 and one in neonates with candidaemia, 48 were from the same team of investigators and reported similar baseline characteristics in babies according to CVC removal or retention. [47][48][49] In the three studies involving bacteria, the risk of recurrent bloodstream infection was similar in the groups with and without CVC removal.…”

Controversies about the management of invasive fungal infections in very low birth weight infants

“…Existe consenso, porém, de que uma única hemocultura positiva para Candida constitui-se em evidência suficiente de infecção, e que a terapia antifúngica apropriada deve ser iniciada prontamente. Da mesma forma, considera-se componente essencial da terapia a remoção dos cateteres vasculares centrais existentes até que a cultura se torne negativa 19,22 .…”